Ring Avulsion Injuries

1
Ring Avulsion Injuries

• Lip Teh
• Sir Charles Gairdner Hospital

2
Clinical Case

• Mrs Whitehouse 59yr old female
• Admitted 29.6.03
• Balancing up to get key, slipped and caught
  wedding ring.
• Sustained circumferential skin laceration

3
Examination

• Venously congested
• Intact sensation
• No skeletal injury
• Long tendons intact

4
Dorsum
5
Volar
6
Operative Findings

• Circumferential degloving
• No intact patent veins
• Radial side digital artery avulsed
• Ulnar digital neurovascular bundle intact
• Tendons intact

7
Clinical course

• Dorsal vein repaired
• Good venous return
• 36hrs later development of venous congestion
• Returned to theatre

8
Clinical course

• Venous repair thrombosed
• Patent dorsal veins found on dissection distally
• Two dorsal veins repaired with vein grafts

9
Ring Avulsion

• Ring finger
• Grip
• Continence of cupped hand
• Symbolic role
• Significance of injury often under-appreciated

10
Classification

• Urbaniak 1981
• I. Circulation Adequate
• II. Circulation Inadequate
• III. Complete degloving or amputation
• Nissenbaum modification 1984
• IIA. Circulation Inadequate (only arteries
  injured)

11
Prognosis

• Kay et al. J Hand Surg 1989
• Retrospective review 55 patients
• Class I (n3)
• Class II (n25)
• Class III (n27)
• 8 primary amputations
• Class II (n3)
• Class III (n5)

12
Prognosis

• 44 microsurgical repair
• Class II (n22) Class III (n22)
• 9 secondary amputations (vascular insufficiency)
• Success rate
• Kay 1989 Urbaniak 1981
• Class II 86 100
• Class III 73 71

13
Methods

• Repaired 3 veins on average
• 50 vein grafts for veins
• 50 required skin grafts
• Venous and cross finger flaps in 11
• Hyperbaric oxygen in 20

14
Findings

• No difference in salvage, function and
  sensibility with Class II and III.
• Presence of skeletal injury
• More likely to require secondary procedures
• Reduced function
• Later return to work

15
Findings

• Arterial or venous only compromise 100 salvage
• Both arterial and venous compromise 70-75
  salvage (similar to replant)

16
Proposed Classification

• Kay 1989
• I. Circulation Adequate
• II. Circulation Inadequate (arterial and venous),
  no skeletal injury
• III. Circulation Inadequate (arterial and
  venous), skeletal/joint injury
• IV. Complete amputation
• Subclasses a and v for arterial and/or venous
  compromise

17
Lessons

• Salvagable injuries
• Multiple venous anastamosis
• Vein grafts to traverse past zone of injury