Ring injuries of the finger: long-term follow-up

Abstract

Purpose: The purpose of this study was to report on the injury patterns and outcomes of a series of patients treated at our institution between the years 1983 and 2010 who were injured by rings worn on their finger. The series included typical ring avulsion injuries as well as all other injuries caused by rings.

Methods: Retrospective chart review was conducted on 33 patients with ring injuries treated by the senior author and colleagues. Eight cases were classified as Urbaniak class I, 13 class II, and 12 class III.

Results: Satisfactory finger motion occurred with salvage of fingers in which no damage occurred to the proximal phalanx or flexor digitorum sublimus or profundus tendons. All patients with flexor tendon injury or proximal phalangeal fracture or both had loss of PIPJ motion and total active motion as compared to class II injuries without tendon and bone involvement. Four class III injuries were treated with replantation. One failed requiring revision amputation at the metacarpalphalangeal joint level due to ischemia. The remaining eight were treated by primary amputation.

Conclusions: As a guideline to digit salvage with ring injuries, the authors propose accurately documenting and basing treatment on all injured structures. Particular attention should be given to fractures of the proximal phalanx and laceration of the flexor digitorum sublimus and profundus tendons, as injury to these structures led to significant loss in mobility of the finger in this series. While some current guidelines advise revascularization of class II ring avulsion injuries, our series suggests caution in anticipating good results with sublimus or profundus tendon laceration and proximal phalanx fracture. If the profundus tendon only is lacerated, particularly in zone I injuries, results of finger salvage may still be acceptable, but associated (distal interphalangeal joint) DIPJ injury may require K-wire stabilization and later fusion. Replantation in class III injuries, while possible, is warranted only in select situations (patient-specific and cultural factors).

Keywords: Avulsion; Reconstruction; Ring.

Fig. 1

Class I ring avulsion injury to skin only

Fig. 2

Type II ring avulsion injury

Fig. 3

a Class III ring avulsion injury with complete amputation through the DIPJ. b, c Class III ring avulsion injury after successful replant

Fig. 4

a Class II ring avulsion injury, which occurred when a 28-year-old male was climbing into a boat after water skiing. The patient’s ring caught on a bolt on the transom of the boat and when the boat jerked forward, his finger was nearly amputated. The photo shows a circumferential laceration around the finger caused by his wedding ring. The ring has been removed and the finger is clearly nonviable. b Photo is taken in the operating room and shows the extent of the injury. The skin has been degloved to the level of the DIPJ. The DIPJ has been dislocated and is hinged on the ulnar collateral ligament. Both digital arteries and the radial digital nerve have been completely lacerated, while the ulnar digital nerve remained intact. The terminal tendon insertion of the dorsal apparatus has been lacerated, but the FDP remains intact. c Photo shows the hand 3 months later. d Full flexion and extension is noted at 3 months follow-up. e Photo shows the hand 25 years later in full flexion and f extension; DIPJ fusion was performed 1 year after the initial injury for a mallet deformity

Fig. 5

A 44-year-old male jumped from his dump truck, catching his ring on a bolt protruding from the bed of the truck and lacerating his finger during the fall. Evaluation in the emergency department revealed dusky, cool fingertip with an open injury to the DIPJ (a). In the operating room, both digital arteries were found to be lacerated with extensive intimal damage. The dorsal venous circulation was disrupted as well. Both digital nerves appeared intact, confirming moderate sensation to light touch during preoperative evaluation. In order to restore arterial flow to the finger, a reverse vein graft was taken from the ipsilateral wrist and sutured from the ulnar digital artery proximally to the radial digital artery distally (b). After final debridement, the wound was closed loosely. Leach treatment was used postoperatively for 24 h to alleviate venous congestion. He was taken back to the operating room 2 weeks later for full-thickness skin grafting of a relatively small, but persistent skin defect (1 × 1 cm). At 1 year follow-up, PIP motion was from 0° to 100° of flexion, and DIP motion was from 35° to 75° of flexion with intact sensation (c, d)