Thursday, June 19, 2008

Ring Finger Avulsion

 Updated 3/2017-- all links removed as many no longer are active.

Dr Smak:
Mr. Zink was the coolest teacher in my middle school. Everyone liked him: nerd, jock, cheerleader alike. He taught science, and if you were lucky you got him two years in a row. In those few minutes after the lesson finished, but before the bell rang, he would tell us the grossest stories that he knew.
I still remember them. The one about the kid playing basketball with his class ring on, who left his ring and its attached finger on the rim after a dunk, connected by all the tendons from his finger to his shoulder. (Can that really happen?)
Yes, that can happen. Well, not the "to his shoulder" part as the tendons to the fingers don't originate that high in the arm, but the avulsion of the ring finger can and does. (III type injury) A typical story may be
She had avulsed the skin off her ring finger of her right (dominant) hand whilst attempting to jump over a spiked fence, catching her ring on the spike.

The physics/mechanics of the injury is explained well here.
The first 1998 study conducted under Dr. David M. Kupfer, Department of Plastic and Orthopaedic Surgery, University of San Diego in California, involved dropping a 30-pound weight attached to a ring bearing finger hanging from a hook, from a 9-inch height.
Results showed that in more than 90% of cases, the injuries caused by rings and wedding bands are Class II (29%) and Class IV (61%). On the tested sample (41 fingers), Class I injuries (10%) occurred at less than 80 N and the first ring avulsions at 111 N. Maximum finger resistance is 346 N with average resistance at 154 N. Film records also show that the skin is the finger’s strongest part. Once the skin tears, the remaining finger degloves or quickly avulses. Accordingly, although thin and narrow or tight rings are less resistant to traction and cause the skin to shear under traction, they are more dangerous than wide, thick rings.

Classification of Injury (Urbaniak)
Class I
  • Circulation adequate.
  • Standard bone and soft tissue treatment is sufficient.
Class II
  • Circulation inadequate.
  • Vessel repair preserves viability permitting immediate or delayed repair of other tissues
Class III
  • Complete degloving or completed amputation.

  • Judgement is essential because, although a complete amputation can be revascularised and viability restored, the potential for function is limited.
  • In degloving injuries, the potential for useful function exists, but revascularisation is not easy or may not be possible.

These injuries are best avoided.
Be careful if you are in the building/construction, logistics and transportation industries. Consider not wearing your wedding ring while at work (that's exactly what I have told my husband).
Remove any rings or wedding bands during activities where the risk of injury is especially high. This includes many DIY activities, gardening, and handling heavy objects.
Your thumb, index, and middle fingers are most crucial for hand function. Consider wearing rings only on the ring or pinkie.

Ring Avulsion Injury: The Do's and Don'ts of Initial Management; The Internet Journal of Orthopedic Surgery ISSN: 1531-2968; A Atrey, MRCS, P Landham, MRSC, T Lasoye, FRCS
Recommendation on the Risk of Wearing Rings and Wedding Bands; THE CONSUMER SAFETY COMMISSION (15th December 2005)
Finger Avulsion Injuries: A Report of Four Cases; Indian Journal of Orthopaedics, Vol 42(s), pp 208-211, 2008; Fejjal N, Belmir R, El Mazouz S, Gharib NE, Abbassi A, Belmahi AM
Microvascular management of ring avulsion injuries; J Hand Surg Am 1981;6:25-30; Urbaniak JR, Evans JP, Bright DS. [Pubmed]


mark's tails said...

I think this is top of the list of grossest pictures you've ever posted, gross but I was still fascinated. I'm usually not averse to these things but even I gave a loud "Ewww!" at these. I promise never to jump any fences with my ring on.

rlbates said...

I'm glad you will be taking good care of your hands, Mark. :)

Anonymous said...

I love how you phrase it, "These injuries are best avoided". Totally made me laugh (and yes, they are best avoided!)

Dr. Smak said...

Ok, Ramona, that was gross.

Interesting, but gross.

I guess I can't complain, I started it.

Chrysalis said...

My grandfather was a farmer. One day, he had an accident where his wedding ring caught on something or other, and he hung by it for a bit. After that, he told my grandmother that he loved her dearly, but the wedding ring was coming off during farming.

Anonymous said...

Whoah... that was so gross my husband refused to look! Well done! I'm putting a link in my next newsletter to this post of yours. And yes, it does seem that "these injuries are best avoided." ;)

Øystein said...

I have to agree with the others. The first picture here was absolutely gross. But interesting article, as always.

I always thought "degloving" was a horrible word. A good but bizarre analogy.

rlbates said...

But "degloving" is so descriptive.


DrB said...

OK, so I'm a little late in commenting, but MY favorite is in the "typical story" link: the photo of the "poor presentation of a digit" takes the cake. I started laughing so hard, I almost knocked my cat out of my lap. As a hand surgeon, these are the ones that you just don't want to get a call from the ER on, because there is ALWAYS miscommunication--unless in a trauma center.
Thank you, and by the way, nice pics, by my count. But I'm a little biased!

rlbates said...

Drb, thanks for commenting and welcome to the blog world. Hope you'll contribute to SurgeXperiences sometime.

Anonymous said...

My ex-husband had a shop that rebuilt auto parts. When my friends asked why he never wore his wedding ring this is exactly what I told them. Too dangerous.