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Original article

Can ring finger injuries be prevented by pre-fragilized rings? About threeclinical cases

Les traumatismes de type doigt d’alliance peuvent-ils être prévenus par des bagues pré-fragilisées ?À propos de trois cas cliniques

A.S. Matheron, S. Hendriks, S. Gouzou, P.A. Liverneaux *, S. FaccaDepartment of hand surgery, Strasbourg university hospitals, 10, avenue Baumann, 67403 Illkirch cedex, France

Received 12 January 2014; received in revised form 16 March 2014; accepted 24 March 2014

Abstract

Prevention of finger trauma can be directly related to the manufacture of pre-weakened rings. We report on three clinical cases of finger injuriescaused by pre-weakened rings. Lesions were less severe than conventional ring finger injuries, such as those caused by iron fences. Surgery wasrequired in all three cases and chronic cold sensitivity was noted in one case. This small series advocates the imposition of a ring manufacturingstandard at the European level. Given this lack of consensus, the idea is to prevent injuries by developing rings with intentional weak points thatopen automatically in case of trauma. These pre-weakened rings have never been subject to clinical study to demonstrate their potential safety.# 2014 Elsevier Masson SAS. All rights reserved.

Keywords: Ring-related trauma; Ring finger; Pre-weakened rings

Résumé

La prévention des traumatismes digitaux passe notamment par la fabrication de bagues fragilisées. Nous rapportons ici 3 cas cliniques de lésionsdigitales provoquées par des bagues pré-fragilisées. Les lésions étaient moins graves que les classiques doigts d’alliance, s’apparentant aux plaiespar grillage. Dans les 3 cas, elles nécessitaient une intervention chirurgicale et provoquaient 1 fois des séquelles à type de douleurs au froid. Cettecourte série plaide l’imposition d’une norme de fabrication des bagues à l’échelle européenne.# 2014 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Traumatisme par bague ; Doigt d’alliance ; Bague pré-fragilisée

Available online at

ScienceDirectwww.sciencedirect.com

Chirurgie de la main xxx (2014) xxx–xxx

1. Introduction

So-called ‘‘ring finger’’ injuries are complex multi-tissuelesions that typically require emergency microsurgery. Theirseverity, classified into four stages, extends from a simple skinbruise to complete finger amputation by avulsion [1,2]. Most ofthe published cases are stage 4 injuries. Some authors considerthat replantation should be attempted at all costs [3,4], while

* Corresponding author.E-mail address: philippe.liverneaux@chru-strasbourg.fr (P.A. Liverneaux).

Please cite this article in press as: Matheron AS, et al. Can ring finger injuChir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004

http://dx.doi.org/10.1016/j.main.2014.03.0041297-3203/# 2014 Elsevier Masson SAS. All rights reserved.

others consider the potential consequences to be unjustified[5,6].

2. Observations

2.1. Patient A

Female 13-year-old schoolgirl, non-smoker, right-handed,presented to the emergency department with a lesion of thethird right finger caused by a pre-weakened ring (Fig. 1). Themechanism of injury was a similar to those caused by iron

ries be prevented by pre-fragilized rings? About three clinical cases.

Fig. 1. Patient A - Finger injuries caused by a pre-weakened ring: Palmar aspect. Note the longitudinal deep wound of the three phalanges (A). Dorsal aspect. Note thetrack of the ring without deep skin lesion (B). Ring. Note the complete and incomplete breakage at the various intentional weak points. Also note the twist in the ringindicative of insufficient weakening (C).

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fences. The patient underwent emergency surgery (Fig. 1). Thefinger flexor sheath was opened but no tendon, blood vessel ornerve injury was noted. We performed skin debridement,exploration, flexor sheath lavage and skin suture. Thepostoperative course was uneventful and consisted of oneovernight hospital stay and interruption of leisure activities fortwo months. At a follow-up of one and half years, the patientwas pain-free, the Quick DASH was 0/100, range of motion andpulp sensitivity were complete and she presented no coldsensitivity.

2.2. Patient B

Male 13-year-old student, non-smoker, right-handed, pre-sented to the emergency department with a lesion of the thirdleft finger caused by a pre-weakened ring. Mechanism of injurywas a fall from the top of a wall. There was a deep longitudinalwound of the first two phalanges and the patient underwentemergency surgery. Since there was no nerve or blood vesselinjury, we performed skin debridement, exploration and skin

Please cite this article in press as: Matheron AS, et al. Can ring finger injuChir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004

suture. The postoperative course consisted of one day only ofschool attendance and interruption of leisure activities for threeweeks. At one year and three months of follow-up, the patientwas pain-free, the Quick DASH was 0/100, range of motion andpulp sensitivity were complete and he presented no coldsensitivity.

2.3. Patient C

Female 22-year-old student, non-smoker, right-handed,presented to the emergency department with a lesion of thefourth right finger caused by a pre-weakened ring. Themechanism of injury was unclear. The wound was deep and thepatient underwent emergency surgery. Since there was no nerveor blood vessel injury, we performed skin debridement,exploration and skin suture. The postoperative course consistedof a three-night hospital stays and interruption of leisureactivities for two weeks. At four and a half years of follow-up,the patient was pain-free, the Quick DASH was 0/100, range of

ries be prevented by pre-fragilized rings? About three clinical cases.

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motion and pulp sensitivity were complete. However, shepresented with cold sensitivity.

3. Discussion

Finger ring injuries are no longer limited to ring fingersamong married patients. Currently, these injuries affect allfingers including the thumb in increasingly young patients [7],as we also observed in our small clinical series. Studies havebeen performed to look at how to prevent such serious injuries[8–11]. Children’s toys must now include intentional weakpoints [12]. Rings for adults can be modified to incorporateinvisible weak points that would break before tearing the finger[13]. However, to be effective, this method implies therecalibration of the drill guide for every ring model and alsorequires the manufacturer to bear the high costs, which explainsits very limited uptake. The safety of other ring weakeningmethods has never been evaluated.

Our three cases of injury by pre-weakened rings illustratethis latter process. The ring broke into two pieces during traumaand its edges made a deep, proximal to distal longitudinal skinlesion indicative of a traction mechanism. This mechanism canbe likened to that of ring finger injuries caused by iron fences[14]. Even though the lesions caused by these pre-weakenedrings in our series were less serious than those caused byconventional rings, they still required surgery, hospitalization,financial costs and were responsible for sequelae such coldsensitivity. This could have been avoided if a manufacturingstandard had been in effect. Australia obligated all manufactu-rers to cap their fences to prevent finger injuries [15]. Whycouldn’t the European Union do likewise for ring finger injuryprevention by imposing a standard, such as the processdescribed by Dubert et al. [13]?

Please cite this article in press as: Matheron AS, et al. Can ring finger injuChir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004

Disclosure of interest

Philippe Liverneaux has conflicts of interest with NewclipTechnics, Integra, Argomedical. The other authors declare thatthey have no conflicts of interest concerning this article.

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[12] Décret no 2010-166 du 22 février 2010. Sécurité des jouets. JORF2010;46:3476.

[13] Dubert T, Diop A, Voeltzel P. An experimental study of ring avulsioninjuries and two preventives devices. J Hand Surg Br 2000;25:418–21.

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ries be prevented by pre-fragilized rings? About three clinical cases.