Case 4: Unmasking the Decollement: Timely and Successful Primary Full-Thickness Skin Grafting in Complex Lower Leg Trauma

Keywords: Decollement injury, full-thickness skin graft, primary full-thickness skin grafting, lower leg trauma, soft tissue debridement, perforating blood supply, atypical decollement, plastic surgery, trauma management, diabetes, case report Authors: Laura Emilie Marr Spore, MD., Claes Hannibal Kiilerich, MD. Institution: Department of Orthopedic Surgery, Holbæk Hospital, Denmark Abstract An 84-year-old female sustained significant lower leg trauma after a fall on a staircase. Intraoperative evaluation revealed a decollement injury. Defined as separation of the skin and subcutaneous tissue, from the underlying fascia, separating the perforating blood vessels from the subcutaneous tissue—with the affected skin area destined for necrosis, if not acted upon. Prompt debridement and primary full-thickness skin grafting of the affected skin were performed within hours. Early recognition and management are often needed, to avoid devastating injuries. This case highlights a successful treatment, and the need to focus on these injuries, as no clinical guidelines exist. Patient medical history The patient, with a history of type 2 diabetes, CKD 5 (Cronic Kidney Disease Stage 5, eGFR < 10, weekly dialysis) and poor skin quality, experienced a fall from standing height on a stone staircase. These factors contributed to a complex decollement injury despite the low-energy trauma. She hit the staircase corresponding to her tibial tuberosity, and a grinding motion during the fall resulted in the visual distal open lesion — only a small proximal wound suggesting where she struck the stairs initially, where the decollement lesion was later discovered to be starting from. The decollement injury is most commenly seen in victims in severe traffic accidents and typically involves opposing, intense forces that tear the skin and the subcutaneous layer away from the underlying fascia, thereby compromising the blood supply to the skin. And is often underdiagnozed and hard to recognize.