# "DEGLOVING"



## George Wallace (28 May 2007)

DEGLOVING

I think that with some of the discussion that is going on about protective clothing and whether or not it is required, it is time for someone with the knowledge and experience to explain to the many here what "degloving" is.  To explain how it happens, as well as the effects it has on the body and what it will mean to medical staff treating the 'injured' who may survive.  It is a gross topic to cover, but may bring home the reason protective gear is made and why it must be worn.  Having all the flesh and muscle torn off your bones is a major concern that should be explained to the unknowing.


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## RHFC_piper (28 May 2007)

I have actually witnessed 'degloving' in a civilian workplace... Twice... it was pretty gross to see, both times.  Can't wait to read the input from the med types here.

Personally, what I've learned from both experiences; Don't wear rings / watches in a machine shop, and don't reach into a winding machine when it's running at 4500 rpm.


good topic.


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## Greymatters (28 May 2007)

Not pretty, and it certainly doesnt reflect the difficulty of the process when combined with combat injuries.


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## RHFC_piper (28 May 2007)

If there are any PMeds out there who have delt with this, either during operation or otherwise, what is the prescribed treatment for this injury?


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## GAP (28 May 2007)

I have not worn rings for 40+ years after seeing my work companion loose all the flesh on his finger when an ore car caught his ring as it was being tipped sideways to dump its' load.

Having been hung up by a watchband on my way down a ladder, eliminated that piece of jewelry from my wardrobe also. Nothing serious happend in this incident, but the possibilities scared the bejesus out of me.


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## HItorMiss (28 May 2007)

Piper PMed's don't deal with that type of medicine. The regular Med A's do though I am sure they will chime in here soon enough.


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## RHFC_piper (28 May 2007)

HitorMiss said:
			
		

> Piper PMed's don't deal with that type of medicine. The regular Med A's do though I am sure they will chime in here soon enough.



Roger that.

Either way; I was just wondering if throwing some gause on it was a good idea or not... it's not like it requires a tourniquet, and I don't think a puncture wound bandage would do the trick... but I figured the gause would just stick to the icky bits (ie, the whole hand).  In each experience I had with these types of wounds, the extent of my involvement was hitting the big red stop button on the machines and letting the shop managers take over.


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## Armymedic (29 May 2007)

This would be an excellent first question for the Q&A thread above: http://forums.milnet.ca/forums/threads/62712/post-571419.html#msg571419

A degloving injury is an avulsion of the skin of the hand (or foot) in which the part is skeletonised by removal of most or all of the skin and subcutaneous tissue.

Basically skin and underlying tissue is ripped of exposing part of the skeleton underneath. Most common cause is a finger ring being caught and pulling all the skin off that finger. But it can happen to feet as well.

Treatment:
-control the bleeding by covering the wounded area and use direct pressure. As the most common degloving injury is a finger, direct pressure will work. 
-cover the wound and splint in position of function. Splint and brace as req'd for patient comfort.

Tourniquet probably would not be useful in this injury the wound is generally below the wrist or ankle. As the vessels are smaller, direct pressure will work. QC....nah, I won't even go there. No worries about your dressing sticking to the wound. We can deal with that at the hospital.

Prevention: wear gloves, no rings on fingers, do not put you hands in front of outgoing large caliber rounds, do not stick your toes into grain augers, or post hole diggers.





			
				RHFC_piper said:
			
		

> If there are any PMeds out there who have dealt with this, either during operation or otherwise, what is the prescribed treatment for this injury?


Treatment given by a PMed: well once they are done vomiting and get up after passing out at the sight of the blood, they would call a first aider over to help.  ;D


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## Blackadder1916 (29 May 2007)

Let me add a little.

http://everything2.com/index.pl?node_id=1358997&lastnode_id=0


> Degloving injuries are the result of trauma to the body that causes tissue planes to separate. The name "degloving" invokes a mental image that is only partially accurate. Picture the removal of a glove from a hand, now make the glove one or more planes of living tissue. Scalping is a degloving injury. These are *open degloving injuries*.
> 
> *The injury can also be closed*. If a shearing force is applied to the body with sufficient power but of brief enough duration the skin may not tear. The separation of the tissue planes breaks blood vessels. The upper layers of the separated tissue may become necrotic from a lack of blood supply. The more planes of tissue involved, the more difficult it will be to heal. In a closed degloving injury the skin may be abnormally loose as it lacks the normal connections to underlying tissues.
> 
> Degloving injuries are often the result of an accident with machinery or a pedestrian struck by a car. They have also occurred during routine neonatal circumcision, where the skin of the penis shaft is pulled back too hard during the procedure. Trauma to the mouth can result in a degloving injury of the gingivae and mucosa.


During the course of my military career (particularly the early part when I was still a MA) I had occasion to provide initial care to at least four degloving injuries. 

Two of these were stereotypical ring finger injuries, one open and one closed.  Both of these the result of the ring being caught on the door of a 'deuce and a half' (the old '50s version) when the driver jumped down from the cab.  I don't know how true it was, but back then I was told that this occurred with relative frequency.  One finger lost, one mostly saved.

An other incident was a partial degloving of the left hand when a individual , while using a vehicle winch, snagged his gloved hand on the cable and it was pulled into the drum of the winch. 

The most impressive (and probably the dumbest) was a local worker on the camp in Ismailia, Egypt.  He had been mowing what passed for a lawn in front of the medical unit.  When the mower stopped due to something snagging the blades, he turned it over and cleared the obstruction.  However, he did not turn off the motor first.  He lost most of the flesh from the palms of both hands and several fingers

While the following illustration doesn't deal with first response it will give those interested an idea about treatment for a typical severe finger injury.


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## Armymedic (29 May 2007)

Good addition, Blackadder1916.


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## George Wallace (29 May 2007)

Could you go on to explain the affects of 'blast' or 'explosive events' that result in "degloving"?  

For instance, when bodies are found 'naked' at the site of an IED or other 'explosive event', and what traumatic event resulted in death or dismemberment?  Degloving, is more often going to be the result of a 'blast' in a Cbt situation, than a ring caught on an object.  How serious and how often would that be the case?


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## PMedMoe (29 May 2007)

St. Micheals Medical Team said:
			
		

> Treatment given by a PMed: well once they are done vomiting and get up after passing out at the sight of the blood, they would call a first aider over to help.  ;D



Well said, SMMT.  Why do you think I remustered?? Why do you think I have suggested that PMeds change their cap badges to something other than medical??
However, in this thread http://forums.army.ca/forums/threads/60154.0.html you stated that PMeds do and see things that are "just gross" so I doubt we'd be vomiting......passing out? Maybe..  Calling over a first aider......aren't we all supposed to be first aid trained?  We have been told they want us to get the TCCC course as personnel have been looking to the PMeds (cap badge issue  : ) for medical treatment.  I can only wonder if the same applies to HCAs vs. MOs???  ???


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## Armymedic (29 May 2007)

Not much except not everyone who wears a medical capbadge would actually know how to treat the injury.

Blast injury would technically, by the definition cause a degloving injury. Treatment would depend on how severe the damage to the tissue is and where on the body. You can reasonably assume that a blast causing the tissue being removed completely from and arm or leg, would result it amputation. On the body or head, skin grafting.


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## Old Ranger (29 May 2007)

To add for Treatment,

Burn dressings! ( Especially if the area is large.)
Alittle Sterile water sprinkled ever so gingerly, wrapped with a nice bunch of Kling.

To control the Vomiting,  FOCUS on what you have to do!
When you let yourself "lull" that's when the quezzies will get yah!

One of the first ones I encountered, was OK from the side.
Turning around to retrieve the end of the finger was fine,
Turning back to have this bony protrusion pointing right at my face after "lulling"
Apparently accented the whiteness of my face as it defiantly started the quezzies..

After that, Trauma is, as going to the butcher shop.
The calmer you are the quicker you can stabilize and comfort the patient.

Ben


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## Old Ranger (29 May 2007)

Old Ranger said:
			
		

> To control the Vomiting,  *FOCUS *  on what you have to do!
> When you let yourself "lull" that's when the quezzies will get yah!



Not to be confused with the "FOCUS" possibly said to certain types of patients.

As in "Focus on your breathing; yes, direct it away from me"

F*** Off Cause Your Stupid...

So I've heard..

Ben


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## Blackadder1916 (30 May 2007)

George Wallace said:
			
		

> Could you go on to explain the affects of 'blast' or 'explosive events' that result in "degloving"?
> 
> For instance, when bodies are found 'naked' at the site of an IED or other 'explosive event', and what traumatic event resulted in death or dismemberment?  Degloving, is more often going to be the result of a 'blast' in a Cbt situation, than a ring caught on an object.  How serious and how often would that be the case?



I'll take a stab at this, though a currently serving medic may be more up to date.  I may be stepping outside my lane here because I am not a physician, it has been several years since I have seen any 'blast injuries' (landmines) and even then I was no longer clinical (or active military), though like many I continue to have a interest in those 'gee whiz, isn't that gross but neat' kind of injuries.  Those who recall one particular scene in that old training film at CFMSS Army Medicine in Vietnam will immediately know what I'm talking about.  Degloving injuries that present in a classical manner fall into that category.  

When you say "naked" I'm assuming that you mean the casualty's condition includes soft tissue injuries of the extremities in which the tissues have been 'peeled' off exposing a relatively intact skeletal structure (or other subcutaneous parts) vice a casualty whose clothing has been blown off.  The causative agent of the injury could be the blast pressure or projectiles secondary to the blast.  As was stated above such injuries result when shearing force is applied with sufficient power to cause tissue planes to separate.  In other words, the harder parts stay put, and the softer parts tear away.  Blast injuries, however, are more than 'degloving'.
http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/MilitaryMedicine/Blast%20Injuries/BlastInjuriesRecognitionandManagement.htm


> High-explosive (HE), thermobaric, and nuclear detonations cause extreme compression of molecules in surrounding air or water creating thin bands of locally high overpressure, which are propagated away from the origin of the explosion as a blast shock wave.  *Most casualties within the injury radius of a HE detonation will have common penetrating (Figure 1 & Figure 2), blunt, and burn (Figure 3) injuries managed no differently than similar non-blast trauma*.
> 
> When the blast wave arrives at the surface of an object (vehicle, structure, or human body), it is transmitted into that object as a stress wave (Figure 4).  As the blast wave separates from the stress wave due to the latter moving slower through objects than the blast wave moves around them, pressure differentials cause forces that accelerate surfaces (Figure 5).  When transmitted into the human body, the shock wave causes stress-induced tears at air-tissue interfaces (Figure 6), which result in internal bleeding, weakening of tissue resistance to additional insults, and possible rupture with escape of air from the respiratory tract or spillage of gastrointestinal (GI) contents.
> 
> Massive hemoptysis can compromise the airway.  Management of any associated penetrating, blunt, and thermal trauma will not be discussed in this chapter.


As for the frequency that degloving is associated with blast injuries, I have not been able to locate any related statistics, however some tables in the current Emergency War Surgery Handbook list both blast and degloving.  
http://www.usaisr.amedd.army.mil/ewsh/Chp3Triage.pdf


> Data from more recent American combat operations in Iraq (OIF) and Afghanistan (OEF), 2003–2004, indicating the spectrum of injury type (Table 3-1), mechanism (Table 3-2), and anatomical location (Table 3-3) are found below.



The examples of ring fingers and hands are brought up often because that's what is more often seen by first responders and it is what first comes to mind when 'degloving' is mentioned.  The examples I gave in my previous post all occurred in a military setting and (with the exception of the Egyptian) all occurred in the field, on exercise during tactical scenarios.  The pers involved IIRC were armoured, infantry and MSE.  While DNBI may not be the scourge of military operations that they once were, they still account for a significant proportion of military medical workload.  

The term 'degloving' seems to be applied more often now to avulsion injuries (regardless of anatomical location and cause) than in the past.  As an example of how use of the term 'degloving' seems to be expanding, I recall an article (with some neat pictures) by an RAMC surgeon in Iraq who used it to describe the condition of an Iraqi sniper's lower right arm following being shot (by British soldier) with the round entering at the trigger finger and exiting farther up the arm but with most of the soft tissue along the way displaced.

In conclusion, since I gave the 'finger' before (pun intended) here's something else.


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## RatCatcher (30 May 2007)

Hey Moe, my Sgt and the other MCpl for Roto 4 did receive TCCC (mainly because of the off chance we are not air mobile to inspect the other camps.) 

SMMT, I have never vomited during an emergency, that goes for when I was a Med Tech and after my remuster. 

Cheers


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## PMedMoe (30 May 2007)

RatCatcher said:
			
		

> Hey Moe, my Sgt and the other MCpl for Roto 4 did receive TCCC (mainly because of the off chance we are not air mobile to inspect the other camps.)



I'm not saying it's not good to have the course, I'm just saying I would prefer NOT to be mistaken for a medic (no offense, anyone) or looked to for medical expertise I no longer have (or have maintained).


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## Armymedic (31 May 2007)

RatCatcher said:
			
		

> SMMT, I have never vomited during an emergency, that goes for when I was a Med Tech and after my remuster.


Humour, people, humour....

George, as you can see from B1916 that most of the actual treatment for blast related degloving is in the area of reconstructive surgery. 

As a medic, my expertise is limited, as in putting the pieces together in a transportable package, and getting him to it. "How?" would be answered depending on circumstance.


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