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453 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from

THE OF THE The Immediate Treatment of Crush and Lacerations BA7 JOHN N. BARRON, F.R.C.S.(Ed.) Introduction fine hooks instead of forceps will minimize re- The importance of the of the hand action and encourage scar-free healing. has been unfortunately under-estimated in the A bloodless field is essential for accurate past. This lack of systematic teaching on the surgery and a pneumatic tourniquet can be subject is reflected in general practice and the left in position for an hour with safety. If results of such treatment provide a dis- on removal of the pressure cuff, the operation tressingly large number of patients who re- area is compressed and the arm elevated for quire lengthy reconstructive procedures. two or three minutes most of the capillary oozing will have ceased and the remaining Since the incidence of falls most bleeding points can be tied with a 6/o catgut. heavily upon the fit and able worker, it is Absolute haemostasis should be the ruie as obviously most important to concentrate bleeding will persist in places unsupported by attention on this vital problem. the dressing such as the thenar space and

interdigital webs. Deep haematomata cause Protected by copyright. Principles of Treatment considerable disturbance and lead to massive A thorough knowledge of the minute fibrosis. and the function of the hand is the Most surgical procedures on the hand should only basis for correct diagnosis and treatment. be followed by a carefully applied pressure Much of hand surgery is the surgery of dressing. Wool should be packed in against millimetres, and the operator should be pre- all the skin surfaces and built up until it can pared to equip himself to this degree of be evenly compressed by an elastic bandage so intimacy with its structure and its function. that all parts are supported, oedema is pre- vented and the circulation sustained. Forty- Atraumatic Technique eight hours elevation aids venous and lym- The response of the tissues to a crushing phatic drainage, minimizes post-operative dis- is and fibrosis, degeneration comfort and swelling and allows an early injury oedema http://pmj.bmj.com/ and cicatrix. This is just as true of the return of function. localized crush of a haemostat as it is of a power-press injury and varies only in degree. The Pathology of Injury Multiple small crushing traumata at operation Cutting injuries may cause a widespread vascular protest, with Apart from acute infections, hand injuries its inevitable sequence of oedema and fibrous are caused by cutting, crushing and burning.

replacement. It is important always to consider the on September 24, 2021 by guest. So narrow is the margin of play betveen a differences between a ' crush' and a ' cut.' tendon and its sheath and so intimate the A laceration made by a sharp knife or a razor structure of a capsule and its ligaments, that damages the minimum number of cells com- even a minor invasion by 'the may patible with the size of the injury. Immediate impair dexterity and function. It is well, drainage on to the surface is automatic- then, at operation to limit the necessary ally provided for the damaged tissues, and trauma so that normal structures are not re- intra vascular clotting remains localized to the flexly injured. The lightest touch, a tourniquet capillaries surrounding the wound. The re- and the finest instruments are essential for action to injury then tends to involve only this work. Sharp dissection with sharp in- the cell strata of which the wound is formed so struments and the handling of tissues with long as infection does not supervene. Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from 454 POSTl GRADUATE MEDICAL JOURNAL Octob,er I1947 Crushing injuries classification, and the second group degrees An injury caused by a blunt cutting instru- 3 to 6. A noteworthy point in the pathology of ment will not only lacerate but, by virtue of is that there is always more tissue loss. the superadded crushing effect, will damage than that occasioned by the heat itself. This many more cells in strata further away from takes the form of spreading cell necrosis due the wound surface. These crushed tissues to added infection, progressive intra-vascular have no drainage to the surface and oedema coagulation and degeneration due to oedema results. Whether by reflex mechanism'or by and raised tissue tension. This sequence with toxic absorption, a state of increased capillary its crippling effects can, to a large degree,'be permeability supervenes in the limb, the controlled if rational treatment is instituted at widespread oedema still further impeding the outset. These are the factors which make drainage through the and lymphatics. the diagnosis of depth of all but the severest Intra-vascular clotting starts distally and the burns difficult if not impossible during the blood supply if still further diminished may first few days.' The best indication is gained result in avascular necrosis of the superficial from a study of the causation of the rather layers of the wound. Here is an excellent than a clinical examination of the wound. pabulum in which infection can flourish. The pure ' crush ' injury, although it may Electrical burns not lacerate or fracture, can, by causing severe Electrical burns are caused mainly by the metabolic disturbances, result in total dis- heat generated in the tissues due to their re- ability-the frozen hand. The oedematous re- sistance to the passage of the current. Two action far from being obviously confined to the features are worthy of mention, first that the Protected by copyright. sub-cutaneous planes, invades the musculature, burnt area is well demarcated, and second that the deep spaces, the tendon sheaths and the the necrosed tissues are dehydrated by the . If it is not energetically treated from passage of the current. These facts suggest the outset, much of the fluid becomes fibrinized immediate and active surgical treatment and and later cicatrises. Muscle, tendon and cap- excision and replacement can give results un- sular tissues subjected to high tensions and to obtainable by any other method of treatment. anoxia degenerate, and the motor functions of the hand suffer. Digital and their com- Chemical burns plex sensory ends are strangled in the scar, and Chemical burns provide the greatest puzzle sensory and atrophic disturbances are the in diagnosis of depth. Much depends upon the sequel. strength of the caustic and upon the amount of sweat and dirt on the skin itself and, of course,

In any acute injury, it is valuable to assess http://pmj.bmj.com/ the ratio of the ' crush ' to the ' cut.' Not only upon the skin thickness at the site of injury. in industrial injuries does it lead to much in- Generally speaking, pure Lysol and the con- teresting information about the work our centrated strong acids and alkalis will destroy patients do, but in all injuries it enables us the full skin thickness of the forearm or the more accurately to hazard the risk of infection dorsum of the hand in from IO to 20 seconds, and it points the way to the correct treatment. but will take up to a minute to produce a similar injury of the palmar skin of a work- Burning injuries man. These burns remain demarcated unless on September 24, 2021 by guest. Injuries by burning can be considered as the contact period is long, or they are followed thermal, electrical and chemical. The thermal by infection. burn evokes a very similar reaction to that caused by a crush injury. There is much The Immediate Treatment of Hand variation in effect depending upon the tem- perature and the length of exposure. Here the Injuries skin is first destroyed and, for purposes of Crush injuries treatment, it is convenient to divide burns into These injuries are common and are caused two groups-partial thickness skin loss and by a wide variety of accidents. In industry, total thickness skin loss. The first group com- presses and mills are the worst offenders prise degrees i and 2 in the Dupuytren's apart from the everyday occurrence of a October 1947 BARRON: Skin of the Hand 455 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from heavy weight dropping on the hand. In the bed from the bone the following technique home, serious disabilities may be caused by should be adopted. A small mould is made in the slamming of a door, and in this case the Stent wax or plaster of the of the same are usually involved. ' Crush' injuries on the opposite hand. This is made in are either closed or open. The skin may split the form of a thin plaque, curved to fit the nail in a plane at right angles to the crushing force exactly. It is then applied to the injured nail and the soft tissues may be extruded thence to and accurately held in position by a pressure the exterior. There may or may not be dressing. Many gross deformities can be thus associated fractures. Pain is severe and pro- prevented. Fracture dislocations of the distal longed and is due to the trauma to the sensory interphalangeal joints should be put up in ends. Oedema is soon apparent and traction, preferably on a Bohler's splint. may involve the whole hand. The skin in the areas subjected to the greatest force usually Lacerations without skin loss shows evidence of bruising and ecchymosis Under good conditions of treatment, all whilst necrosis and sloughing may occur. of the hand which can be explored under direct vision, should be closed. In Treatment practice, the main exception to this rule is the Unless there are special indications for the perforating injury of the palm or fingers. When treatment of fractures, the hand should be put the hand has been pierced by a bullet or a up in the position of function. A few degrees sharp instrument, it is impracticable to explore of dorsi flexion at the wrist, all finger joints in all the interstices of the wound and in attempt- about 450 of flexion, the angles increasing a ing to do so potential pathways for dissemina- little in succeeding fingers from the index to tion of infection are opened up. Skin and sub- Protected by copyright. the fifth. The thumb in palmar abduction cutaneous tissue edges should be excised and and opposition. In this position a firm the wound lightly packed. If desired, a fine pressure dressing is applied, and the hand 35 gauge stainless steel wire suture can be slung to a point overhead by a loop of bandage placed across the wound and tied a few dayA or strapping. Severe cases, particularly where later if infection is not present. These cases there are associated fractures, should be chilled should receive prophylactic penicillin ad- with ice bags and the temperature kept between ministration. If a ' crush' element is present 600 and 650 F. This is an efficient anodyne in these injuries and this may be marked if and prevents congestion and oedema. Any bone is involved, pressure dressing, elevation case where there are gaping lacerations which and cooling should be included in the treat- cannot be sutured owing to tension should be ment. An accurate diagnosis as to tendon and should be made at the outset as skin grafted and the graft removed later if the nerve function http://pmj.bmj.com/ skin is redundant. This prevents a granulating the picture may later be complicated by surface from forming, encourages early move- swelling and fibrosis. ments, and decreases the risk of infection. All other lacerations should be subjected to debridment under local, regional or general The crushedfinger tip anaesthesia and a tourniquet. The extent of Cases of this sort requiring treatment usually tissue removal depends upon the ratio of

present in addition a nail injury or a fractured 'crush' and 'cut' in the causation of the on September 24, 2021 by guest. terminal phalanx. The basic treatment is injury, wider excision of the wound surface again the pressure dressing, but the nail or being necessary when the 'crush' element is phalanx may need attention. The subungual predominant. In deep wounds this is most haematoma should be drained by a drill hole easily done under a slow-flowing stream of through the nail and unless this is done, saline in which ragged and torn material may necrosis of the nail bed and the phalanx can be easily be identified. By this method it is also expected if the tension is high. If the nail bed possible to make a more accurate differentia- is split the nail should be sutured into normal tion between damaged and viable. tissue on position to prevent a cleft or other irregularities the woond surface itself. from forming and the drill hole should still be With the volar skin of the manual labourer, made. If there is partial avulsion of the nail it is wise to shave off the cornified skin layer 456 i OST GRADUATE MEDICAL JOURNAL October I 947 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from for I in. around the w.ound margin. This layer Lacerations with skin loss is non-elastic and difficult to suture. It inverts Conservative treatment of skin losses of the the deeper skin layers and in any case separates hand is a potent cause of dysfunction. In the after the stitches have been removed, resulting time taken by all but the smallest of these in slow and imperfect healing. This point is wounds to heal, fibrous tissue forms, contracts worth noting also when making incisions for and shortens, distorting the hand and inter- the drainage of acute infections and wounds fering with its mechanical and sensory func- so treated heal with noticeable rapidity. tions. The prolonged healing period and the Debridment having been completed and loss of dexterity and power owing to disuse, haemostasis secured, the wound should be constitute an important economic problem in sutured. should be closed connection with employment. Too many man- with 6/o catgut only if it tends to retract and hours are wasted waiting for conservative leave a dead space. Skin sutures should be treatment to produce second-rate results. accurate, and exact apposition of the flexion Healing will eventually take place after much creases should be made as stitching proceeds. delay with a poor type of epithelium un- Lacerations crossing the flexion creases on the buffered by normal , contracted, pain- volar aspects of the fingers should be broken ful, disfiguring and disabling. up by the method of Z plasty in order to avoid In general, untreated volar skin losses pro- flexion which are otherwise very duce flexion deformities of the wrist and likely to occur. fingers. Skin losses on the dorsum of the hand The method of Z plasty as applied here is interfere with flexion at the metacarpophalan- as follows:- geal joints and draw the thumb into adduction. Protected by copyright. If AB represents the wound crossing a Skin losses on the backs of the fingers pro- flexion crease CD at 0, take a point E on duce extension or hyperextension deformities AB I cm. distal to 0 and a point F i cm. at the interphalangeal joints. Persistent irrita- proximal to 0. At E construct an angle tion'from infection together with the contrac- OEX of 450, X being a point on this line in tion of the wound causes oedema. Even when the same sagittal plane as F. Construct a healed, the presence of the scar not infre- similar angle at F prolonging the line to Y, quently causes sympathetic vascular dis- a point in the same sagittal plane as E. The turbances with atrophic changes in digits due lines EX and FY are marked on the skin to arterial spasm and capillary paralysis. The and incised with .a knife. Two flaps are effects of this syndrome may be widespread in then formed-FEX and EFY on bases FX the hand and the changes may cause permanent crippling. It can be seen then that there are

and EY respectively. These flaps are under- http://pmj.bmj.com/ mined in the subcutaneous plane back to strong indications for the active surgical their bases, and are transposed so that point treatment of skin loss and this consists of the E lies on point Y, and point F on point X. early replacement of the skin defect. Fine sutures are placed round the flaps and closure takes the form' shown in Fig. 5. Principles of Skin Repair The following stitch will be found useful It is an axiom of reconstructive surgery that lost tissues should be similar for the corner of each flap. The needle takes replaced by on September 24, 2021 by guest. the skin just to the deep layer in the dermis tissues and the more this is adhered to the more in the recipient angle, passes through the successful will be the repair. It is often im- corner of the flap at the same level and possible to observe this rule strictly but if it again through the recipient skin. When the is borne in mind the design of the repair will stitch is tied, the flap advances and lies be on sound lines and the outcome assured. accurately in position. There is, therefore, a primary necessity of The effect of the Z transposition is to making a studied diagnosis of the tissue loss lengthen the suture line between A and B so and a' careful evaluation of the part played by that does not tend to approximate each of the missing structures. these two points and so flexion deformity at the Subcutaneous tissue crease does not take place. Thus on the volar surface of the fingers the October I947 BARRON: Skin of the Hand 457 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from Protected by copyright.

FIG. T.-Fine instruments used in hand dissection.. http://pmj.bmj.com/ on September 24, 2021 by guest.

FIG. 2.-Pressure dressing of wool, crepe bandage and strapping. 458 POST GRADUATE MEDICAL JOURNAL October 1947 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from

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FIG. 4.-The position of function. FIG. 3.-The frozen hand resulting from a crush injury. FIG. 4.-The position of function. FIG. 3.-The frozen hand resulting from a crush injury. October i947 BARRON: Skin of the Hand 459 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from

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FIG. 8.-Strip grafts, spot grafts and patcli grafts. FIG. 9.-Showing method of immobilizing a cross arm FIG. iO.-Thigh flap for the repair of a palmar defect in flap. the region of the second and third webs. FIG. i i.-Thigh flap inset into hand. October I947 BARRON: Skin of the Hand 46i Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from Protected by copyright.

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FIG. I2.-Abdominal flap repair for electrical burn of the ulnar border of the wrist and hand. The burn. FIG. 13.-The abdominal flap attached to the hand. FiG. i I.-The inset completed. 462 POST GRADUATE MEDICAL JOURNAL October 1947 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from

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FIG. I6.-Inset of the pedicle completed. Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from October I1947 BARRON: Skin of the Hand 463 subcutaneous tissue plays a dual role. It acts On the dorsum of the fin,gers neither., the as a cushion for the skin protecting it from subcutaneous tissue nor the whole thickness of trauma, and also guards the tendon and its the dermis need be replaced; and a split skin sheath and the nerves and vessels against in- graft'proves perfectly. adequate. in.all'ccase. jury and subtraumatic stimuli which arie con- On the dorsum of the hand,provided therp,is stantly being applied to this surface. a subcutaneous tissue, covering over the-ten- On the dorsum of the fingers, the function dons, a split skin graft will again be satisfactQ. of subcutaneous is of much less im- It is possible to do tendon surgery,later throuqgh portance; apart from its minor protective role, this split skin graft if it is really thick.(J;.,.,to it conveys the venous plexus up to the hand. 7 skin thickness) and if the primary 'tak,.' Here on the hand, the fat layer, although has been good. normally -thin, allows the free skin movement When the dorsum of the hand has bsp essential to flexion and extension of the fingers. denuded of its fatty layer, as well, all three This movement is nearly 3 in. at the knuckles layers should be replaced if free finger move- between the extreme3 of the range at the ment is to be expected. joints. It also allows unfettered movements of the extensor tendons and provides a medium Methods of Repair of Tissue Loss through which the venous and lymphatic i. Direct suture vessels course. On the palm it is the great shock absorber. This method is applicable only to the Intimately connected with the palmar , it smallest of wounds and on the volar surface and of the hand -and fingers there is very little Protected by copyright. is movable accommodating in flexion but excess of skin available for the repair. Under tightly stretched in extension and is thus well no conditions should tension suturing be re- adapted to the various functions of the hand. sorted to as the inevitable damage to the skin Dermis edges and the subsequent widening of the Through the dermis, the re- scar will reproduce the condition that the ceives its nutrition and in it are found many of wound suture was designed to prevent. On the sensory organs and nerve plexuses. The the dorsum there is greater laxity of tissue, normal metabolism and stability of the skin and by undermining the skin in the sub- depend upon an intact dermis and the in- cutaneous plane certain small defects may be stability of scars is often due to its absence or closed. Transverse tension across the dorsum to defects in its structure. ovef the knuckles should be avoided as the On the volar surface of the hand and fingers full width of skin is required here for free where, owing to constant , the wastage flexion at the metacarpophalangeal joints. http://pmj.bmj.com/ -rate of epithelium is high, these functions of the dermis are of great importance. On the 2. Local skin flaps dorsum of the fingers, however, satisfactory There is a limited application for these function of the skin is possible in the partial methods and two are in common usage for absence of the dermis and on the dorsum of small skin losses. the hand, this is also true provided the sub- (a) Rotationflap. Tlbe rotation flap is useful .cutaneous layer is intact. for closure of triangular defects provided the on September 24, 2021 by guest. From these considerations, we can examine flap incision does not cross flexion creases at the indications for replacement after injury. right angles and so encourage secondary con- On the volar surface of the fingers a full tractures. The main indication is for defects thickness skin and subcutaneous tissue loss in the distal palm, the thenar eminence, or on should be replaced in all its three layers. In the dorsum in the knuckle region. All rota- the palm, the central area between the thenar tion flaps on the hand should be based proxi- and hypothenar muscle groups again demands mally so as to ensure venous drainage. Con- replacement of all three layers. IA free skin -gestion and thrombosis are the penalties for graft over the muscles will, itself, be satis- distally placed flaps. The rotation flap is cut factory because of the good blood supply and by extending the short side of the triangular suppleness of the base. defect by an incision which sweeps round the E Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from 464 POST GRADUATE MEDICAL JOURNAL .October I 947 arc of the largest possible circle compatible Skin Grafts with the presenting surface, and ideally should THICK terninate at a point on the projection of a line drawn through the long axis of the triangle. Wolfe Graft Full thickness .045 int to .032 in. Thick split skin i}. The extension of the incision to this point is o02 iin.n. not always possible as the base of the flap is Pinch Graft .045 in. at centre thereby narrowed under the blood supply and .oo8 in. at periphery. the skin is impoverished. In practice then the THIN incision is lengthened until the flap, when Half skin thickness .020 in. undermined, will close the defect without ten- r Spot grafts sion. When properly designed, this flap One-third split skin .oi2 in. Patch , should leave no secondary defect requiring Strip t closure by a free graft. Thiersch Graft .oo8 in. to .oio in. (b) Transposed flap. The principle of this Wolfe Graft method is to transpose the defect from one site to another where it can be suitably closed by a This graft includes the whole of the dermal skin graft. Thus defects in the central palm and epidermal layers. It is cut either freehand can be transposed to the ulnar border of the or in large areas with a Padgett dermatome. hand where a split skin or Wolfe graft' can be Of all skin grafts it is the least ready to take and expected to take and stabilize without scarring requires every refinement of technique to en- and risk of subsequent breakdown. A central sure successful transplantation. The common palmar defect exposing tendons and nerves donor sites are the abdomen and inner aspect Protected by copyright. can in such a manner be closed by incising of the upper arm. The donor site must be across the palm to the ulnar border and then closed by suture or by a split skin graft to turning the incision proximally upwards to- avoid prolonged healing and unnecessary wards the wrist. When the palmar skin is scarring. undermined the flap outlined will move across If cut freehand, a pattern of the defect is to close the primary defect, leaving a secondary marked on the donor skin and outlined with a triangular defect over the abductor minimi knife, one edge is lifted with a skin hook and digiti which is a good base for the reception of by careful dissection the graft is split off a skin graft. This principle can be used in the between the dermis and the subcutaneous fat. treatment of defects in the interdigital webs Not a vestige of fat should remain on the graft for skin losses on the volar of or the take will be jeopardized. The skin must and small aspect be handled without trauma- and should be

the fingers. In both these instances, the http://pmj.bmj.com/ defects can be transposed to the sides or backs manipulated only with the fingers or with a in which situations skin sharp hook. The crushing effect of forceps of the fingers, grafts will cause points of necrosis in the devitalized are satisfact6ry. skin. 3. Free grafts To prevent collections of serum or blood The free skin grafts which were formerly under the graft, it should be punctured at half- described as either Thiersch gra,fts or Wolfe inch intervals over its whole surface with a grafts, are now subdivided into a number of large, straight cutting needle pr with a fine- on September 24, 2021 by guest. categories. In the hand there are important pointed knife. These puncture wounds heal indications for adapting a particular type. of rapidly after allowing drainage from the wound graft to the area grafted, and much importance in the first crucial hours after operation. Graft should be attached to this if optimum results drainage has an important place in the hand are to be obtained. where irregular surfaces are to be covered and ,-The emergency surgery of hand defects absolute immobility is difficult to obtain. offers great scope for the use of the free graft. The Wolfe graft is accurately sewn into the -It is by far the most useful method of repair edges of the defect by either interrupted fine and the saving of time and disability should silk sutures or by a running mattress stitch. -recommend it to those who deal with acute Exact edge to edge alignment and eversion are hand injuries. necessary if marginal scarring is to be reduced Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from October I 947 BARRON: Skin of the Hand 465 to a minimum. As with all free grafts, a firm graft is elevated on a needle point and while pressure dressing and immobilizing'splint is tented upwards is sliced off cleanly with a used during the first seven to ten post-operative knife. It is thin at the edges and full thickness days, after which time the dressing is removed in the centre, and is well suited to these small and the graft inspected. Further care consists defects. of protective dressings, general exercises and Where possible the proximal edge of tip measures to encourage stability of the skin. defects should be trimmed to run parallel with Infection or the risk of infection is an the papillary ridges in this region then the scar absolute contraindication for the use of a will be minimal and there will be less likelihood Wolfe graft. One should hesitate to employ it of secondary pulp distortion. on a hand injury more than six to eight hours The Wolfe graft is also indicated for closure old, and only then after a careful debridment ofcentral palmar defects in the triangle bounded has been done, particularly if there has been a by the bases of the fingers and the borders of crush' element present. the thenar and hypothenar eminences. Pro- The principle indication for the Wolfe graft vided the subcutaneous layer is intact, these is for the replacement of skin defects of the grafts do well and may even be satisfactory volar surfaces of the fingers and thumb in over small exposures of palmar fascia. Ragged which the subcutaneous layer is intact. Here wounds of the palm which need grafting are the full buffering effect of the dermis is im- better trimmed into a triangular shape with portant and this layer should be replaced when the edges parallel to the various creases. Sub- sequent contraction of the marginal scars is destroyed. Whatever the shape or size of the Protected by copyright. defect, if it crosses a flexion crease on a digit reduced to a minimum, scars which if badly it should be enlarged until its lateral margins placed so easily cause deformities at the meta- run along the lateral axes of the finger, or a carpophalangeal joints and transverse palmar triangle of intact skin should be sacrificed with shortening. its apex at a point on, or posterior to, this line. In this way, a secondary contraction of the The Thick Split Skin Graft marginal scar can be prevented. This graft, although differing little in thick- The lateral axial line is determined by ness from the Wolfe graft, has certain different flexing all the finger joints and viewing the properties. It takes more readily on trans- digit from the side. The posterior limits of the plantation but the epithelium does not mature flexion creases are marked and when the finger in quite the same fashion presumably owing to is straightened a line is drawn through these partial lack of dermal support. It is thus in- points. It will be noted that this line is a herently slightly less stable than its full thick- http://pmj.bmj.com/ little more posterior than would at first be ness counterpart. This minor defect can, how- apparent. ever, be overcome by using it on an ideal base, In practice any'longitudinal incision anterior and in the hand such an area is found on the to this line may, during healing, cause a flexion thenar or hypothenar muscJes. When there is contracture, so that incisions for access to the skin loss in either of these regions or in the finger should be designed accordingly. ulnar border of the first web which is formed A common indication for the Wolfe graft is by the first dorsal interosseus muscle, satis- on September 24, 2021 by guest. for the repair of skin losses on the finger tips. factory and permanent function of the graft can An accurate diagnosis of the loss should be be expected. In any appreciable size the thick made and if there has been destruction of much split skin graft can be cut only with a derma- of the pulp substance this must be replaced by tome, a pattern should be used and its method other methods. of application is the same as for a full thickness A common tip injury is caused by a bread or graft. bacon slicer which removes a circular area of skin off the terminal pulp. This defect has The Thin Split Skin Graft sloping margins, the loss being thickest in the This is the graft used to replace the skin on centre and when small may confidently be re- the dorsum of the hand and fingers. Normally paired with a Pinch graft. The skin for this the dorsal skin is much thinner than that on Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from 466 POST GRADUATE MEDICAL JOURNAL October I 947 the volar surface and its function is that of an can be covered which, although it has little elastic rather than a protective covering or an application in hand surgery, may be' of con- of touch. Thermal stimuli are more siderable importance in widespread bums. readily appreciated through the dorsal skin, In general, the heavier the infection the but it lacks fine discriminatory sensibility smaller the graft unit used. Thus even when which is found on the palmar aspect of the there is frank pus on a recent wound it is fingers. possible to obtain a good take by spot grafting. These grafts take more easily than is the Patches and strips are used ot less heavily case with thick grafts, and can even be relied infected surfaces, but in the presence of a good upon, if drained by multiple punctures, to blood supply remarkable results can be survive in the presence of infection. Demand- achieved by their use, even in the presence of a ing less nutriment for survival they can be fairly profuse infection. based on relatively avascular capsular or tendon These graft units coalesce by epithelial re- tissues and are of great value in the early treat- generation from their edges, thus the interven- ment of burns. The one-third thickness graft ing areas are held by scar epithelium. Graft provides an adequate permanent cover for, the units should therefore be placed close together dorsum of the fingers, and half thickness skin leaving just a millimetre or less for drainage is used for the knuckle region and the dorsum between them, and strips should be' placed in of the hand. The tendency for the thinner the long axis of the dorsum of the hand, trans- graft to contract after healing is compensated versely on the volar surface of the fingers and for by the pull of the long flexor tendons and parallel with the normal creases on the palm. Protected by copyright. by' the absence of concave surfaces on the This prevents the development of scars which dorsum. Provided there is a good initial take are at variance with the principles of surgery subsequent contractures should not arise. of the hand, early freedom of 'movement is possible, secondary deformities are less likely The Spot, Patch and Strip Grafts to be troublesome. So great is the importance The grafts previously described are used in of early epithelialization of hand wounds and sheets. Each sheet covers completely an area burns, that with these methods at our disposal denuded of skin. Even for the thinnest sheet grafting procedures should not be left until the graft, infection, with its liberation of pus and defects are sterile. Each'day that a raw surface exudate from the wound surface, is a formid- is allowed to remain detracts from the final able deterrent to adhesion. A relatively small result.

amount of exudate will balloon the graft off its http://pmj.bmj.com/ bed and the regenerative processes between the Pedicle Grafts two become impossible. The accumulation of These more complicated methods of repair toxic products macerates both the skin and the have a place in the immediate treatment of wound surface, so that by injudicious grafting hand injuries. These procedures are done in the healing time may be greatly prolonged. two stages because the grafts contain skin and Various advantages are gained by dividing subcutaneous tissue and must thus be trans-

thin skin up into small units, and the three in planted in vascular continuity to survive. The on September 24, 2021 by guest. common use are spots (the size of pin heads), impossibility of transplanting skin and fat patches (from W to i cm. square), and strips together as a free graft has been mentioned, (i to i cm. in width and variable in length). bnt there are frequent occasions for the re- These units are placed on the wound surface placement of both these layers, and it is then leaving spaces between them so that drainage that the pedicle method of transference from can escape into the dressings and so be con- distance is used. Briefly, the indications for ducted away from the deep surface of the skin. pedicle grafting are skin and subcutaneous The problems of movement are not so acute tissue losses on the volar surface of the with this method as motion at a is not fingers, the central palmar triangle -and the necessarily transmitted over the whole of the dorsum of the hind. grafted skin. Further, for a given amount of There are two contraindications for the use skin cut from a donor site a much larger area of this method. If the wound is more than -October I947 BARRON : Skin of the Hand 467 Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from six to eight hours old and, by the nature of its abdomen encourages sweating and maceration causation, infection is likely to occur, the of the skin and infection of the suture line is pedicle flap should not be used. Similarly if difficult to prevent. the tissue loss is caused by a severe crushing The best choice lies between the opposite injury or is accompanied by a crush in another forearm or the internal aspect of the thigh on part of the hand, the difficulty of controlling the same side as the donor site and of the two, oedema and the subsequent prolonged joint the forearm is' usually more convenient. stiffness rule out this method as a primary re- A suitable position for the flap is found on pair. Under these conditions it is preferable the front of the forearm and is based proxim- to close the defect by one of the free grafts, ally. The flap is raised and the donor defect whichever may be indicated, regarding this as grafted, using a 4 split skin graft. The flap is a temporary skin dressing which can be re- sewn into the palmar defect and the two arms moved when the danger of infection and are immobilized together in plaster. The oedema is passed and proceeding then with position is fairly comfortable and easy to main- the pedicle flap reconstruction. tain for two weeks when severance of the flap 'A suitably chosen free graft will overcome is completed. the problem -of infection and a pressure The same technique is used for the thigh dressing and elevation will control the oedema. flap but here the problems of immobilization There is some evidence to show that treat- are much more difficult and it is better to ment by cooling may be effective in the pre- reserve the operation for children and ado- vention of oedema if ice packs are used post- lescents in whom such fixation is less irksome. operatively. The full pressure dressing and Abdominalflap Protected by copyright. elevation routine may be discarded and the This flap should be restricted to the repair use of primary flap repairs may be extended to of defects on the dorsum of the hand. The certain crush injuries. position during transfer is natural and ample The variations in this type of transplantation material is available. Th-e flap can be based are limitless and much depends upon the in- above and medially, below and laterally, or can genuity of the operator as to the method of have a double base and thus become ' a bridge choice for a given defect. The ideal is to re- flap.' The donor site is the lower quadrant place lost tissues by similar tissues both in and should be somewhat more lateral in women qualitv and in quantity. Thus it is ridiculous owing to the excessive fatty deposition over the to replace the dorsum of a hand with an lower third of the rectus muscle. epidermal flap containing the full thickness of When an abdominal flap with a base the abdominal fat, the result is functionally and is contemplated, it should be designed so that http://pmj.bmj.com/ cosmetically grotesque, nor is it reasonable to the base is at least equal to the length of the replace digital skin with a bulky mobile flap flap. The circulation will then be sufficient. which on compression flows aimlessly round When this rule is followed it is permissible to the supporting phalanges. Accurate quantita- trim off all excess of fat and leave just enough tive replacement is just as important as the in the flap to replace the subcutaneous tissue proper choice of the donor site. loss on the hand. It is sometimes necessary to enlarge the hand defect so that a safe flap of on September 24, 2021 by guest. Examples of Pedicle Flaps this type can be used and there need be no The repair of central palmar defects hesitation in so doing. The commonly advocated abdominal flaps When there is a narrow defect crossing the are not ideally suited to this type of case. In entire width of the dorsum a bridge flap can order to prevent the flap from kinking in the be used and a safe ratio between length and bridge between the abdomen and the hand, base in this case is 5 to 2. the latter must be held in full supination. This The donor site of the flap should be closed is an unnatural position and is impossible to by a split skin graft so that all raw areas are maintain unless a massive plaster jacket with covered. Failure to obtain complete closure is an arm extension is made. If pronation does the commonest cause of sepsis, delayed healing, occur the contact between palmar skin and the and scar formation in the flap. Postgrad Med J: first published as 10.1136/pgmj.23.264.453 on 1 October 1947. Downloaded from 468 POST GRADUATE MEDICAL JOURNAL October 1947 When the flap has been sewn into the defect, made. In gross injuries, however, there are the position of the hand and arm is maintained occasions when a temporary skin graft should by strapping it to the chest and abdomen be used for the hand and subsequently re- with elastoplast. With, children, however, it placed with skin and fat. In-these cases mUch is safer to use plaster immobilization and for time and an operative stage can be saved if at them a light plaster jacket with a rigid arm the emergency operation a tubed pedicle is extension serves the purpose well. made which will be ready to transfer to the The second stage is done within two or hand after the acute phase of the injury has three weeks. The base of the flap is severed subsided. The planning of tubed pedicle re- and set into the margin of the hand defect. pairs is fraught with difficulty, and an accurate This should truly be a marginal inset as in all forecast of the whole surgical programme must cases at least iths of the flap should be attached be made before the size and situation of the to the hand at the first operation, the design tube is decided upon. An error in judgment at allowing for just a short bridge between the the first operation may jeopardize the whole abdomen and the hand. result and it may not be apparent until several These flaps allow successful extensor tendon subsequent stages have been completed, by suture to be done during the first stage so which time the mistake may well be irrevocable. long as the fingers can be splinted in full ex- tension. They also provide an excellent Conclusions medium for subsequent tendon grafting, and The pathology and treatment of recent skin the grafts can be tunnelled through the fatty and subcutaneous tissue injuries of the hand Protected by copyright. layer underneath the flap. are viewed from the angle of the plastic sur- geon. Some of the more general aspects of the The Tubed Pedicle burnt hand are mentioned but in view of the This cannot be used in an emergency as a extensive literature already in existence, details means of importing tissue as the skin tube are not given. The basis of early treatment of must be formed on the abdomen or chest at these injuries is the prevention of infection, least three weeks before transference can be oedema and granulating surfaces. BIBLIOGRAPHY BUNNELL, S. (944), ' Surgery of the Hand,' Lippincott. ISELIN, M. (I945), 'Chirurgie de la Main,' Masson. WOOD-JONES, E. (194I), 'Principles of Anatomy as Seen in the Hand,' Bailliere, Tindall and Qox. BROWN, J. B., and BYARS, L. T. (1940), Lancet, 6o, 503, November. http://pmj.bmj.com/ EDITORIAL (continued from page 452) high, and there is a considerable difference In cases of extrahepatic block, where the between the pressure in it and in the vena portal itself is affected, porto-venocaval cava. Success in these cases for this reason anastomosis is not feasible and spleno-renal should approach the success commonly ob- anastomosis has to be carried out. Technically, tained in arterial anastomosis. Blakemore and Whipple find the vitallium Seventeen of Blakemore's cases have been on September 24, 2021 by guest. tube technique to be of great value but a tube followed up for more than six months and of adequate calibre should be used. Failure some up.to two years. In addition to the dis- from thrombosis at the site of anastomosis has appearance of haemorrhages and ascites the been uncommon; it should be noted, however, majority have shown considerable gains in that successful anastomosis is more likely to be health, weight and appetite and improvement obtained in cases of portal hypertension than in in liver function. ordinary vein-to-vein anastomosis, where failure is common as a result of the low BIBLIOGRAPHY Whipple, A. O., Annals of Surgery, 122, OCt., '945. pressures in the systemic veins. In portal Blakemore, A. H., Annals of Surgery, 122, OCt., 1944. hypertension the pressure in the portal vein is Blakemore, A. rI., S.J.o., 84, 645, April, I944.