Abstract
Dermal substitutes such as Integra® have been used in surgery since 1981. This product was developed to cover large skin burns but it may have a role in reconstructive upper limb surgery. In upper extremity avulsion, the choice of skin cover depends on many variables. Dermal substitute is an alternative when split-thickness skin grafting is appropriate. We present a case of severe upper limb avulsion, or ‘degloving’, in a child of 9 years old which was treated successfully with Integra. Integra® is particulary useful in growing children to cover large skin losses.
Extensive avulsion injuries of the upper limb are usually the result of traffic accidents or industrial injuries. The skin and subcutaneous tissue loss exposes the underlying fascia, tendons and muscles, which may also be severely damaged. Adequate skin cover must be achieved to restore function and is largely achieved by split skin grafting, except where vital parts of deeper structures are exposed and/or repairs of these structures are necessary. The cosmetic result both at the primary site and the graft donor site are a concern and are often poor. Although these injuries are uncommon in children, the future limb growth after grafting can be a problem.
Dermal substitutes were primarily developed to cover large skin burns (Heimbach et al., 2003; Yannas and Burke, 1980) and appear to be a good alternative to full-thickness skin grafting (Dantzer and Braye, 2001). Dermal substitutes have also been used to resurface free flaps (Moore et al., 2003), to close chronic or acute wound (Moore et al., 2003; Jeschke et al., 2004), after release of post-burn contractures (Frame et al., 2004; Hunt et al., 2000), in the treatment of giant congenital naevi (Abai et al., 2004) and, more recently, in trauma cases (Wolter et al., 2005). This resurfacing technique is safe. It can be used in children (Lorenz et al., 1997; Ozerdem et al., 2003; Young and Burd, 2004) and has been claimed to give better results than other methods of wound coverage, both from a cosmetic and functional point of view (Dantzer et al., 2001; Frame et al., 2004).
This report presents a case of severe degloving of the upper limb in a child of 9 years old and its successful management with Integra, a dermal substitute.
CASE REPORT
A nine year-old boy suffered a severe degloving injury in a road traffic accident (Fig 1). The degloving injury included total avulsion of the skin and the subcutaneous tissues of the distal third of the anterior aspect of the arm, the flexor aspect of the forearm, the radial side of the wrist and the thumb. He had a partial humeral condylar fracture. There was also damage to the biceps brachialis muscle, the brachialis muscle, the brachio-radialis muscle and the soft tissues of the flexor aspect of the elbow. The thumb was almost entirely degloved, excepting the distal phalangeal segment. The pulp and the nail were preserved. The metacarpophalangeal joint and the inter-phalangeal joint of the thumb were open. The median and ulnar nerves were also intact.
At the initial operation, an external fixation device was applied to stabilise the elbow in 70° angle of flexion (Fig 1) and a partial lesion of the radial artery was repaired. He underwent three further debridements over a period of one week to achieve complete cleaning of the wound. At this stage, there were no signs of infection and bacterial swabs were negative.
At a fourth operation, on day 10, a pedicled groin flap was used to cover the open joints of the degloved thumb (Fig 2). This was stabilised by linking the upper limb external fixator to the iliac crest. At this operation, the skin loss of the arm and forearm defects was replaced by three pieces of Integra®, an artificial dermal substitute. Prophylactic antibiotics were started pre-operatively. The dressing was changed every day to check for infection and serous effusion but no postoperative exudate or infection occurred.
Three weeks later, the silicone layer of the Integra® was peeled off (Fig 3), and a split-skin graft from the scalp was applied to the dermal substitute (Fig 4). To obtain a better cosmetic results, the graft was not meshed. At the same procedure, the pedicle of the groin flap was divided. The graft and the donor site were dressed. Complete skin healing was achieved in a further fifteen days without graft necrosis. The patient was discharged at 40 days. At this time, physiotherapy was started and a compression garment manufactured and fitted.
Three months later, an area of flap necrosis appeared on the dorsal part of the thumb, exposing the interphalangeal joint and half of the proximal phalanx. The distal part of the proximal phalanx, was resected with arthrodesis of the interphalangeal joint. Later, the thumb also required a flexor tenolysis and the web space required a release and Z plasty.
At 18 months, this resurfacing technique had achieved skin cover with no adhesion to the deep tissues, excepting a small area measuring 4 × 2 cm on the flexor aspect of the arm. The cosmetic result was satisfactory with acceptable skin colour in comparison to the original skin remaining on the arm and forearm (Figs 5 and 6). The artificial dermal substitute gave strength and elasticity to the resurfacing skin graft. The elbow had a range of motion of 120°. The forearm supinated to 60° and pronated to 70°. The wrist remained stiff, with a range of 100° from 60° of flexion to 40° of extension. Thumb mobility remained restricted, particularly in respect of flexion and opposition movements.
DISCUSSION
Split thickness skin autograft provides thin skin cover which is not only cosmetically poor in many instances but is also inadequate cover of open joints, bare bone and tendon, major nerves and repairs of the vital structures. Full thickness skin graft is in some ways better but is insufficient in amount for skin defects of this size. Previously expanded full thickness skin grafts have been used to treat the sequelae of burn injuries (Foyatier et al., 1995) but this technique requires a delay of 2 to 3 months to obtain the desired amount of skin.
Integra (LifeSciences Corporation, Plainsboro, USA) is a 2-mm thick layer composed of a crosslinked collagen and chondroitin-6-sulphate dermal replacement layer silicone temporary epidermal substitute (Yannas and Burke, 1980). As soon as the dermal matrix is grafted onto the wound, this dermal substitute acts as a template for new dermis formation and a split skin graft may be applied within 2 to 3 weeks. The Integra constitutes a barrier against infections during the 3 weeks necessary for the matrix to be ready to receive the skin graft.
Unglaub et al. (2005) pointed out a major advantage of Integra® in reconstructive surgery: it is immediately available and in large quantities. They also pointed out various disadvantages: a need for two operations, risk of infection, high price and time-consuming dressing changes. However, Integra is preferable to split skin graft alone for cover of large degloving injuries affecting muscles, vessels and nerves. It allows the use of a single method of cover, involves simpler operating procedures and gives a more homogeneous cosmetic result. The artificial dermal component has the capacity to limit adhesions to the deeper structures and, also, reduce wound contractures and hypertrophic reactions (Chou et al., 2001; Frame et al., 2004). By limiting adhesion to the deep structures, it creates a thicker and stronger final ‘skin’, more akin to a full thickness skin graft or a flap than a split skin graft. Because of these properties, the new skin also facilitates physiotherapy and allows limb growth . In our case, the quality of the skin allowed earlier and easier rehabilitation of the limb.
Dantzer and Braye (2001) used Integra® for the reconstruction of full-thickness skin defects after release of burn scar contractures with excellent functional and cosmetic result. During the follow-up period of 3 month to 3 years, the range of motion and function were stable. Frame et al. (2004), in a multicentre evaluation of the use of Integra with a variety of adjunctive therapies, including splinting (64%), physiotherapy (57%) and pressure garments (46%) in burn patients, reported good results with satisfying cosmetic results, including soft skin without adherence to the deeper tissues and the appearance of normal skin creasing.
As in our case, Wolter et al. (2005) used Integra® to cover an avulsion injury of the upper extremity in a young man with an excellent functional and aesthetic outcome at 6 month follow-up. Our middle term results of use of Integra demonstrate that this artificial dermis with split skin graft is a good alternative cover for large upper limb avulsions, particularly in children, in whom split thickness skin is inadequate and extensive reconstructive free flaps are not available or necessary.