ABDOMINAL FLAP FOR DEGLOVING LESSIONS OF THE HAND

(A CASE REPORT)

Sukmana A Hidajat N. N.

Chaidir R

Department of Orthopaedic and Traumatology Faculty of Medicine Padjadjaran University Hasan Sadikin Hospital Bandung

Hand degloving
Incidence
Hongkong : Hand injury 600 / 100.000
Hand degloving : 1,4 %

Indonesia ???

Prognosis : doubtful Result to this patient :

Skin coverage : good Hand function : medical rehabilitation

Miss L 26 yo Employee of a textile factory Right handed

Patient Profile

History

CC : Degloving of the right hand Three hours before admission, the patients hand entraped in a textile machine wounded at the right hand Degloving of the skin of the second to fifth digits Bone , nerve and tendon exposure No medication or first aid before hospitalized

Physical examination

a/r right hand : Look : wound (+), skin degloving at plantar and dorsal aspect of the second to fifth finger at the level MCP joint with tendon and bone ekspos (+), amputee : stuck in the machine Feel : tenderness (+),

Movement : motion of the MCP,PIP, DIP joint ; limited due to pain

X Ray

X ray right hand : fracture line (-), dislocation (-)

Laboratory Finding Hemoglobin Lekocyte Hematocrite Trombocyte : 11,8 g/dl : 9100/mm3 : 35% : 255.000/mm3

Case Report
Diagnosed

Skin degloving at the second to fifth finger or the right hand

Debridement randon pattern abdominal Flap Cefotaxim 2 x 1 gr (iv) gentamicyn 2 x 1 amp Ranitidin 2 x 1 amp

Treatment

Aspilet 2 x 1 p. o
Pain program : ketorolak : 1 amp + tramadol 1 amp / RL 20 gtt/menit Hand warming

First Operation

Size of skin defect

Random pattern abdominal flap

Problem : necrotic of

the distal of the digits at the volar site 1 x 0,5 cm (POD III) Aspilet 2 x 1

Second operation
After 19 days from the first operation Release flap Problem :

Necrotic tissue at the volar aspect (+) (POD II) Wet wound (+)

Third operation

25 days after the second operation Problem : secondary infection; Pus (+) at the distal hand , necrotic tissue (+), bone expose digital II IV (+)
Debridement Disarticulation DIP joint digiti II IV manus dx.

Fourth operation

42 days after the third operation Problem : protruding bone digiti II & III at the end of the stump
Debridement Osteotomy of the protruding bone Separation interdigiti III - IV De fatting FTSG

Fifth operation
35 day after the 4th operation Problem : pus (+) at interdigit II III

Debridement Separation interdigit II III Defatting FTSG for the defect from abdomen

Sixth operation

52 days after the 5th operation Separation of the IV V fingers De fatting FTSG for the defect from the abdomen Post op care ; cefotaxim 2 x 1 gr, aspirin 2 x 50 mg, ranitidin 2 x 1 amp, ketorolak 2 x 1 amp, X ray after op

The Latest Follow-up

4 months

Degloving of the hand

Orthopaedic dictionary :

An injury of the hand or foot that characteristically in avulsion of skin area with Important structures such as tendons, nerves, and bones are exposed and will necrose if not covered adequately

Etiology

Campbells :
Trapped on a moving machine Human bite Tornado missile Augers War wound High velocity missile wound

Diagnose

X ray :
fracture dislocation or foreign body

Laboratory
Blood status for surgery

Treatment
Campbells : the purpose of treatment is to
restore its function

It is necessary to :
prevent infection salvage injured parts and promote primary healing

Treatment

As indicated
Antibiotic Sedative Tetanus prophylaxis Blood transfusion

Skin closure
Direct suture Skin grafts Skin flap

Abdominal Flap

Orthopaedic dictionary : A type of distant flap graft used to provide subcutaneous tissue for coverage of deep soft tissue defect
Same side : a distal flap based; epigastric vessel or superficial circumflex iliac artery Opposite side : a proximal flap based; thoraco epigastric vessel
Supraumbilical Avoid the fat storage areas

Technique : Campbells

Make a pattern on a sterile paper Outline the pattern on the abdomen Raise the skin flap of the desired size and thickness Maintain hemostatis Close the defect of the donor Apply the flap over the entire defect Suture the edges of the flap to those of the defect

Technique
Place a strip of non adhering gauze Prevent kinking, tension, or rotation Bandage around the trunk to support the arm Accessible inspection Steinmann pin if necessary

After Treatment
Inspection in the first 48 hours Tension ?, torsion?, hematome?, too tight sutures? Necrotic ; excised STSG Avoid odor infection Flap detachment ; 3 weeks, in children ; 2 weeks

Medical Rehabilitation Program

Hand function : oral hygiene, Dressing, Bathing, Grooming, etc Sensory : Hyper/Hypo/ un ; esthesia, sensitize or de sensitize Vocational : writing etc.

Outcome

consideration : Attachment Multiple stages operation the patient must be very patient (cooperative) Prolonged hospital stay Doubtful result
Very Important to inform the patient

Discussion
Female, 26 yo

Employee of a factory

Trapped hand on the textile machine

Hand degloving Abdominal flap Separation

DASH Questionnaire

Rehabilitation

Conclusions
Hand trapping on a moving machine can cause degloving of the hand

To close a wide defect , abdominal flap may be sufficient

HATUR NUHUN