Tem- Microvascular management of ring avulsion 01...  Microvascular management of ring avulsion injuries

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Microvascular management of ring avulsion injuries

Microsurgical revascularization has proved to be a useful method in managing the ring avulsion injurywhere both neurovascular bundles are damaged with only partial skin avulsion. Representative corses areused to illustrate guidelines for a practical classification for helping ro decide the optimal ntethod oftreatment of acute ring avulsion injuries in light of digital revascularization techniques. Nine ring fingerswere successfully revascularized of 24 acute ring avulsion injuries reviewed. Sensibil#.v recoveo wasgood and a functional range of motion obtained. No patient who has had his ring finger revascularizedhas requested its amputation because of appearance, painful neuromas, stiffness, or cold intolerance.Complete amputations, especially proximal to the superficialis &sertion, and complete degloving injuriesof the ring finger are usually best managed by surgical amputation ~f the digit.

James R. Urbaniak, M.D., John P. Evans, M.D., and Donald S. Bright, M.D.,

Durham, N.C.

Although Gillies a recommended a tubed pedicle for

treatment of "a denuded finger" in 1940, avulsion in-juries due to a ring were first specifically mentioned inthe English orthopedic literature by Bunnell~ in 1948.Other authors discussed primary amputation,a ~ pri-mary ray resection, 4 5 or complicated resurfacingprocedures,a 4 a-" Some comment has been given con-cerning the microvascular treatment of a single ampu-tated digit, ~, ~0 but no one has published a useful guideto treatment incorporating revascularization concepts.All of these options have complications. The primaryamputation involves complete loss of the finger, loss ofsymbolic position of the ring finger, possible painfulneuromas, or loss of good pulp tissue. Primary rayresection is expedient, but involves the above-men-tioned complications plus loss of palmar width. Long,Complicated skin and neurovascular pedicle operationsinvolve periods of immobilization with frequent occur-rences "of joint stiffness, infection, bulbous fingertips,

and loss of sensibility. These potential complicationscan be avoided with successful microvascular recon-stitution of a severely damaged ring finger.

Treatment guide

To be effective, a classification should be short, easyto remember, and practical, With microvascular tech-niques in mind, ring avulsion treatment can be sepa-

rated into three classes.

From the Division of Orthopaedic Surgery, Duke University Medical

Center, Durham, N.C.

Received for publication Dec. 21, 1979; revi~ed April 21, 1980.

Reprint requests: James R. Urbaniak, M.D., Box 2912--Ortho-paedic Surgery, Duke University Medical Center, Durham, NC27710

Class I: Circulation adequate. Standard bone andsoft tissue treatment is sufficient.

Class II: Circulation inadequate. Vessel repairpreserves viability permitting immediate or delayed re-pair of other tissues.

Class III: Complete degloving or complete ampu-tation. Judgment is essential because, although acomplete amputation can be revascularized and viabil,ity restored, the potential function is limited. In deglov-

ing injuries, the potential for useful function exists, butrevascularization is not easy or may not be possible.

Representative eases

Class I: Circulation adequate. W. W., a 33-year-oldright-handed construction worker, caught the ring on his leftring finger on a falling cinder block, causing an almost cir-cumferential laceration of the skin at the distal end of theproximal phalanx (Fig. 1). Damage involved the ex~-nsormndon, flexor digitorum superficialis and profundus, andopen dislocation of the middle joint with tearing of the volarplate from its insertion. The intact ulnar digital artery andnerve maintained good circulation ~nd turgot to the distal endof the finger. Standard wound care was used involving exten-sor and flexor tendon repair, a volar plate reattachment, irri-gation, and dressing of the wound with subsequent delayedsk!n closure. The patient achieved an essentially full painlessrange of motion (0 to 110 at the proximal interphalangea!joint), normal sensibility, and cold tolerance in the digit.

Class II: Circulation inadequate. J. B., a 24-year-oldright-handed construction worker, fell 8 feet and caught hiswedding ring on the scaffold, sustaining a complete circum-ferential degloving type injury extending to the base of thefingernail (Fig. 2). All tendons and bones were intact. Thedistal joint was dislocated, with rapture of the volar plate andcollateral ligaments..Both neurovascular bundles and all dor-sal v~ins were avulsed with the skin. There was inadequatepeffusion of the distal digit as evidenced by no capillary refill,

0363-5023181/010025+06500.60/0 t981 American Society for Surge~:y of the Hand THE JOURNAL OF HAND SURGERY 25

26 Urbaniak, Evans, and Bright

Fig, 1, Class I type of ring injury in a 33-year-old construc-tion worker. The skin injuU was circumferential with lacera-tion of the extensor tendon, flexor superficialis, and profun-dus and open dislocation of the proximal interphalangeal jointwith injury to the volar plate. One intact neurovascular bundlemaintained good circulation. Standard wound care, tendon,nerve, and volar plate repair, and delayed skin closure re-sulted in a good range of motion and sensibility return,

poor pulp turgor, coldness, and pallor (Fig. 2, B). Immediatecare included irrigation and debridement of the wound withmicrosurgical repair of both digital nerves, three dorsal veins,and one volar vein. A 2 cm vein graft to the radial digitalartery and a 1.5 cm vein graft to the ulnar digital artery wereperformed. The digit survived and had a total active range ofmotion of 225. Two-point discrimination was 9 mm and thepatient recovered power grip strong enough to use a hammeron the job. His cold intolerance subsided after 1 year.

Class III: Complete amputation or complete degloving.D. B., a 23-year-old Lumbee Indian male mechanic, sus-tained an amputation of the left ring finger after catching hisring on a truck (Fig. 3). The fracture involved the proximalinterphalangeal joint and the skin was avulsed from the baseof the proximal phalangeal level. Successful replantation ofthe amputated finger involved proximal interphalangeal jointfusion and repair of the extensor tendon, both digital arteries,and nerves and five dorsal veins. He has recovered 12 mm oftwo-point discrimination and a full active range of motion ofthe metacarpophalangeal joint, but has rigid proximal anddistal interphalangeal joints. He has never been quite satisfied

The Journal ofHAND SURGERY

with the appearance and function of the digit and was out ofwork for n~rly 18 months.

Material

Between 1974 and 1979, 24 patients with an isolatedring avulsion type injury to the ring finger were seen inthe, Duke University Medical Center Orthopaedic Sur-gery Division (Table I). Seven patients who had thedil;it separated completely from the hand had an at-tempt at full replantafion. Of these seven, five digitssurvived and two underwent delayed amputation. Allthree children in the series had complete amputationsan~d all underwent replantation. Two of these replanteddigits survived. Six patients were treated by amputationwithout an attempt at revascularization or replantation.

Sixteen ring fingers underwent revascularization orreplantation and 14 survived. None of these patientshas requested amputation of the revascularized digit.Although the finger may be shorter, all but one patientwas pleased with the appearance.

Primary nerve repair was performed when feasible;however, if the injury was of the severely avulsingtype, secondary repair or delayed nerve grafting wasperformed. None of the patients in the revascularizedseries has required reoperation for resection of a painfuldigital neuroma--a frustrating complication of ampu-tations and ray resections. TM ~-~

Of nine successfully revascularized fingers availablefc~r follow-up, two-point discrimination averaged 10ram (this includes only digits which had nerves severedztnd repaired) and total active motion 206. Threecompletely replanted digits averaged 12 mm of two-point discrimination and total active motion of only145. Most of the restricted joint motion occurred at theproximal interphalangeal joint.

At the present time, our replantation team can replanta single digit in 3 hours or less of operating time. Sincering avulsion injuries frequently damage along sectionof the vessels, vein grafting is frequently necessary andthe procedure may be prolonged an hour or so. Thehospital stay of a single replanted digit is usually 5 to 8days. In our institution the cost of revascularizing a ringavulsion is comparable to the amount of financial com-pensation the patient (who has been injured on the job)would receive from the insurance carrier if the digitwere amputated and not revascularized.

The patients in this study who had revascularizationor replantation of digits have averaged 3 months out ofwork. The patients with complete amputations whichwere not replanted averaged more than 2 months out ofwork. Four patients required on additional operationeach. One patient who had a complete amputation and

al of Vol. 6, No. 1=_,RY~ January 1981 Ring avulsion injuries 27

Fig. 2. Class II type of ring injury in a 24-year-old construction worker. The tendons and bone wereintact. The distal joint was dislocated and all neurowtscular structures were severely severed (A).The digit appeared avascular with no capillary re:fill (R). Because of the degloving type of vasculardamage (C), vein grafts were necessary to both digital arteries. Four veins and both nerves werere