TITLE OUTCOME OF WOUND COVER IN DEGLOVING INJURIES OF THE HAND. BY DR. OMONDI AFULO HAND AND ORTHOPAEDIC SURGEON KENYATTA NATIONAL HOSPITAL

INTRODUCTION The skin of the hand is so unique that wound cover of various defects requires special attention. Degloving injuries of the hand require skin cover which is flexible and easily accesible. Split thickness skin causes contractures on the hand and so limits movements. Full thickness is ideal only for small defects

ROLE OF FLAPS A flap of tissue receives its blood supply from a source other than the underlying bed. Flaps are used in defects with exposed bones, tendons, cartilage and joints. Local flaps provide skin of similar colour, texture and thickness. Local flaps are limited in their size and availability.

FLAPS CONTD Raising local flaps inflict additional injury to the already traumatized limb thereby impairing hand function. Distant flaps provide sufficient tissue for massive defects. After flapping, the hand is fixed in one position for 3 weeks leading to stiffness and discomfort.

FLAPS CONTD A free flap has a permanent vascular pedicle. It allows for ease of movements and limited stiffness. Available in any size and thickness. Permit elevation of a limb and early mobilization. Unaffected by random movements in children and disorientated persons.

PURPOSE OF STUDY To appreciate the importance of proper management of an injured hand. To realise the disability caused by use of split thickness and full thickness skin vs flaps in hand skin loss. To appreciate the extent of freedom of movements a flap offers an injured hand. To visualize the importance of early return to work with a useful functional hand.

MATERIALS AND METHODS A hospital based prospective study in an orthopaedic ward of Kenyatta National Hospital. 15 patients were selected over a period of 2 months between Jan – Feb Inclusion criteria involved all patients of all ages admitted with degloving injuries of the hand. Injuries included pulp avulsion, partial finger-tip amputation, palmar and dorsal skin loss

RESULTS TYPE OF INJURY NUMBER % Pulp Avulsion 4 27 Finger-tip Amputation 3 20 Volar Finger skin loss 3 20 Dorsal Finger skin loss 2 13 Zone 3 volar skin loss 2 13 Zone 3 dorsal skin loss 1 7

RESULTS TYPE OF SURGERY NUMBER % Cleaning and dressing 2 13 Terminalization 2 13 V-Y Advancement flap 2 13 Cross- finger flap 2 13 Reverse cross finger flap 0 0 Thenar flap 2 13 Radial forearm flap 2 13 Groin flap 1 7

DISCUSSION The method of covering wounds on the hand has a direct bearing on recovery and function. Healing of hand wounds by secondary intention leads to scarring and limited or loss of function of the hand. Use of skin graft ( split or full thickness) in the hand is not ideal for future hand function. Flaps offer the best opportunity for hand wound cover in readiness for future use of the hand post-injury

Radial forearm flap Depends on presence of good blood supply through the ulna artery and the palmar arches through the radial artery. The radial artery is mobilised and divided proximally and flap mobilised distally. ALLEN test must be performed to ensure adequate blood flow through both radial and ulna artteries. The secondary defect is covered with split thickness skin graft.

CONCLUSION Early active motion of the hand and fingers is important to promote tendon gliding and lessen oedema. Wound cover of the hand requires a flexible skin which allows for ease of above. Hand therapy is initiated as soon as possible. Complete loss of flap due to ischaemia is uncommon. Adequately cover your wounds