Degloving intramuscular injuries of the semimembranosus and adductor longus muscles in adolescent soccer players.

Degloving muscle injury was described for the rectus femoris where the inner bipennate component is dissociated from its superficial unipennate component. The semimembranosus muscle displays a distinctive dual morphology, featuring both unipennate and bipennate muscle fibers. Nevertheless, this specific tear pattern has not been previously documented. Conversely, the adductor longus muscle showcases an elongated intramuscular tendon segment, indicating a multipennate morphology. We present two separate cases of previous undescribed degloving injuries of the semimembranosus and the adductor longus in teenage soccer players with MRI and ultrasound diagnosis, ultrasound-guided hematoma aspiration, and recovery timelines for return-to-play.

Honey dressing for penile skin avulsion caused by traditional circumcision: a case report.

OBJECTIVE: Penile skin avulsion is a rare complication of circumcision but commonly encountered as the result of traditional practice. We aimed to present the use of honey dressing and the benefit of its wound healing properties for management of such a complex wound. CASE: A 24-year-old male patient with penile bleeding presented to the emergency department after undergoing traditional circumcision. Complete degloving of the penis with active bleeding and foul odour, along with heavy contamination of chewed betel leaves and powdered amoxicillin was found. Honey (Madu Nusantara, PT. Madu Nusantara, Indonesia) was used as dressing after copious irrigation using saline and povidone-iodine with bleeding control. RESULTS: Honey dressing was shown to be effective for secondary wound healing of such a complicated and contaminated wound-in this case due to its antimicrobial, anti-inflammatory, immunostimulatory and autolytic debridement properties. A complete re-epithelialisation of the wound was achieved without progression to the hard-to-heal state by day 43. Suboptimal sexual function and aesthetic result due to wound contracture were observed as surgical reconstruction via split-thickness skin graft was refused due to cost. CONCLUSION: In this case report, honey dressing was shown to be effective for wound healing, even in a penile avulsion with complete skin loss and heavy contamination. In rural settings, where penile avulsion due to traditional circumcision is common, honey should be considered as one of the dressing choices.

Concealed penis in pediatric age group: a comparison between three surgical techniques.

BACKGROUND: Comparison between three different surgical techniques in the management of concealed penis. METHODS: This prospective interventional non-randomized study included 150 pediatric patients with a concealed penis. They were distributed equally into three groups; group A; patients treated by anchoring the penile skin dermis to Buck's fascia at the penile base at 3 and 9 o'clock points using PDS 5/0 (phallopexy), group B; patients treated by complete dissection and excision of dartos fascia and group C; patients treated by phallopexy as in group A after complete dissection and excision of dartos fascia. Follow-up at the end of the 1st post-operative week and then monthly for 6 months as regards penile skin congestion and/or necrosis, wound infection, edema, and/or re-retraction was carried out. RESULTS: Penile edema and re-retraction have a statistically significant difference among the studied groups (p < 0.001 and p = 0.002 respectively). Penile re-retraction was noticed to be lowest in patients of group C, however penile edema was observed to be highest in patients of group B. CONCLUSIONS: Phallopexy after complete dissection and excision of dartos fascia have better results than doing either phallopexy or dartos excision alone in the treatment of concealed penis. CLINICAL TRIAL REGISTRATION: The manuscript was registered in ClinicalTrials.gov Protocol Registration and Results System. CLINICALTRIALS: gov Identifier: NCT05565040. Our manuscript was registered on 4/10/2022.

The Morel-Lavallée lesionLavalleeLavelle.

BACKGROUND: Trauma patients present to the emergency department with various injuries. Few injuries can be easily missed during the evaluation of polytrauma patients. We report one such rare injury in a trauma patient. CASE REPORT: We report the case of a 67-year-old man who presented to the emergency department with an alleged history of trauma. He reported severe pain in the lower abdomen, right hip, and right thigh. An x-ray study did not reveal any bony injury, and an extended focused assessment with sonography in trauma was also negative. Point-of-care ultrasound of his right thigh revealed the presence of a Morel-Lavallée lesion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Morel-Lavallée lesions are post-traumatic, closed, degloving injuries that go unnoticed in many polytrauma patients. Emergency physicians should be mindful of this lesion because delay in diagnosis can result in significant complications.

Morel-Lavallée Lesion Diagnosed by Point-of-Care Ultrasound: A Case Report and Review of Treatment Strategies.

BACKGROUND: Morel-Lavallée lesions, also known as an internal degloving injuries, occur hours to months after high-speed shearing trauma, usually in the peri-trochanteric region. These are uncommon injuries, and are often missed as part of the trauma examination. Failure to diagnose or treat these lesions may result in complications, such as infected seromas, chronic cosmetic deformities, capsule formation, or skin necrosis. There are no formalized societal guidelines for management, but smaller studies have recommended compression alone for asymptomatic lesions, aspiration for small symptomatic lesions, and open debridement for large lesions. CASE REPORT: A young woman presented with swelling, fluctuance, and paresthesia to her right hip after falling off her bicycle 1 week earlier. Physical examination showed a fluctuant and hypoesthetic area over the greater trochanter and point-of-care ultrasound showed a hypoechoic and compressible fluid collection between a fascial layer and a subcutaneous layer, confirming the diagnosis of a Morel-Lavallée lesion (internal degloving injury). Symptoms did not improve with compression alone, but did improve after fluid aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Morel-Lavallée lesions are frequently missed traumatic injuries. Morel-Lavallée lesions can be diagnosed quickly and cost-effectively in the emergency department through the combination of a thorough history, physical examination, and bedside ultrasound. Although there are no formal societal guidelines, limited studies suggest management strategies, including compression, aspiration, and open debridement, with treatments varying by symptom severity and lesion size.

Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap.

BACKGROUND: Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens. METHODS: Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures. RESULTS: At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints. CONCLUSION: The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma.

Integra® Dermal Regeneration Template as an alternative technique to treat degloving injury of fingers.

Soft tissue covering of degloving injuries of fingers remains a common challenge in trauma. In this case, we report the good long-term results after the use of Integra® Dermal Regeneration Template in combination with a split-thickness skin graft as an alternative treatment option for a patient with a traumatic degloving injury of multiple fingers.

Revascularization of a Circumferential Hand and Forearm Degloving Injury Using an Arteriovenous Shunt.

Major upper-extremity degloving injuries with distal dysvascularity are rare and challenging surgical problems. When these degloving injuries occur over nonexpendable regions, such as the glabrous skin of the palm and digits, revascularization or replantation may be the treatment of choice. Because the degloved skin flap is often separated in the suprafascial plane, direct arterial repair may be impossible. We present a rare case of circumferential degloving of the hand and forearm with distal dysvascularity, treated successfully with revascularization with arterial anastomosis, venous anastomosis, and arteriovenous shunt creation. The patient required reoperation for partial flap loss and ligation of the arteriovenous fistula. At final follow-up 16 months after the injuries, she showed independence in activities, reported good functional use of the hand, and worked full-time at her original occupation.

Undiagnosed mandibular degloving following dental trauma.

A 12-year-old girl presented to the Department of Paediatric Dentistry of the Toulouse University Hospital 10 days after a facial injury, complaining of persistent pain and halitosis. Previous examinations only reported trauma of the upper incisors. Further clinical exploration showed an 8 cm laceration of the oral mucosa in the lower labial sulcus, 1.5 cm inferior to the gingival margin and exposing the symphyseal bone. The diagnosis of mental protuberance degloving was established. The treatment consisted of debridement of the wound, removal of the necrotic tissue, multiple plane sutures and antibiotics. Complete healing of the wound with no sensory deficit was achieved. Mental degloving injuries occur when a shearing force is applied to the soft tissues overlying the chin, stripping them from the labial bone. This type of wound is rare and can go undetected if a meticulous oral examination is not performed. Early management is essential so healing is not compromised.

Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered.

OBJECTIVES: To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort. DESIGN: A retrospective case-series between 2006 and 2019. SETTING: All patient care was undertaken at a regional skull base referral centre. PARTICIPANTS: Twenty-one male patients with a median age of 18 (range 16-45 years). MAIN OUTCOME MEASURES: Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence. RESULTS: The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence. CONCLUSIONS: MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

Closed Internal Degloving of the Toes: A Case Report.

Closed degloving injuries are uncommon, high-energy injuries that separate the bony structures from the soft tissue and frequently result in amputation. Because the epidermis is often intact, it is difficult to visualize the extent of the soft tissue damage. Although there is no gold standard of treatment for closed degloving injuries at present, previous cases have reported that neurovascular presentation is a key predictor of amputation Herein, we report a closed degloving injury involving the second through fifth phalanges of the left foot following a crushing injury with a forklift. Despite adequate capillary refill upon initial presentation, the patient ultimately underwent transmetatarsal amputation.

Forefoot Replantation in a 3-Year-Old Boy: Case Report.

Few reports about successful forefoot replantation in children have been published. In this article, we present a case of a 3-year-old boy with severe complete amputation of the left forefoot from a crushed and degloved injury in a motorcycle accident. The replantation was successfully performed, even though total ischemia time lasted 8 hours, of which 4 hours was cold ischemia time. The child was able to walk without significant difficulties from 4 months postoperatively and led a normal life in school at 2 years of follow-up. In this case, we present the replantation of a high-velocity traumatic partial foot amputation in a child with excellent function and cosmetic outcome.

Morel-Lavellée lesions: MRI characteristics in the pediatric patient.

BACKGROUND: A closed degloving injury is often referred to as a Morel-Lavellée lesion regardless of location despite traditionally being associated with the hip in adults. It results from a shearing injury that separates the subcutaneous layers from the fascia with fluid filling a potential space. OBJECTIVE: While the most common location and cause have been described in adults, there is limited literature in pediatric patients. We have seen pediatric Morel-Lavellée lesions commonly occurring at the knee after sports. We set out to describe the magnetic resonance imaging (MRI) characteristics. MATERIALS AND METHODS: A retrospective analysis was performed. All patients with trauma to the pelvis and lower extremities with a subcutaneous fluid collection seen on MRI were evaluated. Age, gender, mechanism of injury, time interval to imaging, and treatment were recorded. The collections were evaluated for location, size, shape and signal characteristics including the presence of fat, blood and septations. RESULTS: Twenty-one patients ages 7 to 17 years old had findings of degloving injury on MRI. The most common etiology was sports related (18/21, 85.7%). The anterior knee was most often affected (18/21, 85.7%). Lesions were ovoid and centered over the medial retinaculum (8/18, 44.4%) or lateral retinaculum (7/18, 38.9%). A capsule was weakly associated with later presentation (P=0.12). CONCLUSION: Pediatric Morel-Lavellée lesions commonly occur in a location not classically described, the anterior knee, and often after sports injury. Commonly, the collections are ovoid and always located at the subcutaneous fat/fascial interface. Recognition of specific imaging characteristics in a common location after sports injury allows for early identification. While most patients recover with conservative management, some need additional intervention with aspiration or debridement.

Deep hypothermic preservation of autologous skin in the treatment of large-area circumferential multi-plane degloving trauma: a pilot study of 2 cases.

To evaluate the clinical outcome of deep hypothermic preservation of autologous skin in the treatment of large-area skin avulsion. Medium or full thickness-skin slices were harvested from large avulsion flaps between July and November 2017. They were stored in liquid nitrogen by vitrification. After the patient's condition became stable and the growth of the wound granulation tissue was satisfactory, the frozen skin slices were reheated quickly and replanted to the wound. Autologous skin that had been kept by deep cryopreservation had a high survival rate when grafted. It did not create new trauma or bring additional pain to patients. Yet it could shorten the course of treatment and reduce the medical cost for patients. It is an effective and economical way to treat large-area skin avulsion.

Specific small bowel injuries due to prolapse through vaginal introitus after transvaginal instrumental gravid uterus perforation: a review.

A small bowel prolapse through the vaginal introitus after a transvaginal instrumental gravid uterus perforation is a surgical emergency. To define the mechanisms of an irreversible, small bowel ischaemia due to small bowel prolapse through a vaginal introitus, ClinicalTrials.gov, PubMed, PubMed Central, and Google Scholar were searched. Out of the 81 articles screened, 28 cases of a small bowel evisceration through vaginal introitus were included. A small bowel obstruction severity grading was defined with risk factors; potential mechanisms of different severity grades after a transvaginal instrumental gravid uterine perforation with a vaginal evisceration. The duration of symptoms or a delay in the diagnosis did not change the incidence of the two most severe grades-mesenteric stripping and a small bowel degloving. Both obstruction types develop immediately during an instrumental abortion. The severity of obstruction does not influence the maternal outcome.

Hidden degloving rotator cuff tears secondary to glenohumeral dislocation.

BACKGROUND: A rare form of rotator cuff tear (RCT) is observed secondary to glenohumeral dislocation, followed by immediate repositioning, as well as formation of scar tissue between tendons and tuberosities. Radiographic diagnosis of such "degloving" tears is problematic because they are obscured by scar tissue. We aimed to describe characteristics of degloving tears and report outcomes following their arthroscopic repair. METHODS: Among 67 patients who underwent arthroscopic repair of RCTs secondary to shoulder dislocation, we identified 8 patients (12%) (7 anterior dislocations and 1 posterior dislocation), aged 54.5 years (range, 38-61 years), with typical characteristics of degloving tears. Preoperative imaging revealed massive 2- or 3-tendon tears in all patients (6 with a ruptured or dislocated long head of the biceps), evaluated preoperatively and at greater than 2 years, using the absolute and age- and gender-adjusted Constant scores, Subjective Shoulder Value, and Simple Shoulder Test score. RESULTS: The absolute Constant score improved from 27 (range, 17-54) to 89 (range, 62-95). The age- and gender-adjusted Constant score improved from 31 (range, 24-57) to 97 (range, 83-100). The Simple Shoulder Test score improved from 2 (range, 0-4) to 12 (range, 9-12), while the Subjective Shoulder Value improved from 18 (range, 10-30) to 90 (range, 60-100). All patients were very satisfied (63%) or satisfied (37%). CONCLUSION: We have described a particular form of RCT secondary to glenohumeral dislocation, resulting in degloving of the rotator cuff, followed by repositioning of tendons. The formation of scar tissue can obscure tendon tears on ultrasound, in which case further imaging is recommended to ascertain the diagnosis and avoid therapeutic delays.

Penetrating Anorectal Injury Caused by a Wild Boar Attack: A Case Report.

Wild boar attacks have rarely been reported in the medical literature. This is the case of an 83-year-old male farmer who was assaulted from behind by an injured adult wild boar. He presented with hemorrhagic shock after sustaining injuries to the right profunda femoris artery and right sciatic nerve as well as significant soft-tissue injuries, bilateral iliac wing fractures, an open pneumothorax, and an anorectal injury. The anorectal injury was treated with fecal diversion but was complicated by soft-tissue infection in the surrounding dead space. The patient needed multiple operations, including removal of the distal rectum and creation of a permanent colostomy. In this report, we highlighted the characteristics of anorectal trauma caused by a wild boar attack. We conclude that penetrating anorectal injuries caused by this type of attack can be associated with extensive soft-tissue damage despite externally appearing to be simple puncture wounds. Anorectal combat injuries have demonstrated similar extensive surrounding soft-tissue injuries and propensity for infection; therefore, this case supports adopting a similar treatment strategy, that of serial and radical debridement, to treat certain wild boar injuries.

Partial medial second toe pulp free flap and dermal substitute with skin graft for salvage reconstruction of a complete skin envelope degloving of the small finger.

Skin envelope degloving of fingers are rare injuries that require rapid care and surgical treatment. Mostly caused by ring finger injuries, these traumas include bone, tendon and neurovascular pedicle damage. The authors present an unusual case of finger degloving limited exclusively to the skin envelope, without skeletal, tendinous or vascular lesion. This rare case of skin envelope degloving rendered microsurgical revascularization impossible. The authors report the results at 12 months following salvage reconstruction combining a partial second toe pulp free flap for the volar side and a dermal substitute with a thin skin graft for the dorsum.

Thumb Reconstruction With Thin Proximal Ulnar Perforator Free Flap.

Soft tissue defects of the thumb with exposure of tendons, periosteum, or neurovascular bundles require a complex reconstruction aimed at restoring both skin coverage and the essential function of pinching and manipulation. When large defects are involved, a free tissue transfer is indicated. The proximal ulnar perforator flap represents an interesting solution without the drawbacks of other more widespread free flaps. This report describes the case of a patient with a squamous cell carcinoma of the thumb that required circumferential resection of the soft tissue of the distal phalanx and the interphalangeal joint. The exposed structures were covered with pliable and texture-matching skin harvested from the proximal volar forearm and based on the proximal ulnar perforator. After 12-month follow-up, the patient was satisfied with the aesthetic outcome. Donor-site morbidity was minimal and no functional impairment in daily-life activities was reported. Even though a skilled microsurgical technique is required for the dissection of the perforator, its constant vascular anatomy and the low risk of damage to the main neurovascular bundle should make this flap reliable for the majority of hand surgeons.

Mandibular Degloving: A Case Report and Literature Review.

BACKGROUND: Degloving injuries of the extremities are well documented; however, there are few reports of degloving injuries to the mandible. A literature review demonstrates several cases of mandibular degloving in pediatric patients. However, no isolated mandibular degloving injuries have been reported in adults. CASE REPORT: We report a case of a 21-year-old male who presented to the emergency department with facial trauma after a motorcycle accident. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. Following completion of maxillofacial computed tomography after primary and secondary survey, the intraoral lesion was found to be a degloving injury of the mandible. This injury was irrigated with bacitracin and betadine before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Facial trauma is a common presentation in the emergency department. It is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. Without a high level of suspicion, such lesions may be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity.