1. Ring Avulsion Injuries Lip Teh Sir Charles Gairdner Hospital

2. Clinical Case Mrs Whitehouse 59yr old female Mrs Whitehouse 59yr old female Admitted 29.6.03 Admitted 29.6.03 Balancing up to get key, slipped and caught wedding ring. Balancing up to get key, slipped and caught wedding ring. Sustained circumferential skin laceration Sustained circumferential skin laceration

3. Examination Venously congested Venously congested Intact sensation Intact sensation No skeletal injury No skeletal injury Long tendons intact Long tendons intact

4. Dorsum

5. Volar

6. Operative Findings Circumferential degloving Circumferential degloving No intact patent veins No intact patent veins Radial side digital artery avulsed Radial side digital artery avulsed Ulnar digital neurovascular bundle intact Ulnar digital neurovascular bundle intact Tendons intact Tendons intact

7. Clinical course Dorsal vein repaired Dorsal vein repaired Good venous return Good venous return 36hrs later – development of venous congestion 36hrs later – development of venous congestion Returned to theatre Returned to theatre

8. Clinical course Venous repair thrombosed Venous repair thrombosed Patent dorsal veins found on dissection distally Patent dorsal veins found on dissection distally Two dorsal veins repaired with vein grafts Two dorsal veins repaired with vein grafts

9. Ring Avulsion Ring finger Ring finger Grip Grip Continence of cupped hand Continence of cupped hand Symbolic role Symbolic role Significance of injury often under- appreciated Significance of injury often under- appreciated

10. Classification Urbaniak 1981 Urbaniak 1981 I. Circulation Adequate I. Circulation Adequate II. Circulation Inadequate II. Circulation Inadequate III. Complete degloving or amputation III. Complete degloving or amputation Nissenbaum modification 1984 Nissenbaum modification 1984 IIA. Circulation Inadequate (only arteries injured) IIA. Circulation Inadequate (only arteries injured)

11. Prognosis Kay et al. J Hand Surg 1989 Kay et al. J Hand Surg 1989 Retrospective review 55 patients Retrospective review 55 patients Class I (n=3) Class I (n=3) Class II (n=25) Class II (n=25) Class III (n=27) Class III (n=27) 8 primary amputations 8 primary amputations Class II (n=3) Class II (n=3) Class III (n=5) Class III (n=5)

12. Prognosis 44 microsurgical repair 44 microsurgical repair Class II (n=22); Class III (n=22) Class II (n=22); Class III (n=22) 9 secondary amputations (vascular insufficiency) 9 secondary amputations (vascular insufficiency) Success rate: Success rate: Kay 1989Urbaniak 1981 Kay 1989Urbaniak 1981 Class II 86% 100% Class II 86% 100% Class III 73%71% Class III 73%71%

13. Methods Repaired 3 veins on average Repaired 3 veins on average 50% vein grafts for veins 50% vein grafts for veins 50% required skin grafts 50% required skin grafts Venous and cross finger flaps in 11% Venous and cross finger flaps in 11% Hyperbaric oxygen in 20% Hyperbaric oxygen in 20%

14. Findings No difference in salvage, function and sensibility with Class II and III. No difference in salvage, function and sensibility with Class II and III. Presence of skeletal injury Presence of skeletal injury More likely to require secondary procedures More likely to require secondary procedures Reduced function Reduced function Later return to work Later return to work

15. Findings Arterial or venous only compromise – 100% salvage Arterial or venous only compromise – 100% salvage Both arterial and venous compromise – 70-75% salvage (similar to replant) Both arterial and venous compromise – 70-75% salvage (similar to replant)

16. Proposed Classification Kay 1989 Kay 1989 I. Circulation Adequate I. Circulation Adequate II. Circulation Inadequate (arterial and venous), no skeletal injury II. Circulation Inadequate (arterial and venous), no skeletal injury III. Circulation Inadequate (arterial and venous), skeletal/joint injury III. Circulation Inadequate (arterial and venous), skeletal/joint injury IV. Complete amputation IV. Complete amputation Subclasses a and v for arterial and/or venous compromise Subclasses a and v for arterial and/or venous compromise

17. Lessons Salvagable injuries Salvagable injuries Multiple venous anastamosis Multiple venous anastamosis Vein grafts to traverse past zone of injury Vein grafts to traverse past zone of injury