Preservation of function following complete degloving injuries to the hand: Use of simultaneous groin flap, random abdominal flap,

and partial-thickness skin graft

Early total wound coverage is effectively achiel'ed in complete degloving injuries to the hand and digits by preliminary skeletal narrowing and shortening, volar partial-thickness skin grafting, and application of a long, axial-pattern attached groin flap to the dorsum of the hand and remaining phalanges. If the thumb has been skeletonized by the initial trauma , simultaneous use of a circumferential random-pattern abdominal flap ensures complete coverage and earlier mobilization. This combination of techniques is effective in preserl'Gtion of pinch power and control, hook function of the medial portion of the hand. and general grasp and release attitudes.

William B. Kleinman, M.D., and J . Anthony Dustman, M.D. , Indianapolis, Ind.

Wound coverage following total degloving injury to the hand is one of the most difficult management problems in hand surgery . The paucity of reports in the literature concerning reconstructive efforts in degloving injuries of the magnitude shown in Figs . 1 and 2 have led surgeons to recommend amputation of the entire hand, or all involved digits, to ensure early mobilization and to preserve the function of remaining uninjured parts, including the thumb. Only one report describes the injury as "complete" (distal to the carpus and the palmar and dorsal branches),! but this report emphasizes limb morbidity and postinjury management problems, even in cases of lesser magnitude. The principles stressed by Holevich 2 of early mobilization by skin grafting after traumatic avulsion injuries are not applicable to such injuries involving soft tissue loss of the magnitude presented in this report (Figs. I and 2) . Even in conjunction with a formidable skin plasty,:I only partial wound coverage can be achieved. Tajima et al. 4 have applied the concept of a large random-patternS abdominal flap to coverage of injured hands or forearms, but their technique is unsuitable for simultaneous volar and dorsal coverage required for large surface areas .
From the SI. Vincent Hospital and Health Care Center, Indianapolis , Ind . Received for publication Feb . 4, 1980; revised June 3, 1980. Reprint requests to: William B. Kleinman, M.D., 8402 Harcourt Rd Ste. 217 , Indianapolis, IN 46260.

In 1974, Miura and Nakamura 6 recommended paired random-pattern abdominal flaps to solve the formidable problem of simultaneous dorsal and palmar skin loss; however, these "vis-a-vis flaps" are insufficient to cover the entire de gloved hand plus the digits. This technique reduces the fixation period to 3 weeks before detachment and avoids the " risks of maceration and infection of the wound" seen with the use of the "abdominal pocket," criticized by Cowen and Giannotto . 7 In 1976, Smith and Furnas 8 proposed a solution to the problem of simultaneous dorsal and volar skin loss by use of adjacent body surfaces to raise two anteriorly based flaps, utilizing the medial aspect of the arm and the anterolateral aspect of the chest wall. Versatility in designing these flaps is quite limited and does not allow concomitant management of a degloved thumb. The Smith and Furnas procedure will not afford flap length sufficient to completely cover the hand and digits following total degloving, and early mobility is precluded by anchoring the hand to two quite immobile randompattern flaps near the contralateral axilla. Kelleher and Dean , 9 in 1974, and Finseth, JO in 1976, recognized the necessity for distant random pedicle flaps in these severe hand injuries; however, fluid dynamics and length-to-breadth ratio constraints limit the dimensions of random flaps , thus reducing their effectiveness. Based on work by McGregor et al. 11 and Smith et alY in 1972, the axial-pattern groin flap has become a
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Fig. 1, A to C. Type I total degloving injury . All surfaces except the thumb are involved .

Fig. 2, A and B. Type II degloving injury. The thumb is included in the total loss of all skin and supportive subcutaneous tissue.

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Fig. 3. The principles of narrowing by second-ray resection and shortening by DIP disarticulation aid in preserving the first web space and facilitate wound coverage by combined axial pattern and random flaps .

Fig. 4. Relationship between axial pattern groin flap and random-pattern abdominal flap when used concomitantly in type II injuries.

standard method of wound coverage in the hand, especially when large areas of denuded tissue and exposed vital structures are involved. 13 Anatomic details and the overall versatility of this flap in surgery of the hand have been well documented by Lister et al. 14 Using a protocol that combines well-founded techniques of wound coverage, we have found that function can be preserved in the completely degloved hand (including the entire palm and dorsum of the hand, all four medial border digits, plus the thumb) as follows: 1. Use an attached groin flap coverage of the entire dorsum of the hand and digits from the wrist level with length enough to wrap the long. axial pattern 5 flap over the end of the phalanges onto the volar digital surfaces at the time of detachment and insetting. 2. Use a palmar partial-thickness skin graft to preserve deep pressure sensibility on the "tactile" portion of the hand, keeping as much bulk as possible off the palm and away from the first web space and maintain-

ing the contour of the transverse and longitudinal palmar skeletal arches. 3. Use second-ray resection to preserve the breadth of the first web space in the face of potential for profound contracture and loss of pinch and prehension (Fig. 3) . 4. Amputate all distal phalanges by distal interphalangeal (DIP) disarticulation (including the thumb, if involved in the degloving mechanism) to avoid avascular necrosis of bone and to facilitate wound coverage (Fig. 3). 5. Emphasize salvage of metacarpophalangeal (MP) flexion only. preserving a modicum of hook function along the medial portion of the hand. 6. Cover the thumb circumferentially with a random-pattern abdominal flap (Fig . 4).9. 10. 15, 16 No previous reports of an organized approach to goals of early mobilization, wound coverage, and preservation of function following degloving of the en-

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Fig. 5. Groin flap lengths greater than 30 cm in adults afford coverage of the entire dorsum of the hand and digits , a high degree of mobility, and additional length at the time of insetting.

tire hand from the wrist distally have been found in the literature. The purpose of this paper is to present a method for successfully achieving these goals. Clinical material By retrospective study of 28 consecutive attached groin flaps performed from 1977 to 1979, we determined that in adults a 30 cm flap could be safely raised without jeopardizing the circulation of the axial-pattern system 14 at the tip of the flap (Fig . 4) . This length is necessary to ensure complete dorsal wound coverage yet provide enough length at the proximal aspect of the flap at the time of detachment to drape over the end of the skeletonized digits onto the volar aspect of the proximal phalanges (Fig. 5) . Using this maximum "safe " length, six cases of severe degloving injury to the hand and digits were studied prospectively, categorized by the presence or absence of thumb involvement in the mechanism of injury. For ease of discussion, type I refers to those cases in which the thumb was not involved in the injury; type II refers to situations in which the entire hand and thumb were degloved . Technique After initial debridement and antibiotic coverage, a delayed second-ray resection is performed with osteotomy through the proximal metaphysis of the meta-

carpal. In one of our type I patients (Fig . 6), traumatic amputation of the long finger at the time of injury necessitated osteotomy and transposition of the index ray to the base of the third metacarpal. A Matev myotomy 17 of the transverse belly of the adductor pollicis should be performed to aid in preservation of the first web space, and the remaining skeletonized medial three digits in type I injuries are disarticulated at the DIP joints. In type II, the degloved thumb is disarticulated in similar fashion through the interphalangeal (IP) joint. Using the technique of Lister et aI. , 14 a large groin flap based on the superficial circumflex iliac system is raised, with primary closure of the donor skin edges . Prior to application of this flap to the dorsum of the degloved hand, a 15/1.ooo-inch partial-thickness skin graft is taken from the contralateral thigh and applied to all raw volar surfaces of the injured hand. No effort is made to separate interdigital clefts . The long, mobile groin flap is then attached to the dorsum of the hand at the wrist level with medial and lateral borders attached directly to the partial-thickness volar skin graft. Redundant flap between the hand and abdomen (usually 10 to 15 cm) is "tubed" on itself to entirely close the system in either type I or II injuries . At 21 days, the groin flap can be safely detached near the abdomen. The tubed portion of the flap is filleted

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Fig. 6. Traumatic amputation of the long finger in this type I injury necessitated index ray transposition and adductor myotomy to preserve the first web space.

open along the original suture line and draped over the distal aspects of the middle phalanges onto the volar surface of the digits at the midproximal phalangeal level. All maturing, hypertrophied volar skin graft overlapped by the flap is dissected off its digital bed, and the proximal end of the long detached flap is inset directly into palmar skin graft (Fig. 7). The same approach can be used in type II patients, since mobility of the groin flap will allow spacial placement of the hand to an area on the abdomen suitable for concomitant design and elevation of a widebased-random-pattern flap to circumferentially cover the degloved thumb (Fig. 8). Raw surface area under this flap is covered by a partial-thickness skin graft. This position is quite comfortable for the patient, and early motion of the wrist and forearm is encouraged (Fig. 9). Discussion Our initial goal for this study was to design immediate total coverage of all areas involved by the degloving

mechanism in a manner that would facilitate early mobilization and ensure adequate function of the remaining hand. The technique combines a simultaneous groin flap, a partial-thickness skin graft, and a random-pattern abdominal flap with principles of narrowing of the palm and shortening of the digits to provide wound coverage. Dorsal hand and digital coverage. The retrospective review of 28 consecutive groin flaps in adults was essential in determining the maximum "safe" length of this flap in adults. This length ensured that not only the entire dorsum of the hand and fingers but all surfaces of the remaining phalanges could be covered by a single flap. In this study the average dorsal skin loss following traumatic degloving measured 15 cm. Blood supply to the distal phalanges of the skeletonized digits was severely compromised, and DIP disarticulation was recommended for all patients both to facilitate wound coverage and to avoid avascular necrosis of distal bone (Fig. 3). All reconstructive efforts in these cases were directed toward salvage of pinch power and preservation of hook function along the medial portion of the hand (Figs. 10 and 11). Dorsal application of an attached groin flap with a mobile subcutaneous tissue base allows a small arc of MP flexion with minimal dermodesis effect over the dorsal aspects of the MP joints; longitudinal and transverse contours of the hand are maintained by a partial-thickness skin graft on all palmar aspects. We feel that the "mitten hand" (Figs. 10 and 11) is a highly functional unit, and reconstructive efforts should be directed towards the thumb and first web space, not to the more medial interdigital clefts. First web space. Contracture of the first web space following major trauma of this kind is profound, and only through efforts directed toward preserving both the web space and the musculature of the thumb can pinch and prehensile losses be minimized. Second-ray resection at the time of initial flap attachment minimizes this severe complication. Coverage of the dorsum of the hand is also facilitated by narrowing the palm (Fig. 3). The propensity for contracture during the first 3 weeks can be retarded by transfixion wires between the first and third metacarpals. Flap detachment and insetting. Attached groin flaps of such extraordinary lengths were necessary in the protocol for this study to cover all phalangeal surfaces with well-vascularized skin and supportive subcutaneous bed. Fig. 7 demonstrates how the remaining phalanges are protected as the detached dorsal groin flap is brought onto the palmar surface of the hand and inset into a maturing, hypertrophying partial-thickness

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Fig. 7. When detached from the abdomen, the long groin flap can be filletted open, brought from the dorsum to the palmar surface, and inset into maturing partial-thickness skin graft to create a "mitten" hand as shown in Figs. 10 and II.

skin graft. This method of coverage effectively preserves the longitudinal and transverse palmar arches. More important, the bulk of the groin flap is kept away from the first web space, preserving the arc of the thumb for opposition and pinch. A volar partialthickness skin grafting will preserve deep pressure sensibility of the palm, which is critical in a hand that would otherwise have no perception of light touch. Thumb coverage (Fig. 8). The versatility of this technique is demonstrated by the two type II cases managed with the same technical considerations described for type I and the additional simultaneous use of a large random-pattern abdominal flap (Fig. 4). The design and elevation of this additional flap for circumferential thumb coverage is made possible by the long, highly mobile pedicle of the attached groin flap. As shown in Fig. 5, once the hand is "plugged into" both flaps, the entire system can be closed, thus minimizing the potential for infection. Summary The importance of an organized approach to the difficult problem of total traumatic degloving of the hand and digits cannot be overemphasized. Each of the combined principles of skeletal narrowing and shortening, wound coverage, preservation of the first web space, the palmar partial-thickness skin graft, and the

Fig. 8. Concurrent use of a large, random-pattern abdominal flap and ipsilateral attached groin flap of greater than 30 cm is facilitated by dorsal attachment of the groin flap. The long axial pattern flap allows mobility of the entire hand and placement in an abdominal area is most suitable for a random flap for thumb coverage in type II injuries.

"mitten hand" is critical to the final goal of preserved hand function. Pinch power and control, hook function of the medial portion of the hand, and the general grasp and release attitudes of the hand can be effectively preserved following the methods outlined in this paper.

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Fig. 9. Type II patient with total degloving at the time of double flap attachment and palmar partial-thickness skin graft. The position of the left upper limb is quite comfortable.

Fig. 10, A and B. Pinch power and prehension maintained in type I patient by using techniques presented in this study.

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Fig. 11, A and B. Pinch power and prehension maintained in type II patient by using techniques presented in this study .

REFERENCES
I. Kendall TE, Nelson GD, Shaw RC , Ferris BG: Total avulsion injuries of the hand . Orthop Rev 7:75-7, 1978 2. Holevich J: Early skin-grafting in the treatment of traumatic avulsion injuries of the hand and fingers. J Bone Joint Surg [Am] 47 :944-57, 1965 3. Holevich J: A new method of skin plasty with pedicle flap and its application in surgery of the hand and digits . Acta Chir Plast 2:261 -73 , 1960 4 . Tajima T, Uchiyama J, Noto S: The procedure of pedicle skin graft covering all the surface of injured hand or forearm primarily. Jap J Plast Reconstr Surg 12:87-8 , 1969 5. McGregor lA, Morgan G: Axial and random pattern flaps. Br J Plast Surg 26:202-13, 1973 6. Miura T, Nakamura R: Use of paired flaps to simultaneously cover the dorsal and volar surfaces of a raw hand. Plast Reconstr Surg 54:286-9 , 1974 7. Cowen NJ , Giannotto , RP: Multiple flap coverage for degloving hand injuries . South Med J 71 :281-8, 1978 8. Smith RC , Furnas DW: The hand sandwich: Adjacent flaps from opposing body surfaces . Plast Reconstr Surg 57:351-4, 1976 9. Kelleher JC, Dean RK: Distant pedicle flaps. In Littler 10 .

11 . 12 .

13.

14. 15 . 16. 17 .

JW , Cramer LM, Smith JW , editors: Symposium on Reconstructive Hand Surgery , vol 9. St. Louis, 1974, The CV Mosby Co, P 104 Finseth FJ: Anatomy and design of flaps. In Krizek TJ, Hoopes JE, editors: Symposium on Basic Sciences in Plastic Surgery. St. Louis , 1976, The CV Mosby Co, P 263 McGregor lA , Jackson IT: The groin flap . Br J Plast Surg 25:3-16, 1972 Smith PJ, Foley B, McGregor lA, Jackson IT: The anatomical basis of the groin flap . Plast Reconstr Surg 49:41-7, 1972 McGregor IA: Flap reconstruction in hand surgery: The evolution of presently used methods. J Hand Surg 4: 1-9, 1979 Lister GD, McGregor lA, Jackson IT: The groin flap in hand injuries. Injury 4:229-39 , 1973 Boyes JH, editor: Bunnell 's Surgery of the Hand, ed 4. Philadelphia, 1964, JB Lippincott Co Shaw DT , Payne RL: One stage tubed abdominal flaps . Surg Gynecol Obstet 83 :205-9, 1946 Matev I: Surgical treatment of spastic " thumb-in-palm" deformity. J Bone Joint Surg [Br] 45 :703-8, 1963