Avulsion Wounds: Tearing into Details

Before you can provide proper wound care, it’s critical that you know the type of wound you’re treating, and avulsion wounds are no different. Misclassifying the wound can cause preventable medical errors, an issue that could already cost the United States nearly $20 billion annually. In fact, medical errors have become such an area of concern that they’ve been recognized as a severe public health issue and reported as the third leading cause of death in the US. 

Education is one way to help prevent and address medical errors, which is why we’re diving into the topic of avulsion wounds here. Whether you’re a new wound care provider or have years of experience, you can use this resource to refresh what avulsion wounds are, potential treatment protocols, and more. 

What Is an Avulsion Wound?

When you hear the word avulsion, what comes to mind?

Some think of abrasions since the words sound similar. However, these are two different types of wounds, and their terms shouldn’t be used interchangeably. Therefore, let’s clarify what an avulsion actually is. 

An avulsion is defined as “the action of tearing away a part of the body as a result of an accident or surgery.” With skin avulsion wounds specifically, all three layers of skin and at least one or more pieces of tissue have been separated from the body. 

Although abrasions may also include some skin being torn from the body, skin avulsions differ since the tearing also includes deeper structures, like bone or muscle. A skin tear, on the other hand, is a minor injury affecting the top layers of skin, typically resulting from friction or shear force, while an avulsion is characterized as a more severe injury that involves a larger section of skin being torn away, often exposing deeper tissues.

An avulsion wound is considered a traumatic injury. They frequently require medical attention, take an extended amount of time to heal, and are painful. Yet, as with most things in life, not even avulsion wounds are all the same. 

Different Types of Avulsion Wounds

One subcategory of skin avulsion wounds is degloving injury. A degloving avulsion occurs when a significant portion of skin and the soft tissue under it is wholly or partly peeled from the connecting tissues and muscles. 

It’s called “degloving” because the skin is stripped back from the injury site like a glove being ripped from the hand. 

There are two types of degloving injuries, open and closed, which we’ll review below.  

Open Degloving

Also known as external degloving, this type of avulsion wound occurs when a part of the skin and tissue is pulled away and leaves the tendons, muscles, and connective tissue exposed. In some cases, even the bones underneath are visible. Wound care professionals may see some of the skin still attached and hanging as a flap near the wound. This form of degloving is a lot more graphic, making it much easier for wound care experts to identify it.

Some Symptoms of open  degloving may include: 

• Pain
• Significant blood loss
• Necrosis
• Deep lacerations 
• Shock
•  Difficulty with movement  

Open degloving is also more likely to happen to the following areas on the body: 

• Face 
• Scalp
• Trunk
• Lower extremities 

Closed Degloving

Close degloving (aka internal degloving) happens when the superficial fascia parts from the deep fascia in a shearing action. It can have more specific names, too, like a Morel-Lavallee lesion when it occurs in the thigh or pelvic region. 

Closed degloving greatly interrupts the lymphatic and vascular channels that spread across these two layers, creating a potential space for subcutaneous fluid collection. This fluid is a hotbed for infection and places the top layer of skin at risk for necrosis. 

Initially, the top layer of skin in closed degloving incidents looks mainly unharmed, making it challenging for clinicians to detect the underlying injury. Some providers may not recognize the problem until they notice signs of tissue death or infection. In some cases, it becomes apparent that closed degloving occurs if fluid starts collecting in the area. The overlying skin begins to firm, and the site enlarges. Most patients also will likely start complaining of severe pain. 

Keep in mind that closed degloving injuries don’t  always occur in the immediate post-traumatic period. Occasionally, they present weeks to months later in a chronic fashion.  

Internal degloving symptoms may include: 

• Edema 
• Tenderness 
• Skin discoloration 
• Dry skin 

The most common area for closed degloving is the greater trochanter (e.g., at the top of the femur and the widest part of the hip). According to one study, this region accounts for over 60% of cases. Other common areas include: 

• Buttock 
• Flank
• Knee
• Shoulder blade
• Lower back 

Other Types of Avulsion Wounds

In addition to degloving injuries, there are several other forms of avulsion wounds as well.

• Brachial plexus avulsion: This severe injury takes place when the nerve root is completely separated from the spinal cord. Patients can experience a range of symptoms, from loss of sensation to severe pain in the shoulder and arm. 
• Auricular avulsion: Occurs when all or part of the ear is separated. Repair is often tricky due to the complex vasculature, delicate skin, and intricate cartilage contouring. 
• Eyelid avulsion: A type of injury where the part or the entire length of the eyelid has been torn from its normal anatomical position.
• Nail bed avulsion: A complete or partial detachment of the nail from the bed. Sometimes, this occurs from trauma or intentional removal due to ingrown nails or other conditions, which should be performed by a doctor.  
• Avulsion fracture: When a small piece of bone attached to a tendon or ligament is disengaged from the primary section of the bone.  
• Dental avulsion: A total displacement of a tooth from its socket in the alveolar bone.

Wound care management primarily involves assessing and treating issues with the skin. However, as you can see, not all avulsions involve skin tearing. It’s important to recognize this issue so you know when a referral is necessary, especially if you’re faced with something out of your scope of practice. 

What Causes an Avulsion Wound?

Avulsion injuries are often associated with high-energy trauma. Some common situations where they might occur include: 

• Car accidents 
• Incidents where skin or limbs are caught in heavy machinery 
• Falls from high places, such as from parachuting 
• High-contact sports involving collisions, such as football, wrestling, soccer, and rugby
• Slip and fall accidents 
• Animal bites 
• A ring being pulled from a finger
• Significant skin friction, such as when sliding down a rope 

While rare, some skin avulsions are caused unintentionally during surgery. For example, one study reviewed the case of a 66-year-old man who experienced a degloving injury during a total knee arthroplasty procedure. Adhesive drapes had been applied to his skin, and during removal, avulsion occurred.

Immediate First Aid Measures

When dealing with a skin avulsion injury, immediate first aid measures are crucial to prevent further damage and promote wound healing. The first step is to stop any bleeding by applying gentle pressure to the affected area with a clean cloth or bandage. This helps to control blood loss and stabilize the injury. Next, clean the wound with lukewarm water and mild soap to remove any debris or bacteria.

Avoid using harsh soap, hydrogen peroxide, or iodine, as these can damage the skin and slow down the healing process. Pat the area dry with a clean towel and apply a thin layer of antibiotic ointment to help prevent infection. Finally, cover the wound with a sterile dressing or bandage to protect it from further irritation and contamination. These initial steps are vital in managing a skin avulsion injury and setting the stage for effective wound healing.

Diagnosing Skin Avulsions 

In some scenarios, you’ll see someone come in with a skin injury and feel certain right away that it’s an avulsion wound. However, it’s important to formally assess the patient first, as it could be something else. Here are some suggestions to make the correct diagnosis the first time. 

Perform a Thorough Medical Exam

• Patient Medical History: It’s crucial to review a patient’s medical and social history to determine how and when the injury occurred, inquire about past and current medical conditions, and what symptoms they’re experiencing.   
• Physical Exam: Clinicians should carefully assess the skin wound’s size, depth, and extent. Does it appear red or swollen, like an infection is starting? Also, pay very close attention to areas where the patient complains of pain, but you don’t see any physical signs of injury. This could be a closed degloving. 
• Wound Assessment: Note if the injury is near any vital structures, all the anatomy involved (e.g., bone or muscle), if it’s chronic, if it will be challenging to keep clean/offload, viability of the skin flap, and more. 

Utilize Imaging Techniques and Other Technology 

• MRI: This is considered the best method for evaluating soft tissue and bone changes, especially swelling. They assist clinicians with detecting the affected ligaments, nerves, tendons, muscles, and associated bony lesions. 
• CT Scan: While not as detailed as an MRI, it provides a cross-sectional perspective of the injured site. It’s helpful for intricate wounds, where it’s difficult to determine the extent. For example, they can pick up on small, avulsed bone fragments. 
• X-ray: Ideal for assessing if any bones have been pulled away, as in the case of avulsion fractures. 
• AI-Powered Wound Imaging Platforms: These AI-powered imaging solutions can help improve wound assessment accuracy by 90%. By using a massive database of wound images, these tools can predict wound duration and deterioration, reduce evaluation times, and more. 

Common Avulsion Wound Treatments

As mentioned earlier, there are different types of avulsion wounds, so the treatment methodology may vary. Nonetheless, here are some potential techniques you could consider for optimal healing. 

Utilize Sutures, if Possible

In some cases, the width of the avulsion wound is too significant, and there’s a great deal of skin loss, making it difficult to perform stitches. However, if the wound is deep but not wide, using sterile thread to sew the two sides together is ideal for closing the wound. 

Reattach Avulsed Skin Flaps

If the skin flap is still viable and attached to the wound, it may be possible to reattach it to its original place. One study found success with reattaching skin flaps without excision and using negative pressure wound therapy (NPWT) for degloving injuries. NPWT assists with removing excess fluid from the wound and encouraging blood flow. 

Perform A Skin Graft

Clinicians should consider skin grafts if the skin flap cannot be reattached. There are different skin graft types, such as: 

• Full-thickness. These grafts contain the full epidermis and dermis. It is often used in facial reconstruction, joint mobility, and lower extremity skin defects. They’re best for small avascular injuries less than 1 cm or larger areas with quality blood supply. 
• Split-thicken. These consist of the epidermis and part of the dermis. Best for larger wounds, traumatic wounds, previously infected wounds, or those unsuitable for full-thickness grafts. These aren’t flexible enough for joints, though. 
• Epidermal transplantation. This technique is gaining popularity because it reduces scarring, is nearly painless, and heals wounds quickly. It involves removing and transferring the epidermis from a healthy skin area and placing it on the wound bed. 

Liposuction for Skin Avulsions?

While this might sound bizarre, there’s a case of a closed degloving injury being treated with liposuction. A 33-year-old woman arrived with a large and painful Morel-Lavallee lesion of the left thigh. She’d been hit by a truck three weeks prior (remember when we said they could be delayed?). An X-ray and CT scan were performed, which revealed fluid collection, so they performed liposuction of the seroma wall and cavity. This led to an immediate reduction in wound size. 

For post-op care, the patient received oral antibiotics, wore a thigh compression device, and used temporary drains. At the end of post-op, the patient reported reduced pain and no recurrence of symptoms. Lastly, it led to an acceptable cosmetic outcome, so we may see more of these liposuction treatments in the future. 

Additional Skin Avulsion Wound Treatments

Other treatments might include: 

• Surgical debridement
• Hyperbaric oxygen chamber use
• Blood vessel reattachment
• Skin substrates 
• Antibiotic prophylaxis 
• Applying wound dressings
• Topical growth factors

Potential Complications of an Avulsion Wound

Given their seriousness, avulsion wounds can cause undesirable and long-lasting complications. However, some patients may recover just fine. One research study explained, “the severity of complications depends on the mechanism, the accompanying injuries, and the anatomic side impacted.” In degloving injuries specifically, researchers say the severity depends on whether the injuries were open or closed. 

One possible complication is infection, as skin avulsions are considered dirty wounds. Osteomyelitis may develop when the bone is exposed, or if the wound is near the bone. 

If there’s notable blood loss or nerve damage, patients could even lose partial or full function of a limb or another part of the body. 

Other complications may include: 

• Compartment syndrome, a painful condition where pressure in the muscles builds up to dangerous levels
• Lymphedema, the buildup of lymph fluid between the muscle and skin
• Contracture, permanent tightening and shortening of skin, muscles, tendons, tissues, and more

Importance of Proper Wound Care

Proper wound care is essential for promoting skin avulsion wound healing and preventing complications. This includes keeping the wound clean and dry, applying antibiotic ointment, and covering the wound with a bandage. It’s also important to change the dressing daily or whenever it becomes wet or dirty to maintain a sterile environment. Additionally, monitoring the wound for signs of infection, such as redness, swelling, or pus, is crucial. If any of these symptoms occur, seek immediate medical attention to address potential complications promptly. Proper wound care can help prevent infection, promote healing, and reduce the risk of scarring, ensuring a smoother recovery process for skin avulsion injuries.

Healing Time and Infection Prevention

The healing time for a skin avulsion wound can vary depending on the severity of the injury and the effectiveness of treatment. Minor avulsions may heal within a few weeks, while more severe cases may take several months. To prevent infection and promote healing, it’s essential to keep the wound clean and dry, apply antibiotic ointment, and cover the wound with a bandage. Additionally, monitoring the wound for signs of infection and seeking immediate medical attention if any symptoms occur can help prevent complications. In some cases, skin grafts may be necessary to promote healing and prevent scarring. By following these steps, patients can support the healing process and reduce the risk of long-term complications associated with skin avulsion injuries.

Avulsion Wounds Require Special Care

An avulsion wound is a severe injury that requires prompt and thorough care from providers. Their complexity and, at times, delayed revelation can interfere with diagnosis and treatment, ultimately affecting patient health outcomes. 

By incorporating best practices and technology, like AI-powered wound imaging platforms and wound care-specific EHRs, clinicians can proactively assess amputation risk, measure wound healing velocity, and more. In addition, implementing wound care workflows can help you spend more time with patients and less time in front of a computer screen. As you might imagine, the latter is crucial with avulsion wounds. 

Utilizing new and advancing technology can help your clinic stay competitive, reduce preventable medical errors, and ultimately enhance patient care.