Ring Avulsion InjuriesRing Avulsion Injuries

Lip TehLip Teh

Sir Charles Gairdner HospitalSir Charles Gairdner Hospital

Clinical CaseClinical Case

Mrs Whitehouse 59yr old femaleMrs Whitehouse 59yr old female Admitted 29.6.03Admitted 29.6.03 Balancing up to get key, slipped and Balancing up to get key, slipped and

caught wedding ring.caught wedding ring. Sustained circumferential skin Sustained circumferential skin

lacerationlaceration

ExaminationExamination

Venously congestedVenously congested Intact sensationIntact sensation No skeletal injuryNo skeletal injury Long tendons intactLong tendons intact

DorsumDorsum

VolarVolar

Operative FindingsOperative Findings

Circumferential deglovingCircumferential degloving No intact patent veinsNo intact patent veins Radial side digital artery avulsedRadial side digital artery avulsed Ulnar digital neurovascular bundle Ulnar digital neurovascular bundle

intactintact Tendons intactTendons intact

Clinical courseClinical course

Dorsal vein repairedDorsal vein repaired Good venous returnGood venous return 36hrs later – development of venous 36hrs later – development of venous

congestioncongestion Returned to theatreReturned to theatre

Clinical courseClinical course

Venous repair thrombosedVenous repair thrombosed Patent dorsal veins found on Patent dorsal veins found on

dissection distallydissection distally Two dorsal veins repaired with vein Two dorsal veins repaired with vein

graftsgrafts

Ring AvulsionRing Avulsion

Ring fingerRing finger GripGrip Continence of cupped handContinence of cupped hand Symbolic roleSymbolic role

Significance of injury often under-Significance of injury often under-appreciatedappreciated

ClassificationClassification

Urbaniak 1981Urbaniak 1981 I. Circulation AdequateI. Circulation Adequate II. Circulation InadequateII. Circulation Inadequate III. Complete degloving or amputationIII. Complete degloving or amputation

Nissenbaum modification 1984Nissenbaum modification 1984 IIA. Circulation Inadequate (only arteries IIA. Circulation Inadequate (only arteries

injured)injured)

PrognosisPrognosis

Kay et al. J Hand Surg 1989Kay et al. J Hand Surg 1989 Retrospective review 55 patientsRetrospective review 55 patients

Class I (n=3)Class I (n=3) Class II (n=25)Class II (n=25) Class III (n=27)Class III (n=27)

8 primary amputations8 primary amputations Class II (n=3)Class II (n=3) Class III (n=5)Class III (n=5)

PrognosisPrognosis

44 microsurgical repair44 microsurgical repair Class II (n=22); Class III (n=22)Class II (n=22); Class III (n=22) 9 secondary amputations (vascular 9 secondary amputations (vascular

insufficiency)insufficiency) Success rate:Success rate:

Kay 1989Kay 1989 Urbaniak 1981Urbaniak 1981 Class II 86% Class II 86% 100%100% Class III 73%Class III 73% 71%71%

MethodsMethods

Repaired 3 veins on averageRepaired 3 veins on average 50% vein grafts for veins50% vein grafts for veins 50% required skin grafts50% required skin grafts Venous and cross finger flaps in 11%Venous and cross finger flaps in 11% Hyperbaric oxygen in 20%Hyperbaric oxygen in 20%

FindingsFindings

No difference in salvage, function No difference in salvage, function and sensibility with Class II and III.and sensibility with Class II and III.

Presence of skeletal injuryPresence of skeletal injury More likely to require secondary More likely to require secondary

proceduresprocedures Reduced functionReduced function Later return to workLater return to work

FindingsFindings

Arterial or venous only compromise – Arterial or venous only compromise – 100% salvage100% salvage

Both arterial and venous compromise Both arterial and venous compromise – 70-75% salvage (similar to replant)– 70-75% salvage (similar to replant)

Proposed ClassificationProposed Classification

Kay 1989Kay 1989 I. Circulation AdequateI. Circulation Adequate II. Circulation Inadequate (arterial and venous), II. Circulation Inadequate (arterial and venous),

no skeletal injuryno skeletal injury III. Circulation Inadequate (arterial and III. Circulation Inadequate (arterial and

venous), skeletal/joint injuryvenous), skeletal/joint injury IV. Complete amputationIV. Complete amputation

Subclasses Subclasses aa and and vv for arterial and/or venous for arterial and/or venous compromisecompromise

LessonsLessons

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