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Sukmana A
Hidajat N. N.
Chaidir R
Department of Orthopaedic and Traumatology Faculty of Medicine Padjadjaran University
Hasan Sadikin Hospital Bandung
ABDOMINAL FLAP FOR DEGLOVING LESSIONS OF THE HAND (A CASE REPORT)
Hand deglovingHand degloving
Incidence Incidence – Hongkong : Hand injury 600 / 100.000Hongkong : Hand injury 600 / 100.000
Hand degloving : 1,4 %Hand degloving : 1,4 %
– Indonesia ???Indonesia ??? Prognosis : doubtful Prognosis : doubtful Result to this patient :Result to this patient :
– Skin coverage : goodSkin coverage : good– Hand function : Hand function : medical rehabilitation medical rehabilitation
Patient ProfilePatient ProfilePatient ProfilePatient Profile
CC : Degloving of the right hand CC : Degloving of the right hand
Three hours before admission, the Three hours before admission, the patient’s hand entraped in a textile patient’s hand entraped in a textile machinemachine
wounded at the right handwounded at the right hand Degloving of the skin of the second to Degloving of the skin of the second to
fifth digitsfifth digits Bone , nerve and tendon exposureBone , nerve and tendon exposure No medication or first aid before No medication or first aid before
hospitalized hospitalized
History
Miss L 26 yo Employee of a textile factory Right handed
a/r right handa/r right hand ::
LookLook : wound (+), skin degloving at plantar : wound (+), skin degloving at plantar and dorsal aspect of the second to fifth and dorsal aspect of the second to fifth finger at the level MCP joint with tendon finger at the level MCP joint with tendon and bone ekspos (+), and bone ekspos (+),
amputee : stuck in the machineamputee : stuck in the machine
FeelFeel : tenderness (+), : tenderness (+),
Movement : motion of the MCP,PIP, DIP joint ; Movement : motion of the MCP,PIP, DIP joint ; limited due to painlimited due to pain
Physical examination
Laboratory Finding
X Ray
X ray right hand : fracture line (-), dislocation (-)
Hemoglobin : 11,8 g/dl
Lekocyte : 9100/mm3
Hematocrite : 35%
Trombocyte : 255.000/mm3
Case ReportCase Report
Skin degloving at the second to fifth finger Skin degloving at the second to fifth finger
or the right handor the right hand
Debridement Debridement randon pattern abdominal Flap randon pattern abdominal Flap
Cefotaxim 2 x 1 gr (iv)Cefotaxim 2 x 1 gr (iv)
gentamicyn 2 x 1 ampgentamicyn 2 x 1 amp
Ranitidin 2 x 1 ampRanitidin 2 x 1 amp
Aspilet 2 x 1 p. o Aspilet 2 x 1 p. o
Pain program : ketorolak : 1 amp + tramadol 1 amp / RL 20 Pain program : ketorolak : 1 amp + tramadol 1 amp / RL 20
gtt/menitgtt/menit
Hand warmingHand warming
Diagnosed
Treatment
Size of skin defect Size of skin defect – Random pattern Random pattern
abdominal flapabdominal flap Problem : Problem : necrotic of necrotic of
the distal of the digits the distal of the digits at the volar site 1 x at the volar site 1 x 0,5 cm (POD III)0,5 cm (POD III)– Aspilet 2 x 1 Aspilet 2 x 1
First Operation
Second operationSecond operation
After 19 days from After 19 days from the first operationthe first operation
Release flapRelease flap Problem :Problem :
– Necrotic tissue at Necrotic tissue at the volar aspect (+) the volar aspect (+) (POD II)(POD II)
– Wet wound (+)Wet wound (+)
Third operationThird operation
25 days after the 25 days after the second operationsecond operation
Problem : Problem : secondary secondary infection; Pus (+) infection; Pus (+) at the distal hand , at the distal hand , necrotic tissue (+), necrotic tissue (+), bone expose digital bone expose digital II – IV (+)II – IV (+)
Debridement Debridement Disarticulation DIP Disarticulation DIP
joint digiti II – IV joint digiti II – IV manus dx.manus dx.
Fourth operationFourth operation
42 days after the third operation42 days after the third operation Problem : protruding bone digiti II & III at the end of the Problem : protruding bone digiti II & III at the end of the
stumpstump– DebridementDebridement– Osteotomy of the protruding boneOsteotomy of the protruding bone– Separation interdigiti III - IVSeparation interdigiti III - IV– De fatting De fatting – FTSGFTSG
Fifth operationFifth operation
35 day after the 435 day after the 4thth operation operation
Problem : pus (+) Problem : pus (+) at interdigit II – IIIat interdigit II – III– DebridementDebridement– Separation Separation
interdigit II – III interdigit II – III – Defatting Defatting – FTSG for the defect FTSG for the defect
from abdomen from abdomen
Sixth operationSixth operation
52 days after the 552 days after the 5thth operation operation Separation of the IV – V fingersSeparation of the IV – V fingers De fattingDe fatting FTSG for the defect from the abdomenFTSG for the defect from the abdomen Post op care ; cefotaxim 2 x 1 gr, aspirin 2 x 50 mg, ranitidin 2 x 1 Post op care ; cefotaxim 2 x 1 gr, aspirin 2 x 50 mg, ranitidin 2 x 1
amp, ketorolak 2 x 1 amp, amp, ketorolak 2 x 1 amp, X – ray after opX – ray after op
The Latest Follow-upThe Latest Follow-upThe Latest Follow-upThe Latest Follow-up
4 months
Degloving of the handDegloving of the hand
Orthopaedic dictionary : Orthopaedic dictionary :
An injury of the hand or foot that An injury of the hand or foot that characteristically in avulsion of skin characteristically in avulsion of skin area with Important structures such area with Important structures such as tendons, nerves, and bones are as tendons, nerves, and bones are
exposed and will necrose if not exposed and will necrose if not covered adequately covered adequately
EtiologyEtiology
Campbell’s :Campbell’s :
– Trapped on a moving machineTrapped on a moving machine– Human biteHuman bite– Tornado missileTornado missile– AugersAugers– War woundWar wound– High velocity missile woundHigh velocity missile wound
Diagnose Diagnose
X – ray :X – ray :– fracture fracture – dislocation or dislocation or – foreign bodyforeign body
Laboratory Laboratory – Blood status for surgeryBlood status for surgery
Treatment Treatment
Campbell’s : Campbell’s :
the purpose of treatment is to the purpose of treatment is to – restore its functionrestore its function
It is necessary to : It is necessary to : – prevent infection prevent infection – salvage injured parts salvage injured parts – and promote primary healingand promote primary healing
TreatmentTreatment
As indicatedAs indicated– AntibioticAntibiotic– SedativeSedative– Tetanus prophylaxisTetanus prophylaxis– Blood transfusionBlood transfusion
Skin closureSkin closure– Direct sutureDirect suture– Skin graftsSkin grafts– Skin flapSkin flap
Abdominal FlapAbdominal Flap
Orthopaedic dictionary : Orthopaedic dictionary : A type of distant flap graft used to provide A type of distant flap graft used to provide
subcutaneous tissue for coverage of deep subcutaneous tissue for coverage of deep soft tissue defectsoft tissue defect
– Same side : a distal flap based; epigastric Same side : a distal flap based; epigastric vessel or superficial circumflex iliac arteryvessel or superficial circumflex iliac artery
– Opposite side : a proximal flap based; thoraco - Opposite side : a proximal flap based; thoraco - epigastric vesselepigastric vessel SupraumbilicalSupraumbilical Avoid the fat storage areasAvoid the fat storage areas
Technique : Campbell’sTechnique : Campbell’s
Make a pattern on a sterile paperMake a pattern on a sterile paper Outline the pattern on the abdomenOutline the pattern on the abdomen Raise the skin flap of the desired size and Raise the skin flap of the desired size and
thicknessthickness Maintain hemostatisMaintain hemostatis Close the defect of the donorClose the defect of the donor Apply the flap over the entire defectApply the flap over the entire defect Suture the edges of the flap to those of Suture the edges of the flap to those of
the defectthe defect
Technique Technique
Place a strip of non adhering gauzePlace a strip of non adhering gauze Prevent kinking, tension, or rotationPrevent kinking, tension, or rotation Bandage around the trunk to support Bandage around the trunk to support
the armthe arm Accessible inspectionAccessible inspection Steinmann pin if necessary Steinmann pin if necessary
After TreatmentAfter Treatment
Inspection in the first 48 hoursInspection in the first 48 hours Tension ?, torsion?, hematome?, too Tension ?, torsion?, hematome?, too
tight sutures?tight sutures? Necrotic ; excised Necrotic ; excised STSG STSG Avoid odor Avoid odor infection infection Flap detachment ; 3 weeks, in Flap detachment ; 3 weeks, in
children ; 2 weeks children ; 2 weeks
Medical Rehabilitation Medical Rehabilitation ProgramProgram
Hand function : oral hygiene, Hand function : oral hygiene, Dressing, Bathing, Grooming, etcDressing, Bathing, Grooming, etc
Sensory : Hyper/Hypo/ un ; esthesia, Sensory : Hyper/Hypo/ un ; esthesia, sensitize or de sensitize sensitize or de sensitize
Vocational : writing etc. Vocational : writing etc.
OutcomeOutcome
consideration :consideration :– AttachmentAttachment– Multiple stages operation Multiple stages operation “the “the
patient must be very patient” patient must be very patient” (cooperative)(cooperative)
– Prolonged hospital stayProlonged hospital stay– Doubtful resultDoubtful result
Very Important to inform the patientVery Important to inform the patient
DiscussionDiscussion DiscussionDiscussion
Female, 26 yo
Employee of a factory
Trapped hand on the textile machine
Hand degloving
Abdominal flap
Rehabilitation
Separation
DASH Questionnaire
ConclusionsConclusions ConclusionsConclusions
Hand trapping on a moving machine can Hand trapping on a moving machine can cause degloving of the handcause degloving of the hand
To close a wide defect , abdominal flap may To close a wide defect , abdominal flap may be sufficientbe sufficient
HATUR HATUR
NUHUNNUHUN
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