Ring Avulsion Injuries Research Articles

Pronator Quadratus: A Preferable Recipient for Targeted Muscle Reinnervation of Neuromas in the Hand.

Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

Ring Avulsion Injuries: About Three Cases And Review of the Literature

Ring avulsions are rare and represent a wide variety of soft tissue and bone injuries, ranging from circumferential lacerations with or without vascular involvement to complete amputations. Treatment options are variable and depend on the injury pattern as well as functional and aesthetic requirements. We hereby report three cases of ring avulsions in three young males; all classified Urbaniak III, two treated with a revision amputation and the other with intrapalmar ray resection. In last follow-up of 12 months, the three patients were satisfied with cosmetic as well as functional results.

An ultra-thinned groin flap for reconstruction of complete digital ring avulsion injuries.

In complete digital ring avulsions, amputation is usually carried out when replantation of the avulsed tissue is not an option or has failed. The purpose of this study was to report our experience in treating Urbaniak Class III degloved fingers using an ultra-thinned pedicled groin flap. Sixteen patients from ages 11 to 26years were included. In all cases, the flexor digitorum superficialis tendon, extensor apparatus and proximal interphalangeal joint were intact. Rehabilitation included immediate active mobilization, with flap division at day 21. At a mean follow-up of 15months, all patients but one were satisfied with the appearance. Two had mild subjective cold intolerance. No flap failure was recorded. The mean total active motion was 183° and the mean QuickDASH score was 8.8/100. Patients recovered S1 sensibility according to the Mackinnon and Dellon classification. The ultra-thinned groin flap has proved to be a reliable technique for non-replantable ring avulsions.Level of evidence: IV.

Practical Techniques to Ensure Success in Digital Ring Avulsion Injuries.

Summary:A ring avulsion results from a longitudinal traction to a digit. We discuss practical microsurgical techniques essential in achieving good functional outcomes in these challenging cases, including aggressive debridement of the affected tissues and vessels, liberal use of vein grafts and arterialized venous flow through flaps when needed, and a meticulous microsurgical technique. We have found that patient selection is key in digit salvage and a good outcome is often achieved with the winning triad of optimal patient factors, surgical factors, and intensive hand therapy. We also include a case performed by our senior author to illustrate what can be achieved.

Avoiding Ring Avulsion Injuries With Silicone Rings: A Biomechanical Study

Finger avulsion injuries account for 5% of upper extremity injuries requiring evaluation in an emergency room. They are devastating injuries that require microvascular reconstruction or amputation. As public awareness rises, there is a growing market for silicone rings, with limited data on their ability to prevent ring avulsion injuries. Five cadaver forearms were attached to a custom fixture, allowing for ring avulsion simulations. Specifically designed silicone or metal rings of varying sizes (#4-#11) were assigned to one of five fingers on each forearm, based on fit. The contralateral corresponding finger was tested using a ring of the same size in the other material. A preload of 2 N was applied to each ring, and ultimate failure force was determined by applying an upward force at a loading rate of 500 mm/sec until failure. Additionally, a fifth cadaver forearm was used to determine the ultimate failure force of silicone rings in a clenched fist position. The average ultimate failure force for silicone rings of all sizes was 53.0 N, compared to 495.2 N for metal rings of all sizes. The average ultimate failure force of silicone rings in the clenched fist position was increased across rings of all sizes, with an average of 99.9 N. There were no degloving injuries in the silicone ring avulsion group. Biomechanically, silicone rings have a significantly lower failure force than metal rings and may help prevent ring avulsion injuries. The use of silicone rings should be encouraged in professions where ring avulsion injuries are more likely, such as heavy labor.

A Case Report of Ring Avulsion Injury: Under-recognized for Its Unique Implications in Transfer.

IntroductionRing avulsion injuries consist of a characteristic injury pattern resulting from sudden intense force pulling on a finger ring. While ring avulsion injury is a known entity in the hand surgery literature, there is scant description of the injury pattern in emergency medicine, much less its management and transfer implications in the emergency department (ED).Case ReportThis is a report of a patient presenting to the ED with ring avulsion injury after a workplace accident, initially transferred to a tertiary care hospital with general hand surgery, who then required a second transfer for consideration of microsurgical revascularization.ConclusionIn addition to fully assessing the degree of injury, including neurovascular and tendon involvement, emergency physicians must recognize cases of severe ring avulsion injuries without complete amputation as potential opportunities for microsurgical revascularization.

Digital avulsion injuries: epidemiology and factors influencing finger preservation.

The surgical treatment of ring avulsion injuries is still challenging. This study provides data concerning epidemiology and factors influencing finger survival rate. We wanted to answer the question whether microsurgical advancement and a high level of surgical expertise nowadays may improve the outcome. Between 11/2007 and 06/2016 95 ring avulsions were treated (classified according to Kay). Complete documentation was available from 87 patients (25 female). The mean age was 34 (4-82) years. Intact perfusion (Kay I) was preoperatively seen in 20 fingers while 67 were avascular (Kay II-IV). In 89%, the ring finger was injured during mainly private accidents. Primary amputation was performed in 38 Kay II-IV injuries. Revascularization was applied to 29 fingers while 8 of them (28%) primarily failed. After initially successful revascularization/replantation of 21 fingers, 6 had to be amputated secondarily (success rate: 52%). There was no significant correlation between affected finger and rate of finger preservation. Climbing over a fence as trauma mechanism significantly correlated with lower finger preservation rates and higher incidence of Kay IV injuries. Despite microsurgical advances and high levels of surgical expertise the finger survival rate after ring avulsion injuries still seems to be mostly influenced by the extend of intrinsic damage.

Against all odds: traumatic thumb amputation following ring avulsion injury

Background. Replantation of an avulsed digit often poses a surgical challenge even to an experienced microsurgeon. Therefore, it is often difficult to choose the treatment path for traumatic amputation of digit following ring avulsion injury, be it completion amputation or replantation. We discuss the surgical challenges encountered and management strategies used in this case of an unfortunate child who sustained an amputation of his dominant thumb.
 Clinical case. We present the case of a 10-year-old boy who sustained a complete amputation of his right thumb following a ring avulsion injury which was reconstructed with multiple approaches and surgical techniques to address difficulties at different stages. We replanted the avulsed thumb, reconstructed the tendon, soft tissue coverage with the use of allograft skin and local flap, and improvised surgical tactic to overcome complications encountered intra- and post-operative states such as thrombosis of arterial anastomosis and venous congestion.
 Discussion. There is scarce literature on the management of ring avulsion injury of the thumb and to the authors best knowledge, there was only one reported case in children. In the case described here, we report a good outcome with complex reconstructive surgery despite all odds in an attempt to salvage the thumb, especially in a pediatric population. Post-surgical reconstruction, the boy achieved a successful and acceptable outcome in terms of function and aesthetic appearance.
 Conclusion. The journey through replantation of an amputated digit following avulsion injury poses various challenges both to the microsurgeon and patient. The decision of surgical tactics must be tailored and thoroughly reason based on the knowledge, experience, and good microsurgical skill. A good surgical outcome can be achieved even in a complex injury in the pediatric population with careful planning and the right intervention in each complication peri-operative.

Microsurgical repair of ring avulsion injuries

Objective To investigate the clinical effect of microsurgical repair after ring avulsion injuries. Methods From March, 2009 to December, 2014, 6 cases (6 fingers) of ring avulsion injury were repaired. There were 4 males and 2 females with an age range of 18-30(mean, 22) years, which were 4 cases of ring finger and 2 cases of middle finger. The plane of injury was metacarpophalangeal band. Fracture and dislocation was reduced and fixed if damage fingers following with fracture and dislocation of interphalangeae. The damage ligament and volar plate and extensor tendon was repaired. The digital arteries and veins were repaired, and the digital nerves were sutured. System rehabilitation exercise carried out postoperatively. Results All fingers survived, and were followed-up for 8 to 30 months. The appearance of the fingers was excellent. The avarege range of motion of the proximal interphalangeal was 80°(ranged from 70° to 100°). The distal interphalangeal was 50° (ranged from 40° to 60°). The sensory recovery of finger pulp ranged from S3 to S3+. The two-point discrimination was 5 mm to 12 mm. According to the Evaluation Criteria for Finger Replantation and Reconstruction Issued by Chinese Hand Surgery of Chinese Mdical Association, 4 fingers had excellent while 2 had fairly good function. Conclusion Microsurgical repair of ring avulsion injury can achieve satisfactory clinical results by rehabilitation exercises postoperatively. Key words: Fingers; Ring avulsion injury; Repair; Microsurgical technique

Complete ring finger avulsion: Review of 16 years of cases at a Hand Emergency Unit

Replanting complete ring avulsion injuries remains a challenge for hand surgeons. The prognosis depends on achieving satisfactory function. We present the results of our 16 years’ experience with managing this type of injury. Our cohort consisted of 83 cases of complete ring avulsion injuries in patients with an average age of 23.5 years, treated in a Hand Emergency Unit between 1998 and 2014. Seventy-two were replanted. A vein graft was used in 57 cases to bridge the arterial injury and direct anastomosis was performed in 15 cases. Forty-one cases were a microsurgical success. Twenty-four patients were reviewed with an average follow-up of 87 months. The mean of total active motion was 164°, with 64° range of motion in the proximal interphalangeal joint on average. The two-point discrimination for sensitivity averaged 6mm. Two cases of severe cold intolerance were noted. Using a graft for vascular repair increases the odds of microsurgical success. The functional outcome depends on the condition of the proximal interphalangeal joint. Cold intolerance and lack of sensitivity have little effect on the functional outcome and patient satisfaction. Replantation of complete digital avulsion injuries should be attempted. Amputation at the metacarpal base is better discussed later on, after the initial surgery.

Ring Avulsion Injuries: A Systematic Review.

Ring avulsion injuries can range from soft tissue injury to complete amputation. Grading systems have been developed to guide treatment, but there is controversy with high-grade injuries. Traditionally, advanced ring injuries have been treated with completion amputation, but there is evidence that severe ring injuries can be salvaged. The purpose of this systematic review was to pool the current published data on ring injuries. A systematic review of the English literature published from 1980 to 2015 in PubMed and MEDLINE databases was conducted to identify patients who underwent treatment for ring avulsion injuries. Twenty studies of ring avulsion injuries met the inclusion criteria. There were a total of 572 patients reported with ring avulsion injuries. The Urbaniak class breakdown was class I (54 patients), class II (204 patients), and class III (314 patients). The average total arc of motion (TAM) for patients with a class I injury was 201.25 (n = 40). The average 2-point discrimination was 5.6 (n = 10). The average TAM for patients with a class II injury undergoing microsurgical revascularization was 187.0 (n = 114), and the average 2-point discrimination was 8.3 (n = 40). The average TAM for patients with a class III injury undergoing microsurgical revascularization was 168.2 (n = 170), and the average 2-point discrimination was 10.5 (n = 97). Ring avulsion injuries are commonly classified with the Urbaniak class system. Outcomes are superior for class I and II injuries, and there are select class III injuries that can be treated with replantation. Shared decision making with patients is imperative to determine whether replantation is appropriate.

Ring avulsion injury の治療経験

Ring avulsion injury の治療経験

Extended distally based DMCA flap in combination with autologous amputate skin transplantation as a salvage procedure for ring avulsion injury.

A 23-year-old male student presented to our clinic with a traumatic complex ring avulsion of his right dominant index finger. Clinical evaluation revealed a complete distal amputation of the DIP joint with a laceration of the soft tissue at the middle phalanx and a rupture of the FDP-2-tendon far proximally. We hereby present the patient’s clinical outcome after reconstruction with a distally based extended DMCA-II flap. To our own knowledge, this is the first report of an extended distally based DMCA flap for coverage of a class IVd ring avulsion injury in combination with autologous amputate skin transplantation.Level of Evidence: Level V, therapeutic study.

Secondary restoration of fingertip sensation with Littler's heterodigital neurovascular island flap after ring avulsion injury: Report of two cases

Treatment of ring avulsion injuries is technically challenging. Surgical success depends not only on revascularization and anatomic restoration but also on functional recovery. A functional finger is mobile and sensible. We report two cases of secondary restoration of the finger pulp's sensibility with Littler's heterodigital neurovascular island flap after a ring avulsion injury. Two patients (47-year-old physiotherapist and 21-year-old student) suffered a degloving injury of the 4th finger on the left hand, classified in Urbaniak class III and Kay-Adani class IVd. The emergency treatment consisted in replantation with suture repair of the ulnar proper palmar digital artery; the nerve was not repaired due to its avulsion from the pulp. Four months later, once the vascularization was stable, restoration of the fingertip's sensibility was done using Littler's heterodigital neurovascular island flap. The 3rd finger's ulnar palmar digital pedicle was dissected using a hemi-Bruner incision. The pedicled flap was brought to the host site after being tunneled through the 4th finger's base. A split skin graft was performed at the donor site. After three years of follow-up, two-point discrimination on the 4th finger's radial pulp was 5mm and cortical integration was satisfactory. The donor site had only tactile sensitivity. The DASH (Disabilities of the Arm, Shoulder and Hand) score was 13.3 and 11.7, and the total arc of motion was 90° and 180°, respectively. Littler's flap seems to be appropriate for restoring sensation at fingertip after ring avulsion injuries. Donor site complications seem acceptable.

Long-term outcome after use of an acellular collagen matrix in a finger degloving injury

In ring avulsion injuries, replantation may not always be possible because of the extent of the injury or the loss of the severed part. Under these circumstances, other treatment options should be considered. We describe our 5-year follow-up experience after the coverage of a complete digital ring degloving injury with an acellular collagen matrix. The distal phalanx needed to be amputated. Acceptable long-term functional and cosmetic outcomes were attained. Level of Evidence: Level V, therapeutic study.

Ring injuries of the finger: long-term follow-up.

The purpose of this study was to report on the injury patterns and outcomes of a series of patients treated at our institution between the years 1983 and 2010 who were injured by rings worn on their finger. The series included typical ring avulsion injuries as well as all other injuries caused by rings. Retrospective chart review was conducted on 33 patients with ring injuries treated by the senior author and colleagues. Eight cases were classified as Urbaniak class I, 13 class II, and 12 class III. Satisfactory finger motion occurred with salvage of fingers in which no damage occurred to the proximal phalanx or flexor digitorum sublimus or profundus tendons. All patients with flexor tendon injury or proximal phalangeal fracture or both had loss of PIPJ motion and total active motion as compared to class II injuries without tendon and bone involvement. Four class III injuries were treated with replantation. One failed requiring revision amputation at the metacarpalphalangeal joint level due to ischemia. The remaining eight were treated by primary amputation. As a guideline to digit salvage with ring injuries, the authors propose accurately documenting and basing treatment on all injured structures. Particular attention should be given to fractures of the proximal phalanx and laceration of the flexor digitorum sublimus and profundus tendons, as injury to these structures led to significant loss in mobility of the finger in this series. While some current guidelines advise revascularization of class II ring avulsion injuries, our series suggests caution in anticipating good results with sublimus or profundus tendon laceration and proximal phalanx fracture. If the profundus tendon only is lacerated, particularly in zone I injuries, results of finger salvage may still be acceptable, but associated (distal interphalangeal joint) DIPJ injury may require K-wire stabilization and later fusion. Replantation in class III injuries, while possible, is warranted only in select situations (patient-specific and cultural factors).

Salvage of Complete Degloved Digits With Reversed Vascularized Pedicled Forearm Flap: A New Technique

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

Removal of a titanium alloy ring

British Journal of Hospital MedicineVol. 72, No. 9 Case ReportRemoval of a titanium alloy ringS Bleibleh, J Childs, M BaqaiS BleiblehSearch for more papers by this author, J ChildsSearch for more papers by this author, M BaqaiSearch for more papers by this authorS Bleibleh; J Childs; M BaqaiPublished Online:16 Aug 2013https://doi.org/10.12968/hmed.2011.72.9.529AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Fejjal N, Belmir R, El Mazouz S et al. (2008) Finger avulsion injuries: A report of four cases. Indian J Orthop 42(2): 208–11 Crossref, Medline, Google ScholarKapickis M, Kutz JE (2007) Titanium alloy ring crush injury. Am J Emerg Med 25(9): 1084 Crossref, Medline, Google ScholarUrbaniak JR, Evans JP, Bright DS (1981) Microvascular management of ring avulsion injuries. J Hand Surg Am 6(1): 25–30 Crossref, Medline, Google ScholarWilliams D (2001) The golden anniversary of titanium biomaterials. Med Device Technol 12(7): 8–11 Google Scholar FiguresReferencesRelatedDetailsCited byRing Removal: A Comprehensive Review of TechniquesThe Journal of Emergency Medicine, Vol. 63, No. 2Evaluation of a two rubber band technique for finger ring removalThe Annals of The Royal College of Surgeons of England, Vol. 98, No. 5Review of techniques for the removal of trapped rings on fingers with a proposed new algorithmThe American Journal of Emergency Medicine, Vol. 31, No. 11 1 September 2011Volume 72Issue 9ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 16 August 2013 Published in print 1 September 2011 Information© MA Healthcare LimitedThe authors would like thank to Dr David Kendrick who was involved with this patient's management along with Barrow Fire Brigade and Furness General Hospital Works Department.PDF download

Double Cross-Finger Flaps

A new approach "Double Cross-Finger Flaps" was used for coverage of ring avulsion injuries. In our series, 22 cases of ring avulsion injuries were operated upon by this new technique. Choice of the patient suitable for such technique is based upon fulfillment of certain criteria. Two cross-finger flaps were harvested, one to cover the palmer aspect and the other to cover the dorsal aspect after being de-epithelized and turned over. Split-thickness graft was then applied to cover the raw areas. Both functional and aesthetic outcomes were reported after a mean of 6 months period of follow-up.

Salvage of Degloved Digits With Heterodigital Flaps and Full Thickness Skin Grafts

The purpose of this paper is to report the salvage of degloved digits (class III ring avulsion injuries [Urbaniak et al classification] [J Hand Surg Am. 1981;6:25-30]) using the heterodigital neurovascular island flap (originally developed by Moberg and Littler) in addition to full thickness grafting.Six fingers with class III ring avulsion injuries (Urbaniak et al classification) were included. The volar surface is covered with a heterodigital island flap from the adjacent finger, while a full thickness graft is applied to the dorsum.All flaps survived. Mean graft take was 85%. Mean static two point discrimination was 8.3 mm. The mean total active range of motion in the digits with intact tendons was 190 degrees. In the digits with absent tendons the total active range of motion was 90 degrees. Cold intolerance and cross sensibility were reported in half of the patients. Mean follow-up was 20.3 months (range: 6-42 months).The technique described is useful to salvage degloved digits when replantation is not feasible and the patient refuses amputation despite careful counseling. Donor finger morbidity however is a major concern, and in this regard both patient and surgeon should consider the decision carefully.