Hidalgo D A
Clin Plast Surg. 1986 Oct;13(4):701-10.
Avulsion injuries are best treated by removal of the avulsed tissue and replacing it as a full-thickness skin graft. Additional meshed split-thickness skin grafts from a separate donor area may be necessary to complete the soft-tissue coverage. Fractures commonly accompany avulsion injuries and require appropriate treatment. The atypical avulsion injury is a special problem that occurs infrequently but results in considerable morbidity. This injury is most commonly seen in individuals run over by heavy vehicles, particularly buses. The shearing forces involved cause extensive undermining of tissues, although the external surface of these areas appears uninvolved. This results in an under-estimation of the true extent of the injury. If not recognized, there may be either delayed full-thickness necrosis of large areas of skin and subcutaneous tissue or the development of sepsis due to deep necrosis of the fat and fascia at the shear plane. If the true extent of injury is initially recognized, a dilemma exists in terms of deciding how much of the normal-appearing tissue to excise. The proper treatment plan for the atypical injury is not yet established with certainty. However, quantitative dermofluorometry has proven to be a valuable means of assessing the viability of extensively undermined areas of skin and subcutaneous tissue. This test is easily performed and can be used for serial study. Viable areas that are undermined and left in place require an early limited debridement of the undersurface to remove necrotic fascia and subcutaneous fat. This may require additional incisions for exposure. Plantar avulsions are another separate category of avulsion injury. Traditionally, the avulsed plantar surface has been sewn back into place, although this frequently resulted in the loss of this specialized tissue. It has become clear that it is possible to revascularize the plantar surface when major avulsion injuries occur. The plantar surface is thus similar to digital amputations and major scalp avulsion injuries in that replantation or revascularization is worthwhile and should be performed whenever possible. Soft-tissue loss around the ankle frequently co-exists with these injuries, and free tissue transfer may be necessary to complete soft-tissue coverage following revascularization.
撕脱伤的最佳治疗方法是切除撕脱组织，并将其作为全厚皮片进行移植。可能需要从单独的供皮区获取额外的网状中厚皮片，以完成软组织覆盖。骨折常伴有撕脱伤，需要进行适当治疗。非典型撕脱伤是一个特殊问题，虽不常见，但会导致相当高的发病率。这种损伤最常见于被重型车辆碾压的个体，尤其是公交车。所涉及的剪切力会导致组织广泛潜行剥离，尽管这些区域的外表面看似未受影响。这会导致对损伤的真实范围估计不足。如果未被识别，可能会出现大面积皮肤和皮下组织的延迟性全层坏死，或者由于剪切平面处脂肪和筋膜的深部坏死而发生败血症。如果最初能识别损伤的真实范围，在决定切除多少外观正常的组织方面就会陷入两难境地。非典型损伤的正确治疗方案尚未完全确定。然而，定量皮肤荧光测定法已被证明是评估皮肤和皮下组织广泛潜行剥离区域活力的一种有价值的方法。该测试操作简便，可用于系列研究。潜行剥离但保留原位的存活区域需要早期对其下表面进行有限清创，以清除坏死的筋膜和皮下脂肪。这可能需要额外的切口以进行暴露。足底撕脱伤是另一类单独的撕脱伤。传统上，撕脱的足底表面会被缝回原位，尽管这常常导致这种特殊组织的丢失。现在已经明确，当发生严重撕脱伤时，足底表面有可能实现血管再通。因此，足底表面类似于手指离断和严重头皮撕脱伤，即再植或血管再通是值得的，应尽可能进行。踝关节周围的软组织缺损常与这些损伤并存，血管再通后可能需要进行游离组织移植以完成软组织覆盖。
