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In
medicine Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pr ...
, an avulsion is an injury in which a body structure is torn off by either
trauma Trauma most often refers to: *Major trauma, in physical medicine, severe physical injury caused by an external source *Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic inju ...
or surgery (from the Latin ''avellere'', meaning "to tear off"). The term most commonly refers to a surface trauma where all layers of the
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...
have been torn away, exposing the underlying structures (i.e.,
subcutaneous tissue The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and m ...
,
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of mus ...
,
tendons A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle to bone. It is able to transmit the mechanical forces of muscle contraction to the skeletal system without sacrificing its abilit ...
, or
bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...
). This is similar to an abrasion but more severe, as body parts such as an eyelid or an ear can be partially or fully detached from the body.


Skin avulsions

The most common avulsion injury, skin avulsion often occurs during motor vehicle collisions. The severity of avulsion ranges from skin flaps (minor) to
degloving A degloving injury is a type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply. It is named by analogy to the process of removing a glove. The causes of degloving can vary ...
(moderate) and
amputation Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on indi ...
of a finger or limb (severe). Suprafascial avulsions are those in which the depth of the removed skin reaches the
subcutaneous tissue The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and m ...
layer, while subfascial avulsions extend deeper than the subcutaneous layer.Jeng, S.F., & Wei, F.C. (1997, May). Classification and reconstructive options in foot plantar skin avulsion injuries. '' Plastic And Reconstructive Surgery, 99(6)'', 1695-1703. Small suprafascial avulsions can be repaired by suturing, but most avulsions require skin grafts or reconstructive surgery.


Rock climbing

In
rock climbing Rock climbing is a sport in which participants climb up, across, or down natural rock formations. The goal is to reach the summit of a formation or the endpoint of a usually pre-defined route without falling. Rock climbing is a physically a ...
, a "flapper" is an injury in which parts of the skin are torn off, resulting in a loose flap of skin on the fingers. This is usually the result of friction forces between the climber's fingers and the
holds A hold (abbreviated HLD, H or HD) is awarded to a relief pitcher who meets the following three conditions: :1. Enters the game in a save situation; that is, when all of the following three conditions apply: :: (a) He appears in relief (i.e., ...
, arising when the climber slips off a hold. To fix this injury and to be able to continue climbing, many climbers will apply sports tape to the flapped finger to cover up the sensitive area of broken skin. Some climbers may even use super-glue to adhere the loose skin back to the finger.


Ear avulsions

The ear is particularly vulnerable to avulsion injuries because of its position on the side of the head.Davison, S. P., & Bosley, B. N. (2008). ''Ear, Reconstruction and Salvage''. Retrieved January 15, 2009, fro

The most common cause of ear avulsions is human bites, followed by falls, motor vehicle collisions, and dog bites. A partially avulsed ear can be reattached through
suturing A surgical suture, also known as a stitch or stitches, is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery. Application generally involves using a needle with an attached length of thre ...
or microvascular surgery, depending on the severity of the injury. Microvascular surgery can also be used to reattach a completely avulsed ear, but its success rate is lower because of the need for
venous Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated ...
drainage. The ear can also be reconstructed with
cartilage Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck ...
and
skin graft Skin grafting, a type of graft surgery, involves the transplantation of skin. The transplanted tissue is called a skin graft. Surgeons may use skin grafting to treat: * extensive wounding or trauma * burns * areas of extensive skin loss du ...
sSaad Ibrahim, S. M., Zidan, A., & Madani, S. (2008). Totally avulsed ear: New technique of immediate ear reconstruction. ''Journal of Plastic, Reconstructive & Aesthetic Surgery, 61'', S29-36. or an external ear prosthesis can be made by an
anaplastologist Anaplastology (''Gk. ''ana''-again, anew, upon ''plastos''-something made, formed, molded ''logy''-the study of'') is a branch of medicine dealing with the prosthetic rehabilitation of an absent, disfigured or malformed anatomically critical locati ...
.


Eyelid avulsions

Eyelid An eyelid is a thin fold of skin that covers and protects an eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. The human eye ...
avulsions are uncommon, but can be caused by motor vehicle collisions, dog bites,Avram, D.R., Hurwitz, J.J., & Kratky, V. (1991, October). Dog and human bites of the eyelid repaired with retrieved autogenous tissue. ''Canadian Journal of Ophthalmology, 26(6)'', 334-337. or human bites. Eyelid avulsions are repaired by
suturing A surgical suture, also known as a stitch or stitches, is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery. Application generally involves using a needle with an attached length of thre ...
after a CT scan is performed to determine where damage to the muscles, nerves, and blood vessels of the eyelid has occurred.Huerva, V., Mateo, A.J., & Espinet, R. (2008, January). Isolated medial rectus muscle rupture after a traffic accident. ''Strabismus, 16(1)'', 33-37. More severe injuries require
reconstruction Reconstruction may refer to: Politics, history, and sociology * Reconstruction (law), the transfer of a company's (or several companies') business to a new company *''Perestroika'' (Russian for "reconstruction"), a late 20th century Soviet Unio ...
, however, this usually results in some loss of function and subsequent surgeries may be necessary to improve structure and function. Microvascular surgery is another method of repair but is rarely used to treat eye avulsions.Soueid, N.E., & Khoobehi, K. (2006, January). Microsurgical replantation of total upper eyelid avulsion. ''Annals of Plastic Surgery, 56(1)'', 99-102. Sometimes
botulinum toxin Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neurom ...
is injected into the eyelid to paralyze the muscles while the eyelid heals.


Nail avulsions

Trauma to the
nail Nail or Nails may refer to: In biology * Nail (anatomy), toughened protective protein-keratin (known as alpha-keratin, also found in hair) at the end of an animal digit, such as fingernail * Nail (beak), a plate of hard horny tissue at the tip ...
can cause the nail plate to be torn from the nail bed. Unlike other types of avulsion, when a nail is lost, it is not typically reattached. Following the loss of the nail, the nail bed forms a germinal layer which hardens as the cells acquire
keratin Keratin () is one of a family of structural fibrous proteins also known as ''scleroproteins''. Alpha-keratin (α-keratin) is a type of keratin found in vertebrates. It is the key structural material making up Scale (anatomy), scales, hair, Nail ...
and becomes a new nail. Until this layer has formed, the exposed nail bed is highly sensitive, and is typically covered with a non-adherent dressing, as an ordinary dressing will stick to the nail bed and cause pain upon removal. In the average person, fingernails require 3 to 6 months to regrow completely, while toenails require 12 to 18 months.


Brachial plexus avulsions

In
brachial plexus The brachial plexus is a network () of nerves formed by the anterior rami of the lower four cervical nerves and first thoracic nerve ( C5, C6, C7, C8, and T1). This plexus extends from the spinal cord, through the cervicoaxillary canal in t ...
avulsions, the brachial plexus (a bundle of nerves that communicates signals between the spine and the arms, shoulders, and hands) is torn from its attachment to the
spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the sp ...
. One common cause of brachial plexus avulsions is when a baby's shoulders rotate in the birth canal during delivery, which causes the brachial plexus to stretch and tear. It occurs in 1 to 2 out of every 1,000 births. Shoulder trauma during motor vehicle collisions is another common cause of brachial plexus avulsions.Binder, D. K., Lu, D. C., & Barbaro, N. M. (2005, October). Multiple root avulsions from the brachial plexus. ''Neurosurgical Focus, 19(3)''. Detachment of the nerves can cause pain and loss of function in the arms, shoulders, and hands.
Neuropathic pain Neuropathic pain is pain caused by damage or disease affecting the somatosensory system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous ...
can be treated with medication, but it is only through surgical reattachment or nerve grafts that function can be restored. For intractable pain, a procedure called dorsal root entry zone (DREZ) lesioning can be effective.


Tooth avulsions

During a tooth avulsion, a tooth is completely or partially (such that the
dental pulp The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour. Anatomy The pulp is the neurovascular bundle centr ...
is exposed) detached from its
socket Socket may refer to: Mechanics * Socket wrench, a type of wrench that uses separate, removable sockets to fit different sizes of nuts and bolts * Socket head screw, a screw (or bolt) with a cylindrical head containing a socket into which the hexag ...
. Secondary (permanent) teeth can be replaced and stabilised by a dentist.Merck Manual Online. ''Fractured and Avulsed Teeth''. Retrieved January 15, 2009, fro

Primary (baby) teeth are not replaced because they tend to become infected and to interfere with the growth of the secondary teeth. A completely avulsed tooth that is replaced within one hour of the injury can be permanently retained. The long-term retention rate decreases as the time that the tooth is detached increases, and eventually
root resorption Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. Howeve ...
makes replacement of the tooth impossible. To minimize damage to the root, the tooth should be kept in milk or sterile saline while it is outside the mouth.Kidd, P. S., Sturt, P. A., & Fultz, J. (2000). ''Mosby's emergency nursing reference'' (2nd ed.). St. Louis: Mosby, Inc.


Periosteal avulsions

During a periosteal avulsion, the
periosteum The periosteum is a membrane that covers the outer surface of all bones, except at the articular surfaces (i.e. the parts within a joint space) of long bones. Endosteum lines the inner surface of the medullary cavity of all long bones. Structu ...
(a fibrous layer that surrounds a bone) detaches the bone's surface. An example of a periosteal avulsion is an ALPSA (anterior labral periosteal sleeve avulsion).


Surgical avulsions

An avulsion is sometimes performed surgically to relieve symptoms of a disorder, or to prevent a chronic condition from recurring. Small incision avulsion (also called ambulatory phlebectomy) is used to remove
varicose vein Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. These veins typically develop in the legs, just under the skin. Varicose veins usually cause few symptoms. However, some indi ...
s from the legs in disorders such as
chronic venous insufficiency Chronic venous insufficiency (CVI) is a medical condition in which blood pools in the veins, straining the walls of the vein. The most common cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are ...
. A nail avulsion is performed to remove all or part of a chronic
ingrown nail An ingrown nail, also known as onychocryptosis from el, ὄνυξ () 'nail' and () 'hidden', is a common form of nail disease. It is an often painful condition in which the nail grows so that it cuts into one or both sides of the paronychium ...
.American Academy of Orthopaedic Surgeons. ''Ingrown Toenail''. Retrieved January 15, 2009, fro

Facial nerve The facial nerve, also known as the seventh cranial nerve, cranial nerve VII, or simply CN VII, is a cranial nerve that emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste ...
avulsion is used to treat the involuntary twitching involved in
benign essential blepharospasm Blepharospasm is any abnormal contraction of the orbicularis oculi muscle. The condition should be distinguished from the more common, and milder, involuntary quivering of an eyelid, known as myokymia, or fasciculation. In most cases, blepharosp ...
.McCord, C.D. Jr., Coles, W.H., Shore, J.W., Spector, R., & Putnam, J.R. (1984, February). Treatment of essential blepharospasm: Comparison of facial nerve avulsion and eyebrow-eyelid muscle stripping procedure. ''Archives Of Ophthalmology, 102(2)'', 266-268.Grandas, F., Elston, J., Quinn, N., & Marsden, C.D. (1988, June). Blepharospasm: A review of 264 patients. ''Journal of Neurology, Neurosurgery, and Psychiatry, 51(6)'', 767-772. However, it often requires additional surgeries to retain function and
botulinum toxin Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neurom ...
injections have been shown to be more effective than surgical avulsions in treating benign essential blepharospasm, while causing fewer complications.


See also

*
Degloving A degloving injury is a type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply. It is named by analogy to the process of removing a glove. The causes of degloving can vary ...
*
Physical trauma An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or ...
*
Plastic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes cranio ...
*
Skin grafting Skin grafting, a type of graft surgery, involves the transplantation of skin. The transplanted tissue is called a skin graft. Surgeons may use skin grafting to treat: * extensive wounding or trauma * burns * areas of extensive skin loss du ...


References


External links

* {{General injuries Injuries Medical emergencies