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Ring avulsionand prognosis

injuries: Classification

Fifty-five cases of ring avulsion njurywere eviewedo examineow xtentof injury and urgicalmanagementorrelated with results. After injury, three patients hadadequate irculation. Of52 patients with inadequate irculation, 8 hadprimary mputation;alvage wasattempted n- 44. Of these 44, 9 fingers wereamputatedecondarily,19 were uccessfullyrevascularized, nd16 were uccessfully replanted. Return-to.fforkime averaged etween .5 and10.3 weeks.Coldsymptoms ccurred n 65% f salvaged fingers. Rangeof motionwas usually normalat themetacarpophalangealoint; mostpatients had90 degreesor better combined rc of motionatthe proximal nddistal interphalangeal oints. Two-point iscriminationof less than 10 mmreturnedn 47% f patients with injurednerves. Mostpatients whose ingers weresuccessfullysalvaged wereglad they had hadthe procedure.We onclude that amputated igits, are sal-vageable and proposea classification system that includes skeletal injury; (J HANDURG1989;14A:204-13.)

Simon Kay, MD, Joanne Werntz, MD, and Thomas W. Wolff, MD, Louisville, Ky.

Ring avutsion injuries have long pre-sented complex management roblems. Before the ad-vent of microsurgerydebate centered on whether distalflap coverage or grafting was preferable to amputa-tion.l5 In the era of microvascular repair, the choiceshave becomemore complicated.6 Alternatives includereplantation7 and free tissue transfer in addition to localflap, pedicle flap, or graft coverage,. 9The importanceof the ring finger in grip, continenceof the cuppedpalm, and appearance s well recognized,as is its symbolic ole. To fulfill these functions thedigit must have sensibility and a goodrange of motion(ROM) nd be free of deformity and pain. Despitemicrosurgical advances, the difficulty of achievingthese results in complete degloving injuries or ampu-tations, not to mention the extensive surgery and re-FromThe Christine M. Kleinert Institute for Hand nd Micro Surgery,

Louisville, Ky.Presented at the Fifth Annual Residents and Fellows Hand SurgeryConference, AmericanSociety for Surgery of the Hand, September

1987, San Antonio, Texas.Received for publication March2, 1988; accepted in revised formMay 23, !988.No benefits in any form have been received or will be received froma eommerical arty related directly or indirectly to the subject of this article.Reprint requests: ThomasW. Wolff, MD,250 East Liberty St., Louis-ville, KY 0202.

habilitation involved, have led someauthors to statethat these cases are "usually best managed y surgicalamputation f the digit1 or that "replantation is rarelyindicated."~tThe decision whether or not to complete the ampu-tation or to attempt microvascular alvage, with all itsconsequences or cost, rehabilitation, employment, ndfunction is a difficult one, particularly since consulta-tion with a patient in crisis maybe limited. To assistin makinghis decision, classifications of ring avulsioninjurieslO. 12 ihave been proposed hat contrast with clas-sifications from he premicmsurgical ra. 3, 9The most commonly ccepted classification is thatof Urbaniak t al.,1 whichdivides ring avulsion injuriesinto three classes. Nissenbaum~ added an additionalsubclass, IIA, to the three proposed by Urbaniak andcolleagues. These classes are as follows:I. Circulation adequateII. Circulation inadequate

IIA. Circulation inadequate (only arteries injured)III. Complete degloving or complete amputationUrbaniak t al.~ stated that class III injuries presentthe greatest challenge both to revascularize and toachieve function, and they may best be managedbyamputation. In contrast, class II injuries can be suc-cessfully revascularized in almost.all instances, withsensibility, strength, motion, and appearanceapproach-ing normal n the majority of patients.

204 THE JOURNAL OF HAND SURGERY

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Voi. 14A, No. 2, Part 1March 1989 Ring avulsion injuries 205

Table I. Distribution of ring avulsion injuries: Classification of Urbaniak et al.

Urbaniaklassification Cases(No.) Primaryamputation. SecOndary mputationI 3 0 0II 24 3 (12.5%) 3 (14.2%)IIa 1 0 0

III 27 5 (18.5%) 6 (27.3%)

Successfulsalvage3 (100%)18 (85.7%)I (100%)16 72.7%)

Table II. Operative factors in ring avulsion injury patientsArterie.repaire.per patie(Primaryoperatio

Meanno.arteriesN repaired

Meanno. of Useofoperationsper Mean perative arterial veincase time (hr) grafts

Primary Total No. ofMeanno. N time time V cases N %Primary 1.3 8 1:05 1:45 6 0 0 0 0 0amputationSecondary 3.0 9 5:35 10:55 5 1.4 9 7 9 78amputationClass I 1.7 19 5:30 7:05 15 2.0 19 9 19 47(Successful)Class II 2.5 16 6:35 8:55 12 1.9 16 7 16 44(Successful)

Veinsrepairedper patient(Primaryoperation)Use ofvenousvein grafts

Meanno.veins No. ofrepaired N cases N %0 0 0 0 02.8 9 4 9 44.42.8 18 11 18 61.13.2 16 7 16 43.8

Ultimateate of thefinger nd he classof injury re shownn the teft hand olumn. ertical olumnsecordhe detailsof the operativerocedures.equalshenumbern populationample ith ufficient ata or each actor tudied.

In this retrospective study we have examined a seriesof ring avulsion injuries treated by our clinic in anattempt to establish how the extent of injury and itssurgical managementhas correlated with results. Sincethe extent of injury determines how it is classified, wealso examined the data to see if other classes and sub-classes .might have more diagnostic and predictivevalue.Materials and methods

The population studied consisted of patients with ringavulsion injuries of all grades of severity treated pri-marily by our clinic between 1977 and 1986. Neitherclinic nor hospital data filing systems code specificallyfor ring avulsion injury, so retrieval relied on id.entifyingcases from various sources. These sources of identifi-cation include photographic records, radiographic rec-ords, clinical files, and hospital records. This series ofcases, therefore, probably does not include all suchinjuries for that period, so cases were not necessarilyconsecutive. However, no selection" mechanism that

might bias the data has been identified. Data on everyidentified case has been assembled from chart reviews,telephone interviews, letters, or office visits.The data on many patients is incomplete. In analyz-ing any particular factor, patients with incomplete datafar that factor are excluded. The number of cases withadequate data for that factor is given with each result.Patients were classified using the system of Urbaniaket al. Any class of injury mentioned below refers tothe Urbaniak system unless otherwise noted. Patientswere also classified by the presence or absence of skel-etal injury. Skeletal injury was defined as any fracture,joint, injury, or amputation. :

V~e used the formula for total active motion(IAM)~3"~5 to evaluate range of motion (ROM) n pa-tiients followed for more than 6 months. By definition,"IAM s equal to the total active flexion at the meta-carpophalangeal (MP), proximal interphalangeal (PIP),and distal interphalangeal (DIP) joints minus the ex-tension deficit at these joints. All. patients achievedwithin i0 degrees of normal flexion with, full extension

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206 Kay, Werntz, and Wolff

55 RINGAVULSIONNJURIES

3 CirculationAdequate 52 Circulation nadequateII I8 PrimaryAmputations 44 Attempted alvage9 Secondary mputations 35 SuccessfulReplantations/.Revasculariza~tions(19 Class]]) 16 Class lI)

Fig. 1. Progression f treatment.

of the MP oint; TAMereafter will refer only to motionat the PIP and DIP oints, the joints most affected byring avulsion injury. (Strickland15 excluded MP ointmotion from his revised classification of flexor tendonrepairs for similar reasons.)Operative procedures, complications, amputation,recovery and rehabilitation, ROM, nd sensory returnwere critically reviewed o compare esults.All surgery was carried out with the patient undereither axillary or metacarpal block anesthesia. All pri-mary amputations and class I injuries were treated onan outpatient basis. All others were admitted for ob-servation and fingertip temperature monitoring.Patient satisfaction or dissatisfaction was never in-ferred from the chart but was only registered for thosepatients who esponded o inquiry by telephoneor letter.These patients were asked whether they were glad tohave kept the injured digit in light of subsequent sur-gery, complications, and use and whether they wouldrecommendhis procedure to a friend with a similarinjury.Results

Fifty-five cases of ring avulsion injury receiving pri-mary care during the 9-year period from 1977 to 1986were identified. This group of 35 men and 20 womenhad a mean ge at injury of 34.6 years (range, 9 to 60years). All but one patient suffered injury to the ringfinger. There were no complete degloving injuries inthese 55 patients. Thedistribution of these injuries ac-cording to Urbaniaks classification is shown n TableI. Only hree cases, all in class I, did not require mi-crosurgical restcration of circulation. Of the remaining52 cases, 8 (15.4%) had a primary surgical amputationafter initial clinical assessment.Consequently, 44 patients had attempted microsur-

TheJournal ofHAND SURGERY

Table III. Complications ecorded for allmicrosurgical reconstructions (44 patients)Patients"r~omplication (No.)

Vascul.arnsufficiency* 14Skin os~ 8Skin ontracture 9An:hrodesisr problems ithbone nion 6Tenodesis 1Neuroma? 1Boutonniereeformity 1Quadrigia~: 1

*Nine ingers with vascular insufficiency were amputated.~Associated with stump of secondary amputation.~After secondary amputation.

gical salvage. Of the 44 fingers, 9 (20.5%) had sec-ondary amputation, defined as amputationafter the ini-tial operative procedure. All secondary amputationswere done because of vascular insufficiency. The meaninterval from injury to secondary amputation was 9.6days (range, 3 to 22 days). Nodigit was removed fter22 days for either clinical reasons or becauseof patientdissatisfaction.Of class II injuries in which salvage was attempted,13.6% (3 of 22) had secondary amputation, and 27.3%of class III injuries (6 of 22) had secondary mputation.Thirty-three patients in classes II and III had skeletalinjury to. the fingers that suffered ring avulsion. Thisgroup, of 33 patients with skeletal injury had a secondaryamputation ate of 24.2% 8 of 33). This figure contrastswith a 9% econdary-amputation ate (1 of 11) for thegroup with no skeletal injury.Th~as, in 35 patients microvascular salvage was suc-cessfld in so far as a viable digit resulted. Revascular-ization of class II injuries was 86% uccessful, and thesuccess rate for replantation of class III injuries was73%. The difference between these two groups was notstatis~:ically significant (p > 0.05). Thesuccessrate forrevascularization of digits without skeletal injury was91%, and success rate for digits with skeletal injurywas 76% p ~> 0.05).The average follow-up time for both primary andsecondary amputations was 3.9 months (range, 0 to9 months), and for the successfully salvaged digitsfollow-up averaged 14.3 months. Twenty-three of the35 patients with salvaged digits had further follow-upby phone nterview, office visit, or letter, increasingtheir follow-up .time to 28.4 months range, 1 to 60months).Operativeprocedures.The progression of treatment

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Vol. 14A, No. 2, Part 1March 1989 Ring avulsion injuries 207

Table IV. Arcof active motion (degrees) of the MP, PIP, and DIP joints in~alvaged fingers withadequate follow-upl N [ . MP oint

UrbaniakClass ~: 2 100 0Class I 12 87.3 6.8Class II 13 88.8 - 7.4RevisedClass I~ 2 100 _+ 0Class I 5 88.8 8.5Class II 7 85.0 _ 5.7Class IV 13 88.8 --- 7.4

PIP joint DIP joint* [ TAM~"

82.5 24.8 45.0 7.1 127.5 - 17.780.4 13.4 38.6 18.9 102.5 28.180.8 17.2 22.5 20.2 91.5 21.682.5 - 24.8 45.0 - 7.1 127.5 17.780.0 6.1 47.5 - 19.4 126.3__- 19.780.7 17.4 27.5 --. 9.6 92.0 --- 33.380.8 --- 17.2 22.5 --- 20.2 91.5 21.6

*Excluding hose with DIP joint fusions. "~Total active motion; ncluding those with DIP joint fusions.~:Both patients were followed for only 2 months but are included for comparison.Total active motion (TAM) f the PIP and DIP joints is given including fingers with DIP oint fusions: Cases with inadequate data or follow-up of less than6are excluded.

Table V. Total active motion (TAM) n 25 patients

months

DegreesUrbaniak class Revised class

lli IV0-50 0 0 0 0 050-90 3 4 0 3 490-130 7 8 4 3 8130-175 2 1 1 1 1Patients with TAM>90 75% 69.2% 100% 57.1% 69.2%N 12 13 5 7 13

TAMs defined as the total active flexion at the PIP joint plus that at the DIP joint minus he sumof the extension deficits at these joints. MPoint motion isexcludedsince all patients had almost normal motion at that joint. Patients with DIP oint fusions are included in the table.

for this series of 55 cases is shown in Fig. 1. Thenumber of operations, mean operating room time, andvascular repair information are listed in Table II.In 37 of the 44 reconstructed fingers, both digitalarteries were repaired. Of the 7 without anastomosis ofboth arteries, 3 (43%) resulted in secondary amputationand 4 (57%) were successful. An average of approxi-mately three veins were repaired per finger in all casesof attempted salvage. Almost 50% of the reconstructedfingers required vein grafting for venous anastomoses.

In six patients with class II injuries, circulation was.inadequate because of interrupted venous return. Forthese patients, venous insufficiency was the prime in-dication for microvascular surgery. All six had repairand all required vein grafts. None required secondaryamputation.

More than 50% of successfully salvaged fingers re-quired skin grafts to assist closure. Venous flaps andcross-finger flaps were used in about 11%of the cases.Hyperbaric oxygen therapy was employed in about onefifth of the patients.

Complications. Two patients from the primary am-putation group had complications documented. One hadhyperesthesias in the border digits of a ray amputationand the other had paresthesias in one border digit. Twopatients i!n the secondary amputation group also hadcomplications. Quadrigia developed in one patient anda neuroma of the amputation stump developed in theother patiient. Other complications in the 44 attemptedmicrosurgical salvages are shown in Table III. All pa-tients whose fingers were reconstructed received anti-biotics before operation (usually a cephalosporin) andfor a variable time after operation. There were eight(18.2%) ~,;ubsequent infections. No salvaged finger wasamputatecl because of infection; all secondary ampu-tations were performed for vascular compromise.

A~npumtions. Ray resection (without transposition)was performed as a primary amputation in one patientand as a revision procedure for another patient who hada primary amputation. Of the secondary amputations,ray resection was performed immediately in two of ninepatients a~ad as a revision procedure in one other patient.

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2118 Kay, Werntz, and Wolff The Journal ofHAND SURGERY

Fig. 2. A evised class I ring avulsion njury. Fig. 3. Class I (Urbaniak) r revised class IIv injury.

Table-VI. Results of sensory examination in 17patients with initial nerve injury (minimumfollow-up of 6 months)IPatientsTwo-pointiscrimination (No.)3 to 5 mm 3 17.66 to 10 mm 5 29.4More han i0 rnm 9 52.9

Percentagef total

Nocorrelation was found of age or sex with vascularfailure leading to secondary amputation.In seven of the eight primary amputations, additionalskin cover was required: a full-thickness skin graft fromthe amputateddigit was used in three patients, a split-thickness graft in one patient, and a cross-finger flapin three patients. All secondary amputations were doneat a level that allowed primary closure.Recovery and rehabilitation. All primary amputa-tions and class I injuries were treated on an outpa-tient basis. For successfully salvaged class II injuries(n = t8), the meanhospital stay was 4 .days (range,0 to 7 days) comparedwith 5.7 days (range, 2 todays) for class llI injuries (n = 16); this differencenot statistically significant (p ~> 0.05). In the seven

secondary amputations for which data were available,the length of hospital stay on the first admissionafterinjury averaged 7.4 days (range, 5 to 11 days). Thefirst hospital stay of patients whose njured fingers werelater amputatedsecondarily was therefore longer thanthat of patients with successfully salvaged injuries byan average of 2 to 4 days.Information regarding time initially spent off work

was available in 25 cases, the remainder being un-documented or the patients were not working. Datawere available for only 3 of the 17 total amputations,since this group was rapidly lost to follow-up; meanreturn-to-work time was 4.5 weeks for these threepatients. For class II cases (n = 13), mean eturn-to-work time, was 10.3 weeks (range, 2 to 28) comparedwith 7.8 weeks range, 3 to 20) for class III injuries(n = 9). This also was not statistically different(p > 0.05).Cold intolerance was present in 65.2% 15 of 23)the patients with successful revascularization or replan-tation and in one patient with primary amputation. Formost patie, nts, cold intolerance improvedduring theyear after injury and then leveled off; these patientsfound that wearing gloves when heir hands were coldeliminated most of their discomfort. Cold intolerancewas severe enough, however, in two of the 15 patients(13.3%,one from class II, one from class III) that theycould :not return to work. When atients whose ingershad be, en amputated during the injury were comparedwith those whose fingers were not completely ampu-tated, ~ greater percentage of those with amputationwere found to have cold intolerance: in class III, 11(69%)of 16 patients suffered cold intolerance, and only5 (26%)of 19 in class II suffered cold intolerance.

Range of motion. Precise documentation of ROMwith a minimumollow-up of 6 months was availablefor 25 of the 35 successfully salvageddigits (Table IV).MP oint motionwas within 10 degrees of normal i.e.,85 degrees) in all injured fingers and was thereforeeliminated fi:om TAMalues to prevent biasing the re-sults. "I)kMof the PIP and DIP oints was statisticallyequivalent for classes II and III (p ~> 0.05). Because

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Vol. 14A,No. 2, Part 1March 1989 Ring avulsion injuries 209

Fig. 4. A-C,Class II (Urbaniak) r revisedclass HI injury,, with results of treatment.

there is no classification for motion egainedafter injuryother than that for flexor tendon epairs, these patientshave been categorized according to the Revised Clas-sification System for Tendon Repairs as devised byStrickland,~5 in which a good result is a greater than50% etum of motionand an excellent result is a greaterthan 75% eturn of motion to the PIP and DIP joints;normal motion is designated as 175 degrees. With thisclassification, class II had 75% oodand excellent re-sults and class III had 70% oodand excellent results(Table V).Eleven of the 44 fingers that were reconstructed pri-marily had no record of skeletal injury associated withthe ring avulsion; only one of these fingers had sec-ondary amputation because of vascular failure. Onlyfour of the remaining 10 patients were able to be ex-amined clinical~y for ROM. espite the small size ofthis group, a statistical difference was seen betweenTAM or those with and without skeletal, injury(p < 0.01). By use of the described criteria, 100%those without skeletal injury had at least a good orexcellent result compared with approximately 65%ofthose with skeletal injury.

No DIP oints were fused in the group without skel-etal injury, and 15 (60.0%) of the 25 patients in the

skeletaMnju,~, group had a fusion of their DIP joint(p 0.05). Whenthe skeletaMnjury group was divided according towhether the injury was at or proximal to the PIP jointversus distal to the PIP joint, no statistical differencewas evident (p ~> 0.05).Sensory esults. Of the 38 patients with successfullysalvaged digits, 15 were excludedfrom this portion ofthe study because of insufficient data or follow-up ofless than 6 months. Six of the remaining 23 patientshad no nerve injury. Results of sensory examinationare listed in Table VI.Patient satisfaction~ Twenty-four atients with suc-cessfully salvageddigits were contacted for questioningabout their satisfaction with treatment. Despite the ef-fort inwglvedand the final result, 82% f class II and89% f class III patients were glad that their finger hadbeen sal[vaged and would recommend he same treat-ment o a similarly injured friend. Three patients (twofromclass Ill, one from class III) regretted their expe-rience and would not recommend ttempted salvage toa friend although they did not nowwish the fingeramputated.All three of these patients had stiff fingerswith TAMf less than 60 degrees. In two patients this

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Kay, Werntz, and Wolff The Joumal ofHAND SURGERY

Fig. S. A-D,Class HI (Urbaniak) or revised class IV injury, with results of treatment.

stiffness was the result of postoperative joint infectionand delayed union of bone. In the third patient, loss ofmotion was partially related to skin loss and the re-sulting contracture, poor sensibility, and unattractivedonor site from a local flap.Case reports

Case 1. A 48-year-old man caught his wedding ring onthe cab of his track as he wasexiting. Thering lodged aroundhis PIP joint and had to be removed fter the patient arrivedat the emergency oom. The finger showedno vascular com-promise and there was no skeletal injury (Fig. 2). Thisthus an exampleof a class I ring avulsion injury.Case 2. A 38-year-old housewife caught her weddingringwhile diving from a boat. She sustained a circumferential skinlaceration, with transection of all dorsal veins and the radialdigital neurovascular bundle (Fig. 3). Although he fingertipappearedcongested, it still received arterial flow. We las-sified this injury as belonging to Urbaniak class II or ourrevised class IIv (see Discussion) because only venous flowwas compromisednd there wasno skeletal injury. The radialdigital neurovascular bundle and larger dorsal veins weresurgically repaired. Three months after injury, TAM as-35/70 degrees at the MP oint, 40/80 degrees at the PIPjoint, and 15/55 degrees at the DIP joint. Therapycontinuedand at 9 months after injury, TAM as 115 degrees. Thepatient wassatisfied with her result.

Case 3.. A 21-year-old man caught the wedding ring onhis nc,ndo~:ainant andon a shelf at work.Bothdigital arteries,all dorsal veins, and the extensor mechanism ere interrupted(Fig. 4, A). The digital nerves, however, were intact.fracture waspresent at the distal aspect of the middlephalanx.Weherefore classified this injury as belonging o either classII or our revised class III. Thedigital arteries and five veinswere grafted with donor veins from the flexor aspect of theforearm, the central slip was repaired, and the fracture washeld reduced with Kirschner wires. Nine months after theinjury the patient had completeextension, with flexion of 80degrees at the MP oint, 90 degrees at the PIP joint, and 40degree.s at the DIP oint (Fig. 4; B and C).Case 4. A 45-year-old man caught the ring on his non-dominanthand during a fall at work. The injury resulted ina completeamputation f the digit and thus wouldbe classifiedas belonging o class III or our revised class IV. Themiddlephalanx was amputated distally and the skin was amputated

at the level of the proximal phalanx (Fig. 5, A). The flexordigitorum profundus tendon was avulsed from the musculo-tendinous junction, and the commonigital nerve was avulsedfrom the palm (Fig. 5, B). Theflexor digitomm uperficialiswas ntact. Treatmentconsisted of shortening the finger andfusion of the DIP joint with end-to-end repair of both digitalarteries and nerves. Twodorsal veins were repaired; onerequired a vein graft. Tenmonths fter the injury a tenolysisand nerve grafting to the ulnar digital nerve were done. Fif-teen months fter the injury, the fusion of the DIP joint was

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................ ............ ~ ............. r,~r......ll~ ..........................................................................................

The Journal of212 Kay, Werntz, and Wolff HAND SURGERY

I. Circulation adequate, with or without skeletalinjuryII. Circulation inadequate (arterial and venous),skeletal injury ,III. Circulation inadequate (arterial and venous),fracture or joint injury presentIV. Complete amputationThefollowingsubdivisions of our revised classes 11and III also seem o have predictive value: ~*a. Arterial circulation inadequate onlyv. Venous irculation inadequate only

This classification system differs from that of Ur-baniak in its treatment of class II injuries. Under hisnew ystem of classification, these injuries are dividedinto those without (our revised class II) and those with(our revised class III) skeletal injury. As he class num-ber.increases, so do the seriousness of the injury andthe complexityof treatment required.Revisedclass I injuries are treated as simple lacer-ations or fractures. Our revised class IV injuries (com-plete amputations) have already been examined abovein the discussion of Urbaniaksclass II versus class HIinjuries since our class IV is the same as Urbaniaksclass I11.

This revised classification system reveals meaningfuland important differences between injuries belongingto the new classes II and I11. The differences betweenthe two classes are clinically significant in mostareas.Regarding operative procedures, our revised class IIinjuries required no skeletal fixation or DIP oint fusionsince no skeletal injury was present. By definition, thenew class III injuries neededskeletal fixation of thefracture, and 50% 6 of 12) had DIP joint fusion. Re-garding complications, 36.4% (4 of 11) patients withour revised class II injuries required more than oneoperative procedure (including split-thickness skingrafts, secondary amputation, release of scar contrac-ture, and capsulotomies) and 83.3% 10 of 12) patientswith revised class III injuries required more than oneoperative procedure. These included split-thicknessskin grafts and surgery for venous insufficiency, aninfected PIP joint, delayed union of a DIP oint fusion,and revision of a secondary amputation. The differencein occurrenceof complicationsrequiting further surgerybetween the new classes II and III was significant(p < 0.05).In our revised class II there were no primary am-putations, whereas 16.7% f those in revised class IIIhad primary amputations (Table VII). Secondary am-putations were equal in these two revised classes. Inthe area of recoveryand rehabilitation, our revised class

ld[ patlients recoveredbetter and faster since there werefewer operatwe procedures. Regarding ROM, ll of ourrevised class II patients (5 of 5) had more thandegrees of TAM,while .only 57% 4 of 7) of revisedclass .III patients had more than 90 degrees of TAM(p = 0.05, Table V).Sensory recovery was independent of skeletal injurybut dependent on nerve injury, and so the. two revisedclasse,,; weresimilar in this respect. Patient satisfactionalso was the same in both classes. Overall, patientswere satisfied that their fingers were saved. However,manypatients in these two classes did not realize theseverity of their injury, since their fingers had hot beencompletely amputated.Subclassifications of revised classes II and III ap-peared necessary since the prognosis of salvage wasdiffere~at if either the arterial or venoussupply alohewas compromised. Subclasses a and v (with compro-mise of either the arterial or venoussupply only) bothhad a high degree of successful salvage (100%), whilein revised classes II and HI (with both circulatory sys-tems damaged) he salvage rate was only 70% o 75%,equal to that of a completelyamputateddigit (76.1%).Significant differences in final motion were not found,probably because of the small numberof patients withfolilow-up within each subdivision The designation ofarterial and venous injury therefore seems useful forpredicting outcome of microsurgical salvage, ~" ~ aspreviously discussed by Nissenbaum,~ since the sal-vage rate is lower whenboth arterial and venous sys-tems are; damagedwhetheror not a fracture ig present.Onecould argue that it is unnecessary to separatethe new class III from newclass IV since salvage andfinal ROMs similar in both classes. Class IV, however,had more DIP joint fusions and more operative pro-cedures with less need for grafts (skin and vessel) sincethe skeleton was shortened when eplanted Separationof injuries into these two classes also defines the extentof injury without further explanation.

In cortclusion, this article reports the largest reviewof ring avulsion injuries yet published. On he basis ofthis series, webelieve that completely mputateddigits(Urbaniak class II1 or our revised class IV) are sal-vageable and have comparable esults to ring avulsioninjuries with skeletal injury (Urbaniakclass II or ourrevised class liD. Wehave proposed a revised classi-fication systemcontaining new lasses for injuries withand without skeletal injury since operative procedures,complications, recovery and rehabilitation, and ROMall appear o be quite different in comparison.The pro-posed classification also aids in prognosis by reflecting

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Vol. 14A, No. 2, Part IMarch 1989

the seriousn~ess of injury with its associated surgicalprocedures, number of operative procedures, compli-cations, and implications for recovery (seriousness in-creases along with the number of the class). Further-more, the proposed classification is clinically completeand defines any ring avulsion injury with its impliedprognosis and treatment.

We~ould like to thank the staff of the Louisville HandSurgery, Drs. Harold Kleinert, Joseph Kutz, E. Ataso~, Tsu-MinTsai, GrahamD. Lister, James Kleinert, Luis .Scheker,and WarrenBreidenbach; for allowing us to study and reporton their cases; We lso would ike to thank Kell Julliard forhis help with writing and editing the manuscript.

REFERENCESI. Frederiks E. Treatment of degloved fingers. Hand1973;._ 5:140-4.2. Bevin AG, Chase RA. The management f ring avulsioninjuries and associated conditions in the hand. Plast Re-constr Surg 1963;32:391-9.

3. ThompsonLK, Posch J, Lie KK. Ring injuries. PlastReconstr Surg 1968;42:148-51.4. Crawford J, Horton CE, Oakey RS. Avulsion of ringfinger skin. Plast Reconstr Surg 1952;10:46-9.5. Alonso-Artieda M. Reimplantation of an avulsed ringfinger using a sensory cross-finger flap. J Plast Surg(Br)1971 24:293-5.

Ring avulsion injuries 213

,5. Burkhalter WE.Ring avulsion injuries, care of amputatedp~xts, replacers, and revascularization. EmergMedClinNorth Am1985;3:365-71.

7. Tsai TM, Manstein C, DuBouR, Wolff TW, Kutz JE,KMnertHE.. Primary microsurgical repair of ring avul-sion amputation injuries. J HANDUR~ 984;9A:68-72.8. McGregor A. Degloving injuries. Hand1970;2:130-3.9. Carroll RE. Ring injuries in the hand. Clin Orthop1974; 104:175-82.10. Urbaniak JR, Evans JP, Bright DS. Microvascutar man-agement of ring avulsion injuries. J HArqD URO 981;6:25-30.11. NissenbaumM. Class IIA ring avulsion injuries: an ab-so]!ute indication for microvascularrepair. J HANDUR~1984;9A:810-15. :"12,. Steichen JB, Russell RC, Strickland JW. Revasculadza-.tion of ring avulsi0n injuries by microvasctflar tech-niques. J HANDUR6 978;3:289.13. AmericanSociety for Surgery of the Hand. The hand:examination and diagnosis. 2nd ed. NewYork: ChurchillLivingstone, 1983:107-11.14. KMnert HE, Verdan C. Report on the Committee onTendon Injuries. J HANDURG 983;8:794-8.

15. Stricldand J. Results of flexor tendonsurgery in zone II.Hand Clin 1985;1:167-79.16. Evans P. Class IIA ring avulsion. [Letter to the editor.]J I~[AND URG985;10A:587-8..17. NissenbaumM. Class IIA ring avulsion. [Letter to theeditor. Reply.] J HANDURG985;IOA:588.

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