Patterns and management of degloving injuries: a single national level 1 trauma center experience
Hakim et al. World Journal of Emergency Surgery
Patterns and management of degloving injuries: a single national level 1 trauma center experience
Suhail Hakim 2
Khalid Ahmed 2
Ayman El-Menyar 0 1
Gaby Jabbour 2
Ruben Peralta 2
Syed Nabir 3
Ahammed Mekkodathil 1
Husham Abdelrahman 2
Ammar Al-Hassani 2
Hassan Al-Thani 2
0 Clinical Medicine, Weill Cornell Medical College , Doha , Qatar
1 Clinical Research, Trauma Surgery Section, Hamad General Hospital , Doha , Qatar
2 Trauma Surgery Section, Hamad General Hospital , Doha , Qatar
3 Department of Radiology, Hamad General Hospital , Doha , Qatar
Background: Degloving soft tissue injuries (DSTIs) are serious surgical conditions. We aimed to evaluate the pattern, management and outcome of DSTIs in a single institute. Methods: A retrospective analysis was performed for patients admitted with DSTIs from 2011to 2013. Presentation, management and outcomes were analyzed according to the type of DSTI. Results: Of 178 DSTI patients, 91 % were males with a mean age of 30.5 ± 12.8. Three-quarter of cases was due to traffic-related injuries. Eighty percent of open DSTI cases were identified. Primary debridement and closure (62.9 %) was the frequent intervention used. Intermediate closed drainage under ultrasound guidance was performed in 7 patients; however, recurrence occurred in 4 patients who underwent closed serial drainage for recollection and ended with a proper debridement with or without vacuum assisted closure (VAC). Closed DSTIs were mainly seen in the lower extremity and back region and initially treated with conservative management as compared to open DSTIs. Infection and skin necrosis were reported in 9 cases only. Open DSTIs were more likely involving head and neck region and being treated by primary debridement/suturing and serial debridement/washout with or without VAC. All-cause DSTI mortality was 9 % that was higher in the closed DSTIs (19.4 vs 6.3 %; p = 0.01). Conclusion: The incidence of DSTIs is 4 % among trauma admissions over 3 years, with a greater predilection to males and young population. DSTIs are mostly underestimated particularly in the closed type that are usually missed at the initial presentation and associated with poor outcomes. Treatment guidelines are not well established and therefore further studies are warranted.
Degloving; Soft tissue injury; Debridement; Management; Trauma
Degloving soft-tissue injuries (DSTIs) are often serious
surgical conditions characterized by avulsions or
detachment of the skin and subcutaneous tissue from the
underlying muscle and fascia secondary to a sudden shearing
force applied to the skin surface [
]. DSTIs are more
commonly observed in males due to disproportionately higher
burden of traumatic injuries [
]. Although it may occur
anywhere in the body, the main sites of DSTIs are lower
extremities, trunk, scalp and face with a variable amount
of skin and soft tissue loss [
]. DSTIs could be
categorized as either closed/internal or open/external lesions [
Delayed diagnosis and treatment of these injuries often
result in full-thickness necrosis due to jeopardized blood
supply to the avulsed skin flap [
]. Moreover, patients with
severe DSTI could develop infection or even necrotizing
fasciitis due to mismanagement leading to high morbidity
and mortality [
DSTIs are mostly underestimated lesions due to lack
of clinical diagnostic and prognostic indicators and well
established treatment guidelines. In addition, the marked
variability in the type, magnitude and severity of DSTI
makes it difficult to set a standard management and to
predict outcomes. In closed or internal degloving injury
the shearing forces create a cavity which subsequently
gets filled with hematoma and liquefied fat [
closed internal degloving lesions usually develop over
the greater trochanter and are known as Morel-Lavallee
The DSTI treatment varies considerably from close
observation to active interventions such as early primary
definitive skin closure, superior skin cover, early return
of function and secondary procedures, if needed [
However, distinction between viable and nonviable
tissues may be difficult during early wound management in
both types of injuries [
]. Since, every injury is unique
with variety of lesions; it is difficult to develop an
appropriate decision-making algorithm for treatment and
therefore, the outcome of DSTI often remains
underestimated. Interestingly, there is a paucity of information on
DSTI from our region in the Arab Middle East. In this
study, we retrospectively reviewed the frequency,
pattern, management and outcome of DSTIs from a single
institute over a 3-year period in Qatar.
Data were acquired retrospectively for all DSTI patients
identified from the trauma registry database who were
admitted to the section of trauma surgery at Hamad general
hospital (HGH) between January 2011 and November
2013. HGH is the only Level 1 trauma center facility in
Qatar which admits and treats all traumatic injury
patients. DSTIs are defined as avulsion of soft tissue, in
which an extensive portion of skin and subcutaneous
tissue is detached from the underlying fascia and muscles
]. We mainly diagnosed DSTI by clinical assessment,
ultrasound and CT scanning. DSTI are classified as either
open or closed. In an open DSTI, the skin is torn off the
body though it may still be attached as a flap. Closed DSTI
are soft tissue injuries with disintegration of the
underlying layers in which the subcutaneous tissue is torn away
from the underlying fascia, creating a cavity filled with
hematoma and liquefied fat (i.e., Morel-Lavallée lesion).
We excluded patients in whom the skin is completely
detached as these are considered open wounds rather than
DSTIs. Patients with open wounds are more likely to
require some form of advanced soft tissue coverage. On
arrival, all patients underwent thorough clinical assessment
and resuscitation according to Advanced TRAUMA Life
Support (ATLS) guidelines. Collected data included age,
gender, mechanism of injury, injury severity score (ISS),
type of degloving injury (open and closed), anatomical
location (head, neck, back, limbs, abdomen and
perineum), associated injuries, comorbidities, laboratory
findings, blood transfusion and management [primary
debridement/suturing; initial conservative treatment;
serial debridement and washout with or without vacuum
assisted closure (VAC)]. The term (early) vs (late) was
used based on the initial treatment after the initial
assessment. Complications (infection, skin necrosis and
flap necrosis), discharge disposition (plastic surgery or
rehabilitation), length of stay and mortality were also
reported. Baseline demographic characteristics, mechanism
of injury, site of injury, associated injury, management,
and outcomes were also compared according to open and
closed type of DSTIs.
Data were expressed as proportions, medians, or mean ±
standard deviation (SD), as appropriate. Differences in
categorical variables between respective comparison groups
were analyzed using Chi-Square test or Fisher exact
(observed cell values less than 5) test for categorical variables.
The continuous variables were analyzed using student’s
ttest. Two-tailed p values < 0.05 were considered to be
significant. Multivariate analysis was performed to look for
ISS whether it has a prognostic role or not in both types
of DSTIs. Data analysis was carried out using the
Statistical Package for Social Sciences version 18 (SPSS Inc.
Chicago, Illinois, USA).
A total of 178 patients with DSTIs were included in this
study who was admitted to the Section of Trauma Surgery
during three years period. The mean age of patients was
30.5 ± 12.8 years, and the majority were males (91 %) and
expatriates (83.3 %). Demographics, clinical presentation,
laboratory findings and type of DSTI are presented in
Table 1. Motor vehicle crash (MVC) was the leading
mechanism of injury (54.5 %) followed by falls from height
(12.9 %) and pedestrian injuries (12.4 %). Lower extremity
(40.4 %), head (23.0 %), upper extremity (19.1 %) and
pelvis (16.9 %) were the most frequent associated injuries.
Co-morbidities included diabetes (3.4 %) and hypertension
(1.7 %). The median myoglobin level was 846 with a range
from 21 to 6698 ng/ml. A higher proportion of cases
sustained open/external type (79.8 %) DSTI followed by
closed/internal type (20.2 %). The most frequent anatomic
site of DSTI was lower extremity (44 %) followed by head/
neck (37.3 %) and back (13.5 %) region (Fig. 1).
Table 2 shows the laboratory results, management,
complications and outcome according to the type of
degloving injury. Figures 2 and 3 show examples of open
and closed degloving injuries.
The blood transfusion was needed primarily for
associated injuries, rather than the degloving injury per se.
Primary debridement and closure (62.9 %) was the main
intervention for DSTI cases followed by serial
debridement and washout with or without VAC (19.1 %).
Intermediate closed drainage was done under ultrasound
guidance for 7 cases out of which recurrence observed
in four cases that had to undergo closed serial drainage
for recollection. The definitive treatment for these
patients was finally a proper debridement with or without
VAC. One patient had undergone serial drainage over a
period of three months before final resolution. Initial
conservative management was adopted in 28 (15.7 %)
patients. Late flap (i.e., serial debridement that
eventually required rotational skin flap to close the defect)
coverage was needed in 22 (12.3 %) cases. In those who
underwent serial debridement some of them required
closure by secondary suturing and others left to heal by
secondary intention. Complications such as infection
and skin necrosis were observed in 3.9 % and 1.1 %
cases, respectively. Plastic surgical referral was sought
for 26 (14.6 %) patients. The median hospital length of
stay was 10 (1–393) days.
There were no differences between the two groups with
respect to age, gender, mechanism of injuries and
associated injuries. However, the frequency of pelvic fracture
was significantly higher in the closed group (30.6 % vs.
13.4 %; p = 0.01) as compared to open DSTI. Regarding
the anatomic site, DSTI at the lower extremity (63.9 % vs.
39 %, p = 0.007) and back (33.3 % vs. 8.5 %, p = 0.001)
region were significantly higher in closed group compared
to open group. In contrast, head (scalp) and neck region
were mainly affected in the open group of degloving
injuries (46.1 % vs. 2.8 %, p = 0.001) than closed group.
In comparison to closed DSTI, patients in open group
were more likely to be treated by primary debridement/
suturing (73.9 % vs. 19.4 %, p = 0.001) and serial
debridement and washout with or without VAC (23.2 % vs.
2.8 %, p = 0.003). On the other hand, the frequency of
initial conservative management (77.8 % vs. 0 %, p =
0.001) was higher in patients with closed group when
compared to open DSTI. There was no significant
difference in terms of complications or discharge dispositions
between the two groups. The overall mortality was 9.0 %
(n = 16) and around half (n = 7) of them died within the
first 24 h of admission due to severe associated injuries.
Moreover, the mortality rate was significantly higher in
the closed group (19.4 % vs. 6.3 %, p = 0.01) as compared
to open DSTI group. The mean ISS was greater in the
closed DSTI in comparison to the opened type of DSTI
(16.5 ± 13.04 vs 13.11 ± 10.2; p = 0.09). Multivariate
analysis showed that ISS is a predictor of mortality in closed
DSTI (Odd ratio 1.2; 95 % confidence interval 1.06-1.35;
p = 0.004), however, this effect on mortality was not
observed in the opened type of DSTI (Odd ratio 1.07; 95 %
confidence interval 0.99-1.45; p = 0.07).
This is a unique study from the Arab Middle Eastern
region which provides an insight on the frequency,
patterns, management and outcome of DSTIs among
trauma patients in Qatar. This is a large single-institution
study which enrolled 178 patients as compared to earlier
descriptive studies [
]. Our study shows that the
incidence of DSTI is around 4 % with a greater predilection to
males and young patients. Three quarter of the cases is
traffic-related injuries. It has significant implications for
the treatment and final outcome of our trauma patients.
Most of the current literature on DSTI is mainly based on
specific anatomic regions and are usually drived from case
series or case reports. An earlier study from South Africa
reviewed 16 cases with closed degloving injuries treated
during one-year period [
]. Another study from Pakistan
demonstrated the pattern of degloving injuries in 50 cases;
of which majority sustained open type of degloving
]. Consistent with small number of cases, Milcheski
et al. [
] reported 21 patients with degloving injuries
from Brazil. In the present study, majority of the DSTI
patients were young males which reflect the
disproportionately higher burden of road traffic injuries in Qatar. Our
findings are consistent with previous reports, which also
documented a higher involvement of young males (88 %)
in road traffic injuries [
DSTIs are often associated with severe concomitant
injuries and massive blood loss [
Early diagnosis of DSTI remains challenging as the
initial clinical evaluation could not predict avulsion of
underlying soft tissue particularly in the closed DSTI [
the other hand, prompt recognition of these injuries are
crucial as treatment may be time consuming and such
delay may increase the risk of infection or progression to
necrotizing fasciitis. Severity of DSTI mainly depends on
the mechanism of injury, comorbidities (particularly
Diabetes mellitus), concomitant injuries, anatomic site and
type (open or closed) of DSTI [
]. Our study showed
MVC to be the most common cause of DSTI with
frequent involvement of lower limb and head/neck regions.
Consistent with our findings, several studies have
demonstrated a higher association of lower limb DSTI and MVC
]. Similarly, Khan et al.  reported that higher
frequency of young males (74 %) had degloving injuries of
the lower limb. The present study also showed greater
frequency of open DSTI which mainly affect head (scalp)
and neck region. Although, less frequent closed DSTI
were mainly associated with lower extremity and back.
Contrarily, an earlier study reported greater involvement
of open type (94 %) in patients with degloving injuries of
the lower limb [
]. The present analysis showed that ISS
was greater in the closed DSTI in comparison to the
opened type, moreover ISS was found as a predictor of
mortality only in the closed type of DSTIs.
Diagnosis of DSTI can be made by clinical assessment
of fluctuant area as well as using imaging modalities
such as ultrasonography, computed tomography (Fig. 4)
and magnetic resonance imaging (MRI) [
]. Open DSTI
is clinically self-evident condition that usually presented
as a soft tissue loss of variable extent together with
avulsed skin, subcutaneous tissue flaps from the
underlying deep tissues which is the hallmark of physical finding
together with overlying abrasion, ecchymosis or skin
]. However, the diagnosis of closed DSTI is
usually difficult and can be missed on the initial clinical
evaluation and require radiological investigation for accurate
diagnosis. Closed degloving injury with suspected
MorelLavallée lesions (Fig. 4) could be diagnosed by CT scan,
however, evaluation using MRI is more informative [
As ultrasound typically shows these lesions as anechoic or
hypoechoic, with or without echogenic foci or even fluid/
fluid levels. Therefore, for such cases MRI is the modality
of choice which clearly determines the relationship of the
collection with the underlying fascia [
Direct injury to the cutaneous layers may result in
necrosis of the skin overlying the degloved area. It can also
occur on a delayed basis secondary to swelling of the
degloved cavity, resulting in ischemia of the overlying
]. To prevent potential complications such as,
secondary infection and necrosis, early diagnosis and
intervention are needed. In our series, skin necrosis was
developed only in two cases with open DSTI and was
not evident in the closed type of injuries. Although, skin
necrosis was commonly considered as a complication of
closed degloving injury, it was not observed in any of
the patients in our series.
The primary management approach for DSTI ranges
from optimal preservation of individual structure to
early primary definitive skin cover, superior skin cover,
early return of function and secondary procedures, if
]. Particularly, various modalities for the
treatment of open DSTI include simple debridement with
repair to more complex procedures like flaps, skin grafts,
free tissue transfer, replantation or revascularization
depending on the site, extent, severity and availability of
the treatment. In our series, nearly 74 % of the cases
with the open type and 20 % of the closed type of DSTI
underwent primary debridement and closure. Plastic
surgery consultation was sought in 26 (23 open and 3
closed) DSTIs cases due to wound complexity which
necessitated a complex wound management including flap
coverage and skin reconstruction.
Vacuum-assisted closure is an advanced management
therapy often used to cover open degloving wounds of the
]. Utility of this device to develop the
wound bed for grafting gained wide applicability which is
directly applied to the wound to promote granulation
tissue formation and skin grafting [
]. The present study
showed that thirty four patients who needed serial
debridement and washout due to re-accumulation were
benefitted with an early wound closure from VAC therapy.
Management of closed DSTI is more challenging due
to lack of evidence-based guidelines, these injuries are
either treated by non-operative therapy or percutaneous
and operative techniques. In our study, majority of
patients with closed DSTI (78 %) underwent conservative
treatment. Hak et al [
] performed open debridement of
the Morel-Lavallée lesion with the incision placed close
to the middle of the degloved area with thorough
exploration for possible loculations. However, due to high
incidence of complications such as re-accumulation of
hematoma, wound breakdown and infection, the authors
left the wound open post debridement [
retrospective study by Nickerson et al [
] reported various
treatment options for Morel-Lavallée lesions or closed DSTI
such as compression wraps or observation, percutaneous
aspiration or operative management with
incision/drainage and formal debridement of skin and soft tissues. The
authors observed that aspiration of more than 50 mL of
fluid from Morel-Lavallée lesions was more frequent
among lesions that recurred (83 %) as compared to
those that resolved (33 %). Therefore, it has been
recommend that aspiration of more than 50 mL of fluid from
a Morel-Lavallée lesion should prompt operative
]. However, data of Morel-Lavallée
lesions were not documented in the present series.
Although, we did not quantify the initial drained amount
of fluid in simple drainages, recurrent collection was
observed in patients with initial copious drainage. Such
patients should undergo repeated drainages and ultimately
required proper debridement. The mortality rate was
higher in closed type of degloving injuries. Notably, severe
associated injuries such as traumatic brain injury and
pelvic fracture were predominant in fatal cases which in fact
were the contributing factors for increased mortality in
closed DSTI. In addition, severe associated injuries may
also lead to increased hospital length of stay.
The retrospective nature of the present study is one
limitation. Detailed intervention and management of
specific anatomical injuries were not well elaborated and
the exact volume and the amount of fluid in the
degloving injuries were available only for 37 cases based on
computed tomography findings. Moreover, despite 11
cases with pelvic fracture had closed DSTI,
MorelLavallée lesions were not documented which could be
due to delayed diagnosis secondary to possible
inconsistent clinical presentation. Lastly, this study lacks the
exact details of the radiological investigation particularly
for closed DSTI as the initial diagnose was primarily
based on the clinical assessment. The tissue viability of
the open/closed degloving injury, which is supposed to
be a key factor relating to morbidity, mortality and
ultimate result, was lacking in the available registry data
and need further prospective work to be addressed. The
time frame of management was not given in the
Diagnosis of degloving injury is a challenge as initially
the emphasis concentrates on the most urgent life and
limb threatening issues. Also the fact that some of these
injuries are initially subtle and tend to deteriorate over
time to become obvious as swelling or skin changes and
for that some lesions can be missed and diagnosed at
late stage. Although modern imaging like CT and MRI
can pick these injuries early, they are not asked for that
particular indication and it is commonly observed that
the radiologic report of these images underestimate or
not properly comment on these injuries which are
considered as less important incidental injuries of the
subcutaneous tissue and unless we change our stand and
start to think of it ahead, document and communicate
proactively with the radiologist and multidisciplinary
treating teams; the same challenges won’t be fixed. Early
diagnosis and on-time management of degloving injury
depend on a high index of suspicion, clear protocols and
guidelines on the approaches of management,
standardized diagnostic criteria, and more reliance on clinical
guidance of imaging technology. Current evidence
support the use of MRI to diagnose, characterize and guide
treatment and follow up, whereas ultrasound tends to be
useful at later stage and or for follow up.
The incidence of DSTI is around 4 % with greater
predilection to males and young patients in our series.
Three quarter of the cases is traffic-related injuries.
DSTI injuries are mostly underestimated lesions, with
higher association of morbidity and mortality, if
mismanaged. Open DSTI are more likely to be associated
with head and scalp region whereas closed type are
evident in lower extremity injuries and pelvic fractures. A
high index of suspicion is crucial for the diagnosis and
management of closed DSTI as it needs a
multidisciplinary tailored approach. Moreover, the lower incidence of
skin complication could probably attribute to the early
interventions. To provide appropriate care for these
patients, early tissue restoration and effective rehabilitation
are crucial. Still, the treatment guidelines for DSTI are
not well established; so further studies are needed to
resolve controversial issues for DSTI grading and optimal
diagnostic and treatment approaches guided by
The authors thank the entire registry database team in the Trauma Surgery
Section, SICU and TICU staff, Hamad General Hospital, Doha, Qatar. All
authors have declared no conflict of interest, no financial issues to disclose
and no funding was received for this study. All authors contributed to the
creation of and approved the manuscript.
This study was presented in part at 17th Congress of the European Society for
Trauma and Emergency Surgery in Austria, Vienna from April 24 – 26, 2016.
SH was involved in study design, data acquisition, writing manuscript and
review, KA: data acquisition, interpretation and drafting manuscript; GJ: data
acquisition, interpretation and drafting manuscript; AE: study design, data
analysis and interpretation, drafting and critical review of manuscript; RP:
data interpretation, drafting and review of manuscript; SN: data acquisition,
data interpretation, and review manuscript; AM: study design, data
interpretation, and manuscript drafting; HA data analysis and interpretation,
drafting and manuscript review; AA: data interpretation, drafting and review
of manuscript and HA study design, data interpretation and critical review.
Data availability: anonymous data will be available after getting permission
according to the medical research center (MRC) policy at HMC, Qatar;
. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
The Medical Research Center (IRB#13441/13) at Hamad Medical Corporation,
Qatar, approved the study and has therefore been performed in accordance
with the ethical standards laid down in the 1964 Declaration of Helsinki and
its later amendments. A waiver of consent was granted as there was no
direct contact with patients and all data were collected from the chart
review of the prospectively data collected trauma registry.
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