Traumacenter Linz, Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria.
Plastic, Aesthetic and Reconstructive Surgery Sanitaetsbetrieb South Tyrol (SABES), Bolzano, Italy.
Clin Hemorheol Microcirc. 2019;71(4):403-414. doi: 10.3233/CH-199004.
Degloving injuries of the fingers and especially the thumb are highly demanding problems in hand surgery and replantation often is not successful because of severe soft tissue contusion. Only few cases of successfull replantation for hand degloving injuries in thumbs are reported in literature.
We present the case of a young right hand dominant worker experiencing an occupational accident with a circumferential avulsion of his right thumbs' soft tissue at the level of the metacarpophalangeal (MCP) joint with complete skeletization of his thumb and a deep laceration of the nail bed as he got trapped in a machine.Bony structures and tendons remained intact corresponding Urbaniak class III/Kay class IV injury. Immediate defect coverage by replantation was performed.Additionally, a deep palmar soft tissue defect to his middle finger pulp and a laceration with disruption of his eighth finger nerve on his ring finger was adressed by revision, debridement, direct coaptation of the nerve and occlusive dressing to the middle finger.The patient regained full function and excellent cosmesis without nail deformity but only protective sensibility. He is back to his former sports and occupation.
Though sensitive outcome is poor we recommend primary attempt for defect coverage with replantation following degloving to achieve pliable skin coverage and good cosmesis. Especially in Urbaniak III cases with complete soft tissue degloving lacking fractures or tendon lacerations good functional outcome is possible but we recommend to consent the patient in advance for other reconstructive options and give them realistic exspectations in case of failure.Contrary to popular belief replantation of completely degloved fingers is more than saving nonfunctional parts as motivated patients are able to get back to previous sports and occupation after successful replantation.
手指，尤其是拇指的脱套伤是手外科的棘手问题，再植往往因严重的软组织挫伤而不成功。文献中仅报道了少数拇指脱套伤再植成功的病例。
我们报告了一例年轻的右利手工人在职业事故中受伤的情况，他的右手拇指在掌指关节（MCP）水平处的软组织被环形撕脱，拇指完全骨骼化，甲床有严重的裂伤，因为他被机器夹住了。骨结构和肌腱保持完整，符合 Urbaniak Ⅲ级/Kay Ⅳ级损伤。立即进行再植以覆盖缺损。此外，他的中指指腹有一个深部掌侧软组织缺损，无名指的第八指神经有一个裂伤并中断，我们对其进行了修复、清创、直接神经吻合和中指闭合敷料。患者恢复了全部功能和良好的美容效果，没有指甲畸形，但只有保护性感觉。他回到了以前的运动和职业。
尽管敏感的结果较差，我们仍建议在脱套伤后立即进行再植以覆盖缺损，以获得柔韧的皮肤覆盖和良好的美容效果。特别是在 Urbaniak Ⅲ型病例中，完全的软组织脱套伤，没有骨折或肌腱撕裂，有可能获得良好的功能结果，但我们建议提前征得患者同意，考虑其他重建方案，并在失败时向患者提供现实的预期。与普遍看法相反，完全脱套的手指再植不仅仅是为了保存无功能的部分，因为成功再植后，有动力的患者能够恢复以前的运动和职业。
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