"Degloving
and
Severe
Upper
Extremity
Injuries
in
Motor
Vehicle
Crashes
Involving
Partial
Ejection"
Seattle
CIREN
University
of
Washington,
Harborview
Medical
Center,
Seattle
WA
Kaufman
R.,
Blanar L.,
Bulger E.
– Seattle
CIREN,
UW,
HMC
Lipira A.,
Friedrickson J.
– Harborview
Medical
Center
Upper
Extremity
(UE)
Partial
Ejection
in
Motor
Vehicle
Crashes
(MVC)
•
Noted
as
an
‘arm
‐
or
hand
‐
out
‐
window’
phenomenon
•
Upper
extremity
partial
ejection
in
MVCs
can
result
in
contact
to
exterior
objects,
including
the
ground
in
rollovers,
which
can
result
in
severe
degloving
type
injuries
•
These
severe
injuries
result
in
devastating
and
long
‐
lasting
consequences
J Trauma Acute Care Surg.2013 Feb;74(2):687‐91. Vehicle factors and outcomes associated with
Partial
Ejection
Mitigation
•
Seatbelts
are
99.8%
effective
at
preventing
complete
ejections,
but
only
38%
effective
in
preventing
partial
ejections
in
rollover
crashes
•
Side
‐
curtain
airbags
(SABs)
can
reduced
and
mitigated
risk
of
partial
ejection
•
BUT,
most
partial
ejection
research
focuses
on
head
or
thoracic
injuries
•
Partial
ejection
of
the
upper
extremity
(UE)
remains
a
highly
morbid
mechanism
of
upper
extremity
injury
in
motor
vehicle
collisions
References:
1. Bakker, A., Moseley, J. & Friedrich, J. Vehicle factors and outcomes associated with hand‐out‐window motor vehicle collisions. Journal of Trauma
and Acute Care Surgery 74, 687–691 (2013).
2. Ball, C. G., Rozycki, G. S. & Feliciano, D. V. Upper Extremity Amputations After Motor Vehicle Rollovers. The Journal of Trauma: Injury, Infection,
and Critical Care 67, 410–412 (2009).
3. Nikitins, M. D., Ibrahim, S. & Cooter, R. D. Injury to arms protruding through vehicle windows. Hand Surg 8, 75–79 (2003).
4. Harris, C. N. & Wood, V. E. Rollover injuries of the upper extremity. The Journal of Trauma: Injury, Infection, and Critical Care 18, 605–607 (1978). 5. Funk, JR, Cormier JM, Bain CE, Wirth JL, Bonugli EB, Watson RA – Factors affecting ejection risk in rollover crashes. AAAM 2012;56:203‐11
Severe
Upper
Extremity
Injury
due
to
Partial
Ejection
•
Research
has
been
limited
to
small
studies
from
single
centers
–
No
national
‐
level
studies
•
Research
has
generally
been
limited
in
evaluating
injury
and
crash
details
of
partial
ejection.
•
Research
objectives
:
–
to
evaluate
severe
UE
injuries
in
relation
to
partial
ejection
–
examine
role
of
side
curtain
bags
in
prevention
of
UE
severe
injuries
(and
in
turn,
evaluate
overall
partial
Treatment
of
Contents
•
Definition
•
Causes
•
Classifications
•
Treatments/Procedures
•
Case
Studies
Definition
(Severe
degloving
soft
tissue
injury)
•
Result
of
shearing
force
applied
to
skin
surfaces
•
Separation
of
skin
and
subcutaneous
tissues
from
underlying
muscle
and
fascia
leads
to
the
creation
of
a
space
allowing
for
accumulation
of
fluid
•
Shearing
forces
disrupt
and
perforate
vessels
at
the
fascial
level
which
may
lead
to
skin
necrosis(death)
•
Frequently
associated
with
fractures
and
other
life
Mechanism
of
Severe
Soft
Tissue
Injuries
•
Injury
occurs
during
ejection
in
a
motor
vehicle
crash,
or
when
a
patient
is
thrown
across
a
fixed
surface
•
Entrapment
between
a
fixed
surface
and
a
moving
object
–
arm
exiting
vehicle
contacting
ground
or
trapped
between
vehicle
exterior
and
•
Pattern
1
‐
Abrasion/Avulsion
–
Loss
of
tissue
as
a
result
of
abrasive
force;
little
undermining
of
remaining
skin
edges
•
Pattern
2
‐
Non
‐
circumferential
degloving
–
Majority
of
skin
is
still
present
either
as
a
flap
or
as
an
area
of
extensive
undermining
•
Pattern
3
‐
Circumferential
single
plane
–
Either
open
or
closed
‐
confined
to
a
single
plane(between
deep
fascia,
subcutaneous
fat
and
skin)
•
Pattern
4
‐
Circumferential
multi
‐
plane
degloving
–
Pattern
#
3
plus
breach
of
muscle
groups
or
muscle
and
periosteum
Classifications
for
Severe
Soft
Tissue
Injury
Arnez, Z.M. & Khan, U. (2010). Classification of soft tissue degloving in limb
Treatments
and
Procedures
•
Conservative
–
Subcutaneous
hematoma
and
dead
fat
is
removed
followed
by
drainage
and
pressure
dressings
– Injured muscle not directly inspected
– May hide compartment or crush syndrome
•
Surgical
–
Serial
excisions
prior
to
reconstruction
–
Potential
for
bone
desiccation
and
infection
•
Negative
Pressure
Wound
Therapy
Negative
Pressure
Wound
Therapy
•
Wound
VAC
–
Treatment
of
acute
and
chronic
wounds
–
Contaminated
wounds,
burns,
infiltrations,
Negative
Pressure
Wound
Therapy
•
Wound
VAC
–
Open
degloving
injuries
•
Primary
treatment
•
Secondary
treatment
‐
Temporary
wound
cover;
Serve
as
a
bridge
to
reconstruction;
improves
Length
of
Stay
for
Severe
Soft
Tissue
injuries
•
Required
hospitalization
for
long
periods
•
Involved
multiple
and
repeat
surgeries
•
Graft
procedures
fail,
repeated
•
In
some
severe
cases
an
extremity
may
Severe
Soft
Tissue
Upper
Extremity
Case
Study
#1
•
45 year old male status post side impact of car versus light
pole. Patient found to have right pneumothorax, pulseless
right upper extremity with degloving injury to right shoulder,
right 1‐5 rib fractures, open right humerus fracture and
radio/ulnar fractures
•
Angiography revealed a right brachial artery transection
versus a complete occlusion
Case
Study
#1
‐
Case
Study
#1
‐
Injury
Diagram
Case # ‐
Right Rib fractures 1‐5
(with pnuemothorax) Displaced Right radius and ulna fractures Open humerus shaft fracture Large lacerations and
large avulsion/degloving of the shoulder /arm
musculature with
transection of the
pectoralis major muscle,
transection of the
brachial artery leading to
Operations/Procedures
•
Day
1
‐
OR
#1
–
Part
1:Repair
of
right
brachial
artery
with
interposition
bypass
graft
using
reverse
left
greater
saphenous
vein
–
Part
2:
Open
reduction
and
internal
fixation
of
right
both
bone
forearm
fracture,
irrigation
and
debridement(I&D)
of
open
right
forearm
fracture
–
Part
3:
Open
reduction
and
internal
fixation
of
right
humerus
fracture
•
Day
3
‐
OR
#2
–
I
&
D
right
humeral
shaft
fracture
&
right
forearm
fracture.
Application
of
wound
closure
device,
Operations/Procedures
cont.
•
Day 6‐OR #3
–
I & D right humerus & right forearm, wound VAC change
•
Day 8‐OR #4
–
I & D right humerus & right forearm, wound VAC change
•
Day 11‐OR #5
–
I & D right humerus & right forearm, wound VAC change,
Dressing change
•
Day 15‐OR #6
–
I & D right humerus & right forearm, application of wound
VAC to right upper extremity from wrist to axilla
•
Day 19‐OR #7
–
I & D right humerus & right forearm, wound VAC change
Operations/Procedures
•
Day
22
‐
OR
#8
–
I
&
D
right
humerus
&
right
forearm,
wound
VAC
change
•
Day
25
‐
OR
#9
–
Ligation
of
previous
right
axillo
‐
brachial
bypass
graft
secondary
to
blowout
of
graft
and
subsequent
hemorrhage
•
Day
26
‐
OR
#10
–
Open
through
elbow
amputation
•
Day
28
‐
OR
#11
–
I
&
D
right
upper
extremity
•
Day
30
‐
OR
#12
–
I
&
D
right
upper
extremity
including
debridement,
Operations/Procedures
cont.
•
Day
32
OR
#
13
–
Extend
right
elbow
amputation
to
right
shoulder
disarticulation,
excision
of
residual
and
infected
bypass
graft
of
the
right
arm,
resection
of
chest
wall
wounds
and
rotation
of
large
fascio
‐
cutaneous
flap
to
the
defect
of
the
shoulder
and
chest
wall
•
ICU
days:
1
•
Ventilation
days:
1
•
LOS:
37
days
•
Acute
Healthcare
only
costs:
$264,769.90
Case
Study
#2
•
36
year
old
belted
female
who
was
involved
in
a
low
speed
motor
vehicle
collision
and
rollover.
Patient
reported
that
she
had
her
left
arm
out
of
the
window
when
she
was
hit
on
the
passenger
side
and
rolled
to
the
driver
side.
•
Patient
found
to
have
left
ulnar
styloid
fracture
and
extensive
left
forearm/hand
avulsion
injury
Case
Study
2
‐
Scene/Vehicle
• Case vehicle
– 2004 compact utility vehicle
• Far‐side & Rollover (2 quarter turn to
left
• Objects struck
– V2 (2006 Chrysler Sebring) & the ground
Case
Study
2
‐
Occupant/Impact
•
PDOF
=
Non
‐
Horizontal
(Event
#2)
•
CDC
– 00LDEO01
•
Delta
V
–
Damage
Severity
=
Minor
• Driver
• Female
• 36yrs.
• 5’2”, 220 lbs
• Normal posture
• Restraint Use = Manual lap/shoulder
belt (seat belt retractor pretensioner did not actuate); no air bag
External
Injury
Case # ‐ Left comminuted fracture of the distal ulna. Left degloving injury of the forearm and hand Extensor tendon avulsion Left thumb abrasionOperations/Procedures
•
Day 2‐OR #1
–
Irrigation and debridement(I&D) of left forearm avulsion
injury including skin, subcutaneous tissue, muscle, and
bone‐approximately 400 sq. cm.
–
Exploration of median and ulnar nerves in forearm
•
Day 5‐OR #2
–
I & D left forearm with application of wound VAC
•
Day 7‐OR #3
–
I & D left forearm with wound VAC change
•
Day 10‐OR #4
–
Left forearm and dorsal hand debridement including skin,
subcutaneous tissue, and muscle; wound VAC change
Operations/Procedures
cont.
•
Day
14
–
OR
#5
•
I & D left dorsal forearm including skin & subcutaneous
tissue; wound VAC change
•
Day
21
–
OR
#6
•
Preparation of wound bed for left dorsal forearm and
hand, 400 sq. cm., in anticipation of a split thickness skin
graft
•
Application of split thickness(sheet) graft, 400 sq. cm., to
left dorsal forearm and hand
•
Day
24
‐
Discharged
•
ICU
days:
0
•
Ventilation
days:
0
•
LOS:
24
days
•
Acute
Healthcare
only
costs:
$
134,191.48
–
Does
not
include
professional
fees,
radiology
Case
Study
#
3
•
22
year
old
restrained
male
driver
who
lost
control
of
his
car
impacted
a
wall,
and
rolled.
There
was
a
prolonged
extrication
and
he
was
noted
to
have
his
right
arm
trapped
beneath
the
car
and
the
ground
out
of
the
sunroof.
•
He
was
found
to
have
a
right
forearm
degloving
injury,
120
sq.
cm.,
20
cm.
Case
Study
#3
•
Case
vehicle
–
2005
(4
‐
door
sedan)
•
Near
‐
side,
Rollover
on
to
roof
•
Objects
struck
–
Concrete
block
wall
&
ground
(rollover)
•
Dark,
rainy,
wet
roadways
•
Male
driver
•
22
yrs.
•
6’3”,
220
lbs
–
Seated
height
=
34”/86cms
•
Manual
lap/shoulder
belt
•
Airbag
status
=
Side
impact
and
curtain
air
bag
Impacts
VEHICLE #2
External
Injury
Case # ‐
Right distal ulna
fracture Right forearm degloving
Operations/Procedures
•
Day
1
–
OR
#1
• Irrigation and Debridement (I&D) of right forearm degloving injury
including skin, subcutaneous tissue, and muscle
• Repair and closure of 20 cm laceration • Removal of foreign bodies
• Open reduction and internal fixation of right ulnar fracture
•
Day
5
‐
OR
#2
–
I
&
D
of
right
forearm
including
skin,
subcutaneous
tissue,
and
muscle
–
Delayed
primary
closure
of
8
cm
of
laceration
•
Day
12
‐
OR
#
3
–
I
&
D
of
right
forearm,
split
thickness
skin
grafting,
wound
VAC
application
•
ICU
days:
0
•
Ventilation
days:
0
•
LOS:
16
days
•
Acute
Healthcare
only
costs
:
$
231,000.00
–
Does
not
include
professional
fees,
radiology
Research
Methods
•
Data
source:
NASS
CDS
•
1993
‐
2012
(20
years)
•
Passenger
vehicles
•
Outboard
seats
only
(11,
13,
21,
23,
31,
33)
•
Age
14
and
above
•
Three
‐
point
belt
used
•
Sub
‐
analysis
of
side
airbag
deployment:
–
2000
‐
2012
–
MY
2000
‐
2012
–
Outboard
seats
only
(11,
13,
21,
23,
only)
Upper
extremity
definition
•
Body
region
information
is
determined
by
the
first
digit
of
the
AIS
code
(body
region=7)
•
Upper
extremities
injuries
were
included
if
AIS
was
greater
than
or
equal
to
2
along
with
finger
amputations,
joint
dislocations
and
For
upper
extremity
(all
injuries
are
AIS>2
unless
otherwise
specified:
Severe soft tissue injury refers to: amputations (excluding fingers AIS 1), deglovings,
crush injuries
Moderate soft tissue injury refers to: skin lacerations, avulsions
Functional structure injury refers to: artery and vein lacerations, nerve lacerations,
muscle avulsions
Shoulder joint injury refers to: shoulder joint subluxation (possible AIS 1),
dislocation, acromioclavicular joint subluxation (possible AIS 1), dislocation, Upper arm fracture refers to: humerus fracture, unspecified arm fracture Elbow joint injury refers to: elbow joint dislocations (possible AIS 1)
Forearm facture refers to: radius fracture, ulna fracture, forearm fracture
Hand injury refers to: unspecified hand fracture, carpus fracture, metacarpus
fracture, phalange fracture (AIS 1), carpal joint dislocation (possible AIS 1), and
finger/thumb amputations
Compartment syndrome: compartment syndrome to the arm, forearm, or hand
• Note that the following injuries are AIS >2 but are not included in the analysis of
upper extremity injures: Clavicle fracture, Scapula fracture, Joint capsule injury,
Analysis
•
Primarily
descriptive
statistics
and
chi
‐
squared
test
to
determine
differences
between
groups.
•
To
evaluate
partial
ejection
prevention
associated
with
side
curtain
airbag
deployment,
a
logistic
regression
model
was
used
–
First
univariate
–
Then
adjusted
for
belt
use,
delta
V
Population
demographics
Group
N
Rounded Annual
Mean
N
‡
Percent
(%)*
Total Population**
24,102,898
1,200,000
100
Belted
16,744,426
850,000
69.5
Driver
13,444,984
650,000
80.3
†
Front
passenger
2,785,513
140,000
16.6
†
Other
513,929
25,705
3.0
†
Partially Ejected
235,341
12,000
0.98
Belted and Partially
Ejected
102,123
5,000
0.59
†
Upper Extremity (UE)
Injuries
918,466
46,000
3.81
Belted UE Injuries
520,649
26,000
3.11
†
Rollover
2,865,235
150,000
11.95
‡ Average occurrences per year, 1993‐2012 (N divided by 20)
* Percent of total population (24,102,898) unless otherwise noted ** Outboard occupants, age 14 years or older
Upper
Extremity
Injury
Groups
(Occupant
level)
All
(N=24,102,898)
Belted
(N=16,744,426)
UE
Injury
Group
N
%
N
%
Severe soft tissue injury
16,736
0.070
8,175
0.049
Moderate soft tissue
injury
10744
0.040
8,731
0.052
Compartment
syndrome
44,962
0.190
30,266
0.180
Functional structure
injury
9059
0.038
4,127
0.025
Shoulder joint injury
88,111
0.370
48,706
0.290
Upper arm fracture
196,539
0.820
86,141
0.510
Elbow joint injury
20,885
0.090
10,368
0.062
Forearm fracture
383,059
1.590
215,308
1.290
Hand injury
321,264
1.330
205,358
1.230
Occupant
partial
ejection
and
UE
injury
Total
UE
injury
UE
injury
(%)
No ejection
16,625,163
501,620
3.0
Partial ejection
102,123
16,547
16.0
Complete
ejection
5334
986
18.5
Severe
Soft
Tissue
Injury
(
SSTI
)
Breakdown,
mechanism
(belted)
Contact
with
Ground
or
External
Objects
All*
Partial
Ejection**
Amputation
29%
67%
Crush Injury
57%
79%
Degloving
Injury
44%
70%
All
SSTIs
46%
73%
SSTI = severe soft tissue injury
*Percent of all injury type resulting from contact with ground or external objects
**Percent of all injury type in partial ejection resulting from contact with ground or external
Partial
ejection
w/
specific
UE
injury
types
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% partial complete no ejectionOccupant
partial
ejection
(PE),
belted,
all
crash
types
w/
UE
injury
by
vehicle
body
type
Total
Partial
Ejection
(PE)
PE
with
UE
Injury
%PE*
%
of
PE
with
UE
Injury**
Passenger car
11,300,918
40,162
5359
0.35%
13.6%
SUV
434,351
2,338
1376
0.54%
58.9%
Minivan/van‐
based light
truck
1,251,143
10,198
260
0.77%
2.6%
Pickup truck
1,809,937
25,856
3804
1.44%
14.7%
Other light truck
14,205
506
0
3.62%
0.0%
*Percent of group with partial ejection. Chi‐squared: P =0.0009 ** Percent of partially ejected occupants with UE injury
Partial
ejections
(belted
occupants)
by
Primary
Crash
Type
Principle
crash
type
Total
PE
%
PE*
Front
9,376,921
13,293
0.14%
Rear
1,609,512
10,507
0.69%
Rollover
1,407,023
49,882
3.50%
Nearside
1,836,783
22,447
1.22%
Farside
1,416,343
3535
0.25%
Total
15,646,582
99,804
0.64%
Primary
crash
type
in
partial
ejection
with
UE
and
SSTI
injury
Total
UE
injury
% UE
injury
SSTI
% SSTI
%
Deglove
Injury
Front
13214
3757
28.9% 1367 10.5%
4.8%
Rear
10508
509
4.6%
110
1.0%
0.9%
Rollover
49627
8627
17.6%
3046
6.2%
3.0%
Nearside 21852
1852
8.4%
84
0.4%
0.2%
Farside
3535
1053
29.8%
198
5.6%
2.9%
Total
98,736 15,798 16.0% 4,805 4.9%
2.4%
Primary
crash
type
in
upper
extremity
injury
groups
in
partial
ejection
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% farside nearside rollover rear front
Ejection
paths
in
UE
injury
Groups
Windshieldfront
Left
Right
front
rear
Left
Right
rear
Rear Roof
OtherSevere soft
tissue
injury*
(stat.signif)
173
2,278
664
43
268
0
1,412
0
UE injury
211
11,633
2,116 153
268
112 1,582
33
Partial
ejection
paths
in
rollover
by
quarter
turns
(Belted
Drivers
only)
Quarter Turns
1 Right 1 Left 2 3 to 6 7+ Total
Windshield 429 0 4 0 132 565 Left front 79
