Palmar Hand Avulsion

15 Jul 2022

Case Report

Hospital MetroHealth Medical Center, Cleveland, OH

Reconstruction over the exposed fascia and tendon palmar was achieved using NovoSorb ® BTM and a split-thickness skin graft as an alternative to a free tissue transfer.

After an industrial farm accident, a patient sustained an avulsion injury to his left dominant hand. Due to patient concerns regarding free tissue reconstruction, NovoSorb BTM was selected to aid in dermal reconstruction, providing a vascularized neodermis for application of a split thickness skin graft (STSG). Soft pliable tissue was noted with minimal contracture around the wound margins.

Figure 1: Initial presentation of injury; palmar avulsion with exposed fascia and tendons.

Figure 2: Day 7: Prior to NovoSorb BTM application; exposed soft-tissue defect.

Figure 3: Day 7: NovoSorb BTM applied over exposed fascia and tendon.

Figure 4: 28 days post NovoSorb BTM application; sealing membrane removed.

Figure 5: 28 days post NovoSorb BTM application; a sheet STSG applied.

Figure 6: Day 307 post NovoSorb BTM application; soft pliable tissue with some contracture.

    Background

    A 58-year-old male was involved in an industrial farm accident that resulted in an avulsion injury to his left dominant hand. His injuries included avulsed palmar skin with exposed fascia and tendons; and open fractures of the middle and ring fingers proximal phalanx (Fig 1). There were no associated tendon or nerve injuries. A free tissue reconstruction was discussed with the patient but refused due to the risks and concerns about the donor site morbidity and need for prolonged hospitalization. NovoSorb BTM was selected over immediate grafting due to concerns for secondary contracture and exposed flexor tendons.

    Treatment

    During the initial surgery, a washout was performed, and the integrity of the nerves and tendons was assessed. Fractures were stabilized with buried percutaneous K-wires, and the avulsed skin flaps were loosely approximated. A second-look surgery was performed on day 3 post-injury. Skin flaps at the time were non-viable and debridement left a 110 cm 2 soft tissue defect. At 7 days after the initial injury, NovoSorb BTM was applied over exposed fascia and tendon and dressed with a bolster dressing (Fig 2 and 3). On day 7 post NovoSorb BTM application, the patient underwent occupational therapy for finger range of motion with protective splinting, and the bolster dressing was removed. Subsequent wound checks were performed weekly to assess for reperfusion and integration, which was noted at 23 days post NovoSorb BTM application. On day 28 post NovoSorb BTM application, the sealing membrane was removed and sheet STSG was performed (Fig 4 and 5).

    Outcome

    There was complete skin graft take. On day 63 post NovoSorb BTM applicaton, a skin release was performed due to index finger contracture at the junction of the reconstruction, and a full-thickness skin graft was applied. At day 307 post NovoSorb BTM application, both skin grafts presented some contracture at the wound margins but not over the area of newly reconstructed tissue (Fig 6). Due to associated fractures and other injuries, some functional limitations, such as making a fist, were present. With the application of NovoSorb BTM, a complex free tissue reconstruction was avoided and the patient obtained a soft and pliable reconstruction with good functional use of the hand for most activities.

    A 58-year-old male was involved in an industrial farm accident that resulted in an avulsion injury to his left dominant hand. His injuries included avulsed palmar skin with exposed fascia and tendons; and open fractures of the middle and ring fingers proximal phalanx (Fig 1). There were no associated tendon or nerve injuries. A free tissue reconstruction was discussed with the patient but refused due to the risks and concerns about the donor site morbidity and need for prolonged hospitalization. NovoSorb BTM was selected over immediate grafting due to concerns for secondary contracture and exposed flexor tendons.

    During the initial surgery, a washout was performed, and the integrity of the nerves and tendons was assessed. Fractures were stabilized with buried percutaneous K-wires, and the avulsed skin flaps were loosely approximated. A second-look surgery was performed on day 3 post-injury. Skin flaps at the time were non-viable and debridement left a 110 cm 2 soft tissue defect. At 7 days after the initial injury, NovoSorb BTM was applied over exposed fascia and tendon and dressed with a bolster dressing (Fig 2 and 3). On day 7 post NovoSorb BTM application, the patient underwent occupational therapy for finger range of motion with protective splinting, and the bolster dressing was removed. Subsequent wound checks were performed weekly to assess for reperfusion and integration, which was noted at 23 days post NovoSorb BTM application. On day 28 post NovoSorb BTM application, the sealing membrane was removed and sheet STSG was performed (Fig 4 and 5).

    There was complete skin graft take. On day 63 post NovoSorb BTM applicaton, a skin release was performed due to index finger contracture at the junction of the reconstruction, and a full-thickness skin graft was applied. At day 307 post NovoSorb BTM application, both skin grafts presented some contracture at the wound margins but not over the area of newly reconstructed tissue (Fig 6). Due to associated fractures and other injuries, some functional limitations, such as making a fist, were present. With the application of NovoSorb BTM, a complex free tissue reconstruction was avoided and the patient obtained a soft and pliable reconstruction with good functional use of the hand for most activities.