Ring Avulsion Injuries: A Systematic Review

Case report: Immediate thumb reconstruction using reverse radial flap surgical technique

INTRODUCTION

The human hand is highly mobile and functional, being essential in the prehensile function. Thumb injuries are divided into distal, medial and proximal. Post-traumatic defects in the thumb can lead significant functional impairment. Reconstructive is always de primary goal to preserve function without pain.

CASE PRESENTATION

The case of a 37-years-old male, right hander, with a traumatic avulsion of the thumb in the right hand. On physical examination, exposure of the tendon and bone with distancing from the metacarpophalangeal joint, mobility function and Allen's clinical test of the palmar arch was preserved. We plan a reverse radial flap for coverage.

CLINICAL DISCUSSION

The anatomy of the hand represents a scope in working life and recreative activities. Surgical techniques are the primary tool in the management of reconstruction, being designed with the intention of maintaining integrity and optimal function. Flaps are a fundamental pillar in reconstructive practice.

CONCLUSION

The reverse radial forearm flap provides benefits among the reconstructive methods for soft tissues of coverage dorsal or palmar area of the hand in the scenario where the thumb suffers from slack and tissue is not available for reimplantation and when microsurgical options are not viable.

A Useful Technique for Templating the Reverse Radial Forearm Flap (RFF) for Thumb Degloving Injuries

Degloving injuries of the thumb pose a significant challenge as replantation is usually unsuccessful. A 60-year-old man was transferred to "Queen Victoria Hospital NHS Trust" four hours after having his left thumb completely avulsed at metacarpophalangeal level. The anastomosis repeatedly failed during urgent replantation and a distally based pedicled RFF was utilized. To achieve accurate flap design, we used the amputated part as a template for the missing tissue. After a longitudinal cut exposing the inner surface, the thumb was placed flat on top of a clean gauze package which was used as a paper template for the skin paddle; the flap was subsequently sutured without tension. Since the circumferential soft tissue envelope is three-dimensional, accurate designing of the flap on the forearm is vital. We propose a useful technique using the amputated part to enable a precise estimation of the tissue requirements to reduce potential complications related to flap inset.

Indications for replantation and factors that predict success

Since the advent of replantation techniques, there has been uneven progress in terms of success-even considering whether success is defined as continued perfusion of the digit or long term functional outcomes. Early enthusiasm and success have not been maintained despite increasing familiarity with microsurgical techniques and greater understanding of how to optimize outcomes for the individual components of replantation such as tendon repair, nerve repair, and osteosynthesis. Practitioners participating in the care of patients undergoing replantation should be familiar with the history and current understanding of both the indications and contraindications for the procedure, post-operative rehabilitation, and factors contributing to functional outcomes. A review of the literature from the first publications on the topic demonstrates evolution in practice and understanding of which patients should be indicated for replantation. Indications can be considered in three broad categories: injury factors, patient factors, and care context factors. These factors intersect with one another and can inform the surgeon pre-operatively regarding the most likely outcome for a given patient. This insight is critical to discuss pre-operatively with the patient in order to make a shared decision about how to manage their injury.

Reverse Flow Shunt Restricted Free Venous Flap for a Ring Avulsion Injury

Arterialized venous flaps can be an excellent option for reconstruction of digital defects. Previously, they remained unpopular owing to the high rate of venous congestion. Different techniques of restriction of the arteriovenous shunting have been described to mitigate this problem. In this article, the authors discuss a unique case whereby a reverse flow shunt restricted venous flap was used in an Urbaniak type III ring avulsion.

Staged Reconstruction of Chronic Constriction of Thumb Caused by a Stuck Ring – A Case Report

We report the management of a 45-year-old man with a ring stuck in his dominant thumb for 3 weeks causing vascular and neural compromise and deep-seated infection. Previous reports have described rings embedded in the digits, though we were not able to find any reports of such rings causing ischaemia. We performed staged reconstruction to salvage the thumb. The thumb viability was confirmed after ring removal and the infection was treated as per culture sensitivity report. Both digital nerves were reconstructed with sural nerve graft and the circumferential soft tissue defect was covered with bilobed first dorsal metacarpal artery flap from index and middle finger. At the 6-month follow-up, the patient had useful function of the thumb with well-settled donor site on index and middle finger.

Level of Evidence: Level V (Therapeutic)

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 26 years 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 15 months, 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.

Destructive Arthropathy of the Interphalangeal Joint Following Revascularization After Degloving Hand Injury: A Case Report

It is difficult to achieve satisfactory results in the treatment of advanced degloving injury, which is one of the most challenging injuries in hand surgery. In this report, we present a case of marked destructive arthropathy of the interphalangeal joint that developed following revascularization after degloving hand injury. A 37-year-old, right-handed female manual worker sustained a degloving injury of her fingers, including the dorsal hand. We performed revascularization and secondary surgery, which included tenolysis and a tendon graft, to obtain functional improvement. These 2 procedures provided significant improvement in the active range of motion of the respective fingers. However, the patient complained of postoperative pain in the proximal interphalangeal joint. X-ray revealed destructive changes in the interphalangeal joint, which advanced progressively. Destructive changes in the interphalangeal joint following advanced degloving injury should be recognized as a potential complication that could be a limitation of functional restoration. Follow-up X-ray examination is necessary, even in cases with no fracture of the phalanges at the time of injury. In the management of degloving injury, patients should be informed of the potential risk of destructive arthropathy, which could result in restricted motion with pain.

Use of silicone finger prostheses in amputee patients: An integrative review

This study aimed to perform an integrative review of the literature on the use of silicone finger prostheses in amputee patients. Searches were performed in the PubMed, EMBASE, Web of Science, Scielo, and Cochrane Library databases until July 2021. Descriptors used in this article were: Silicone, finger, rehabilitation, and prosthesis. Clinical research and clinical reports on silicone finger prostheses, available in full and in English were included. Initially, 152 articles were identified. After establishing the inclusion/exclusion criteria, 23 studies were identified and constituted the final sample. Regarding the publication date of the included studies, 17.2% of them were published between 2012 and 2016. Most of the rehabilitations occurred in India (69.9%; n = 16), and the mean age of patients who used prostheses was 38.1 years. The level of scientific evidence of the included studies was IV and VI. Therefore, patients rehabilitated with silicone finger prostheses highlighted significant improvements in functional range of motion, restoration of self-esteem, advantages in psychological therapy, more pleasant social interaction, and changes in their quality of life.

Avoiding Ring Avulsion Injuries With Silicone Rings: A Biomechanical Study

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Biomechanically, silicone rings have a significantly lower failure force than metal rings and may help prevent ring avulsion injuries.

CLINICAL RELEVANCE

The use of silicone rings should be encouraged in professions where ring avulsion injuries are more likely, such as heavy labor.

Photoacoustic Microscopy Provides Early Prediction of Tissue Necrosis in Skin Avulsion Injuries

BACKGROUND

Skin avulsion injuries caused by high-energy traffic and machinery accidents are important topics in the field of repair and reconstruction. The injury generates a skin flap with uncertain vascular basis resulting in ischemic necrosis of the distal portion of the flap. Yet there is lack of reliable way for estimating the extent of blood supply in damaged tissue, which has limited the possibility of prompt surgical intervention. Recent studies have confirmed that photoacoustic microscopy imaging has a wide range of applications in the biomedical field owing to its good performance in angiography.

METHODS

In our study, we successfully surgically induced skin avulsion injury on mice hindlimbs. Then, we used this novel approach to image skin microcirculation and predict skin necrosis with impaired blood supply after injury in live mice.

RESULTS AND CONCLUSION

All skin tissues in the avulsed hindlimb flap group show different levels of necrosis at the end of the observation period. The "dark zone" with impaired microcirculation in PAM images, which continuously extends over time, was seen as a prediction of necrosis of skin tissue and at 60 min after surgery was similar to the area of clinical necrosis on postoperative day 7. All these indicate that photoacoustic microscopy imaging is a feasible, precise, high-resolution, non-invasive technique for early prediction of necrosis in skin avulsion injury, providing a promising tool for surgeons to manage the injury.

Full-Thickness Skin Graft From an Amputated Part: Review of Successful Treatment of Class III Ring Avulsion Injury at Bedside in the Emergency Department

Urbaniak class III ring avulsion injuries involve significant soft tissue and bone loss. Management typically focuses on immediate, temporary soft tissue coverage followed by a planned trip to the operating room for either amputation or replantation. While soft tissue coverage is of utmost importance, maintenance of digital length, functionality, and cost-effectiveness of viable treatment options should also be considered. The use of soft tissue from amputated structures is well documented, especially in the case of planned surgical amputations. This method has also been known to be used in the case of hand injuries with severe soft tissue compromise; however, there are no known, documented reports of acute treatment of injuries such as ring avulsions with such methods. In this report, we present a case of a class III ring avulsion injury treated utilizing a single-stage, full-thickness skin graft obtained from an amputated part in the emergency department.

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

Introduction

Ring 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 Report

This 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.

Conclusion

In 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.

When Marriage Hurts: A Literature Review of Embedded Jewellery Ring Injuries

A ring is traditionally worn as a symbol of love and affection or as decorative ornamental jewellery. However, rings are not without risk. The spectrum of danger can range from debilitating avulsion injuries to simple contact dermatitis. Unknown to many, an unusual rarity exists; previous authors have termed this entity 'embedded ring syndrome'. We sought to review the literature and collate evidence on the common features of this syndrome. A literature review was performed on cases reported from 1947 to 2017 accessed through the healthcare database advanced search (HDAS). A total of 28 cases were analysed for demographics, symptomatology and operative techniques. Overall, 64.3% were females, and 50% had a psychiatric comorbidity. There was a causative event preceding the injury in 35.7% of cases; 71.4% had a reduced range of movement or reported a stiff finger and 32.1% had reduced sensation. The majority of patients underwent ring removal and primary closure, without documentation as to whether neurovascular bundles and tendons were visualised. Embedded ring injuries are rare. Consequently, information is sparsely available regarding its natural history and management. The hand surgeon's approach requires an understanding that the chronicity of these injuries can have a significant traumatic impact on the structures of the finger.

Digital avulsion injuries: epidemiology and factors influencing finger preservation

INTRODUCTION

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.

PATIENTS AND METHODS

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).

RESULTS

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.

CONCLUSION

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.

Outcomes Following Replantation/Revascularization in the Hand

The variability in reported outcomes and outcome measures used in digit replantation makes it difficult to compare results among studies. This article reviews the principles of measuring functional and patient-reported outcomes after replantation, and describes the recommended instruments to use and ways to report results.