Ring Avulsion, a Traumatic Finger Injury

Recently talk show host Jimmy Fallon explained to his audience how a seemingly minor fall nearly cost him a finger – shedding light on a rare yet serious finger trauma known as a Ring Avulsion injury.

Ring avulsion results from the mechanism of crushing, shearing and avulsion, inducing severe macroscopic and microscopic damage. This type of injury often occurs when a ring that an individual is wearing is caught on an object, usually during a fall or jump.  It can also occur when caught on fast moving equipment or just simply in a “freak” accident.

Damage from the abrupt and often harsh tug of the caught ring can range from a simple contusion to “degloving” of soft tissue – pulling the skin off circumferentially and stripping away the nerves, tendons and bone. Severe accidents may result in traumatic amputation of the finger.

Ring avulsion can be among one of the most devastating traumatic finger injuries, as often replantation following severe soft tissue damage is not possible – requiring revision amputation.

Fortunately, advances in microsurgery and interposition graft techniques have improved results with ring avulsion replantation.  Patients should see a hand specialist immediately after the injury is identified.

Symptoms of Ring Avulsion

While Fallon knew he had severely injured his finger in his fall, the extent of the damage and seriousness of the injury was not completely revealed until his examination and x-ray.  Prompt attention and surgical care from a specialized hand team fortunately saved his finger.

The severe damage that can occur in a ring avulsion case is not always evident to a patient. Immediate examination and x-ray assessment are necessary.

Symptoms may include:

  • Pain
  • Bleeding
  • Lack of sensation at the tip
  • Disfigurement
  • Finger discoloration or whitening

In severe cases, part of the finger is removed from the bone or completely severed (traumatic amputation).

Diagnosing and Treating Ring Avulsion

When a patient presents with this type of finger trauma, the wound is cleaned and inspected for visible avulsed vessel, nerve, and tendon.  Damaged skin edges are also assessed.  An x-ray may also be indicated before determining the type of avulsion a patient has incurred.  If a portion of the finger is separated, an x-ray is performed on both the amputated part and the remaining digit to fully asses damage and likelihood of replantation.

If there is a separated part, it is wrapped in a saline gauze and placed in a bag with ice water.  The patient is given antibiotics and tetanus prophylaxis.

The injury is then classified using one of several ring avulsion classification systems that exist.  Most commonly used is the Urbaniak Classification system.  The class of ring avulsion (Class 1, 2, or 3) will help determine treatment.

The goal of the hand surgeon is to salvage, maintain function and, if possible, provide an esthetic appearance.

Commonly used classification chart for Ring Avulsion injuries.

Commonly used classification charts for Ring Avulsion injuries.

Avoiding Risk of Ring Avulsion

It is difficult for patients to understand how otherwise inconsequential stumbles or movements can result in the damage or loss of a digit when a ring is involved.  We often forget that the bones and joints of the hand and wrist are small and capable of sustaining just so much force. Skin is the finger’s strongest part.  Once the skin tears, the remaining tissue quickly degloves. Though rare, the potential harm that a ring can pose should be considered – particularly when performing certain extracurricular or sports activities, or when working with machinery. Unfortunately many accidents resulting in a ring avulsion are not anticipated nor could be imagined.  Prompt attention is key to a successful outcome.

References

Flagg SV, Finseth FJ, Krizek TJ. Ring avulsion injury. Plast Reconstr Surg. 1977;59:241–8.

Brooks D, et al. Ring avulsion: injury pattern, treatment, and outcome. Clinics in Plastic Surgery April 2007 ;34(2):187-95, viii.

Fejjal N, Belmir R, Mazouz S El, Gharib NE, et al. Finger avulsion injuries:  A report of four cases.  Indian J Orthop. 2008 Apr-Jun; 42(2): 208–211.

Sears ED, Chung KC.  Replantation of finger avulsion injuries:  A systematic review of survival and functional outcomes.  J Hand Surg Am. 2011;36(4):686-94.

 

Don’t Let Injuries Dampen Your Family’s Fourth of July Fun!

Coast to coast, the Fourth of the July is one of the most celebrated holidays of summer and an opportunity to enjoy every bit of what the outdoor has to offer.  Unfortunately there are thousands of injuries incurred across the United States every year at this time, as a result of firework accidents.

Ensuring family fun this Fourth of July.

Ensuring family fun this Fourth of July.

Unofficially, those at highest risk for firework injuries are teenaged boys.  Adult men closely follow in the second highest risk group, according to reports of ER physicians and orthopedic hand specialists….

It is estimated that over 40 percent of firework injuries occur to the hand and upper extremity.

Injuries most commonly occur when an ignited firework seemingly fails to go off, though explodes when checked – often in a hand.  Other injuries occur from the unexpected heat many fireworks omit.  Even an unassuming “sparkler” can heat to over 2000 degrees, capable of causing 2nd and 3rd degree burns.

The fireworks most implicated in causing injury include small firecrackers, bottle rockets and sparklers, because they are the least feared.

Among the most common hand and upper extremity traumatic injuries caused by fireworks include:

  • Burns
  • Contusions and lacerations
  • Damage to bones, muscle, ligaments and nerves 

Medical Attention for a Traumatic Firework Injury

To avoid permanent damage to the hand and wrist, it is important to seek immediate attention for a traumatic firework injury.

With approximately 50 nerves in the hand, 34 muscles moving the fingers and thumb, over 120 known ligaments, 30 major joints, 30 bones and a myriad of connective tendons, it is imperative that you follow up with a hand specialist following an ER or urgent care visit should such an accident happen.

Hand function and quality of life is dependent on not only immediate care but proper follow up to a hand injury.  If such injuries are not adequately addressed, irreversible nerve and tendon damage can impair hand feeling and movement, and the early onset of osteoarthritis from post traumatic bone and joint damage can further hinder hand function.

Reducing Risks of Traumatic Firework Injury

While many of the tips for reducing risk of hand injury trauma from fireworks seem common sense, they are often lost during the festivities surrounding such holidays and warrant repeating.

  • Ignite all fireworks with extended lighters.
  • Remain a safe distance from ignited fireworks.
  • Allow sufficient time for fireworks to go off / explode before approaching (and handle previously ignited fireworks with an extended apparatus such as BBQ tongs).
  • Supervise young children holding sparklers, advise teens of the heat hazard of these and other small, seemingly harmless fireworks.

Have a happy and safe Fourth of the July!