Ring avulsion injuries remain challenging for hand surgeons. Careful evaluation and judgment are critical to optimize outcomes after these severe fingertip traumas. This review covers key considerations in assessment, management, and outcomes of ring avulsions.
Injury Mechanism and Grading
- Sudden axial traction causes staggered injury: proximal skin avulsion, distal fracture/dislocation
- Extensive macro/microvascular intimal damage from crushing force
Grading Systems
| Urbaniak Classification | Kay Classification |
|---|---|
| Class I: Intact circulation | Class I: Intact circulation |
| Class II: Compromised circulation | Class II: Arterial compromise only |
| Class III: Complete degloving | Class III: Inadequate circulation with bone/tendon/nerve injury |
| Class IV: Complete degloving/amputation |
Physical Exam and Imaging
- Inspect neurovascular structures and skin edges
- Finger xrays to assess bony injury
- Look for staggered pattern: proximal skin avulsion, distal PIP or DIP fracture/dislocation
Management Goals and Techniques
- Replantation for Class I-II with joint/tendon integrity
- Arterial repair with interposition vein grafting
- Repair at least 2 veins for adequate outflow
- Rigid bony fixation
- Skin flap for coverage
- Revision amputation for Class III-IV
Outcomes and Complications
- Replantation survival around 60%
- Protective sensibility potential, limited motion
- Cold intolerance, contractures, need for revision surgery
- Better outcomes with incomplete avulsions and distal injuries
- Meticulous microsurgical technique gives best chance for success
References:
Bamba R, Malhotra G, Bueno RA Jr, Thayer WP, Shack RB. Ring Avulsion Injuries: A Systematic Review. Hand (N Y). 2018 Jan;13(1):15-22. doi: 10.1177/1558944717692094. Epub 2017 Feb 16. PMID: 28720047; PMCID: PMC5755869.
Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg Am. 1981 Jan;6(1):25-30. doi: 10.1016/s0363-5023(81)80006-8. PMID: 7204914.
Kay S, Werntz J, Wolff TW. Ring avulsion injuries: classification and prognosis. J Hand Surg Am. 1989 Mar;14(2 Pt 1):204-13. doi: 10.1016/0363-5023(89)90008-7. PMID: 2649544.
