+ Models
CHIMAI-877; No. of Pages 3
Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main xxx (2014) xxx–xxx
Original article
Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases Les traumatismes de type doigt d’alliance peuvent-ils être prévenus par des bagues pré-fragilisées ? À propos de trois cas cliniques A.S. Matheron, S. Hendriks, S. Gouzou, P.A. Liverneaux *, S. Facca Department of hand surgery, Strasbourg university hospitals, 10, avenue Baumann, 67403 Illkirch cedex, France Received 12 January 2014; received in revised form 16 March 2014; accepted 24 March 2014
Abstract Prevention of finger trauma can be directly related to the manufacture of pre-weakened rings. We report on three clinical cases of finger injuries caused by pre-weakened rings. Lesions were less severe than conventional ring finger injuries, such as those caused by iron fences. Surgery was required in all three cases and chronic cold sensitivity was noted in one case. This small series advocates the imposition of a ring manufacturing standard at the European level. Given this lack of consensus, the idea is to prevent injuries by developing rings with intentional weak points that open automatically in case of trauma. These pre-weakened rings have never been subject to clinical study to demonstrate their potential safety. # 2014 Elsevier Masson SAS. All rights reserved. Keywords: Ring-related trauma; Ring finger; Pre-weakened rings
Résumé La prévention des traumatismes digitaux passe notamment par la fabrication de bagues fragilisées. Nous rapportons ici 3 cas cliniques de lésions digitales provoquées par des bagues pré-fragilisées. Les lésions étaient moins graves que les classiques doigts d’alliance, s’apparentant aux plaies par grillage. Dans les 3 cas, elles nécessitaient une intervention chirurgicale et provoquaient 1 fois des séquelles à type de douleurs au froid. Cette courte série plaide l’imposition d’une norme de fabrication des bagues à l’échelle européenne. # 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Traumatisme par bague ; Doigt d’alliance ; Bague pré-fragilisée
1. Introduction So-called ‘‘ring finger’’ injuries are complex multi-tissue lesions that typically require emergency microsurgery. Their severity, classified into four stages, extends from a simple skin bruise to complete finger amputation by avulsion [1,2]. Most of the published cases are stage 4 injuries. Some authors consider that replantation should be attempted at all costs [3,4], while
* Corresponding author. E-mail address: [email protected] (P.A. Liverneaux).
others consider the potential consequences to be unjustified [5,6].
2. Observations 2.1. Patient A Female 13-year-old schoolgirl, non-smoker, right-handed, presented to the emergency department with a lesion of the third right finger caused by a pre-weakened ring (Fig. 1). The mechanism of injury was a similar to those caused by iron
http://dx.doi.org/10.1016/j.main.2014.03.004 1297-3203/# 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
+ Models
CHIMAI-877; No. of Pages 3
A.S. Matheron et al. / Chirurgie de la main xxx (2014) xxx–xxx
2
Fig. 1. Patient A - Finger injuries caused by a pre-weakened ring: Palmar aspect. Note the longitudinal deep wound of the three phalanges (A). Dorsal aspect. Note the track of the ring without deep skin lesion (B). Ring. Note the complete and incomplete breakage at the various intentional weak points. Also note the twist in the ring indicative of insufficient weakening (C).
fences. The patient underwent emergency surgery (Fig. 1). The finger flexor sheath was opened but no tendon, blood vessel or nerve injury was noted. We performed skin debridement, exploration, flexor sheath lavage and skin suture. The postoperative course was uneventful and consisted of one overnight hospital stay and interruption of leisure activities for two months. At a follow-up of one and half years, the patient was pain-free, the Quick DASH was 0/100, range of motion and pulp sensitivity were complete and she presented no cold sensitivity. 2.2. Patient B Male 13-year-old student, non-smoker, right-handed, presented to the emergency department with a lesion of the third left finger caused by a pre-weakened ring. Mechanism of injury was a fall from the top of a wall. There was a deep longitudinal wound of the first two phalanges and the patient underwent emergency surgery. Since there was no nerve or blood vessel injury, we performed skin debridement, exploration and skin
suture. The postoperative course consisted of one day only of school attendance and interruption of leisure activities for three weeks. At one year and three months of follow-up, the patient was pain-free, the Quick DASH was 0/100, range of motion and pulp sensitivity were complete and he presented no cold sensitivity.
2.3. Patient C Female 22-year-old student, non-smoker, right-handed, presented to the emergency department with a lesion of the fourth right finger caused by a pre-weakened ring. The mechanism of injury was unclear. The wound was deep and the patient underwent emergency surgery. Since there was no nerve or blood vessel injury, we performed skin debridement, exploration and skin suture. The postoperative course consisted of a three-night hospital stays and interruption of leisure activities for two weeks. At four and a half years of follow-up, the patient was pain-free, the Quick DASH was 0/100, range of
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
+ Models
CHIMAI-877; No. of Pages 3
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motion and pulp sensitivity were complete. However, she presented with cold sensitivity.
3. Discussion Finger ring injuries are no longer limited to ring fingers among married patients. Currently, these injuries affect all fingers including the thumb in increasingly young patients [7], as we also observed in our small clinical series. Studies have been performed to look at how to prevent such serious injuries [8–11]. Children’s toys must now include intentional weak points [12]. Rings for adults can be modified to incorporate invisible weak points that would break before tearing the finger [13]. However, to be effective, this method implies the recalibration of the drill guide for every ring model and also requires the manufacturer to bear the high costs, which explains its very limited uptake. The safety of other ring weakening methods has never been evaluated. Our three cases of injury by pre-weakened rings illustrate this latter process. The ring broke into two pieces during trauma and its edges made a deep, proximal to distal longitudinal skin lesion indicative of a traction mechanism. This mechanism can be likened to that of ring finger injuries caused by iron fences [14]. Even though the lesions caused by these pre-weakened rings in our series were less serious than those caused by conventional rings, they still required surgery, hospitalization, financial costs and were responsible for sequelae such cold sensitivity. This could have been avoided if a manufacturing standard had been in effect. Australia obligated all manufacturers to cap their fences to prevent finger injuries [15]. Why couldn’t the European Union do likewise for ring finger injury prevention by imposing a standard, such as the process described by Dubert et al. [13]?
3
Disclosure of interest Philippe Liverneaux has conflicts of interest with Newclip Technics, Integra, Argomedical. The other authors declare that they have no conflicts of interest concerning this article. References [1] Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25–30. [2] Mitz V. Replantation of the ring finger. Rev Prat 1994;44:2456–60 [In French]. [3] Adani R, Pataia E, Tarallo L, Mugnai R. Results of replantation of 33 ring avulsion amputations. J Hand Surg Am 2013;38:947–56. [4] Barbary S, Dap F, Dautel G. Finger replantation: surgical technique and indications. Chir Main 2013;32:363–72. [5] Chung KC. Invited discussion: long-term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003;51:569. [6] Segret J, Barbary S, Pétry D, Dautel G. Primary ray resection as an alternative to microsurgical replantation in the management of ring finger avulsion. Chir Main 2008;27:202–7 [Article in French]. [7] Sanmartin M, Fernandes F, LaJoie AS, Gupta A. Analysis of prognostic factors in ring avulsion injuries. J Hand Surg Am 2004;29:1028–37. [8] Bevin AG, Chase RA. The management of ring avulsion injuries and associated conditions. Hand Plast Reconstr Surg 1963;32:391–400. [9] Carroll RE. Ring injuries in the hand. Clin Orthop Relat Res 1974;104:175–82. [10] Varela CD. Case report: tang avulsion injuries in a field environment. Military Med 1996;161:308–10. [11] Weil DJ, Wood VE, Fryckman GK. A new class off ring injuries. J Hand Surg Am 1989;14:662–4. [12] Décret no 2010-166 du 22 février 2010. Sécurité des jouets. JORF 2010;46:3476. [13] Dubert T, Diop A, Voeltzel P. An experimental study of ring avulsion injuries and two preventives devices. J Hand Surg Br 2000;25:418–21. [14] Amjadi M, Harries R. Corrugated-iron fence injury to the hand. J Hand Surg Eur Vol 2009;34:809–10. [15] Griffin PA, Robinson DN. Paediatric hand injuries and the galvanized-iron fence. Med J Aust 1989;150:644–5.
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
CHIMAI-877; No. of Pages 3
Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main xxx (2014) xxx–xxx
Original article
Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases Les traumatismes de type doigt d’alliance peuvent-ils être prévenus par des bagues pré-fragilisées ? À propos de trois cas cliniques A.S. Matheron, S. Hendriks, S. Gouzou, P.A. Liverneaux *, S. Facca Department of hand surgery, Strasbourg university hospitals, 10, avenue Baumann, 67403 Illkirch cedex, France Received 12 January 2014; received in revised form 16 March 2014; accepted 24 March 2014
Abstract Prevention of finger trauma can be directly related to the manufacture of pre-weakened rings. We report on three clinical cases of finger injuries caused by pre-weakened rings. Lesions were less severe than conventional ring finger injuries, such as those caused by iron fences. Surgery was required in all three cases and chronic cold sensitivity was noted in one case. This small series advocates the imposition of a ring manufacturing standard at the European level. Given this lack of consensus, the idea is to prevent injuries by developing rings with intentional weak points that open automatically in case of trauma. These pre-weakened rings have never been subject to clinical study to demonstrate their potential safety. # 2014 Elsevier Masson SAS. All rights reserved. Keywords: Ring-related trauma; Ring finger; Pre-weakened rings
Résumé La prévention des traumatismes digitaux passe notamment par la fabrication de bagues fragilisées. Nous rapportons ici 3 cas cliniques de lésions digitales provoquées par des bagues pré-fragilisées. Les lésions étaient moins graves que les classiques doigts d’alliance, s’apparentant aux plaies par grillage. Dans les 3 cas, elles nécessitaient une intervention chirurgicale et provoquaient 1 fois des séquelles à type de douleurs au froid. Cette courte série plaide l’imposition d’une norme de fabrication des bagues à l’échelle européenne. # 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Traumatisme par bague ; Doigt d’alliance ; Bague pré-fragilisée
1. Introduction So-called ‘‘ring finger’’ injuries are complex multi-tissue lesions that typically require emergency microsurgery. Their severity, classified into four stages, extends from a simple skin bruise to complete finger amputation by avulsion [1,2]. Most of the published cases are stage 4 injuries. Some authors consider that replantation should be attempted at all costs [3,4], while
* Corresponding author. E-mail address: [email protected] (P.A. Liverneaux).
others consider the potential consequences to be unjustified [5,6].
2. Observations 2.1. Patient A Female 13-year-old schoolgirl, non-smoker, right-handed, presented to the emergency department with a lesion of the third right finger caused by a pre-weakened ring (Fig. 1). The mechanism of injury was a similar to those caused by iron
http://dx.doi.org/10.1016/j.main.2014.03.004 1297-3203/# 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
+ Models
CHIMAI-877; No. of Pages 3
A.S. Matheron et al. / Chirurgie de la main xxx (2014) xxx–xxx
2
Fig. 1. Patient A - Finger injuries caused by a pre-weakened ring: Palmar aspect. Note the longitudinal deep wound of the three phalanges (A). Dorsal aspect. Note the track of the ring without deep skin lesion (B). Ring. Note the complete and incomplete breakage at the various intentional weak points. Also note the twist in the ring indicative of insufficient weakening (C).
fences. The patient underwent emergency surgery (Fig. 1). The finger flexor sheath was opened but no tendon, blood vessel or nerve injury was noted. We performed skin debridement, exploration, flexor sheath lavage and skin suture. The postoperative course was uneventful and consisted of one overnight hospital stay and interruption of leisure activities for two months. At a follow-up of one and half years, the patient was pain-free, the Quick DASH was 0/100, range of motion and pulp sensitivity were complete and she presented no cold sensitivity. 2.2. Patient B Male 13-year-old student, non-smoker, right-handed, presented to the emergency department with a lesion of the third left finger caused by a pre-weakened ring. Mechanism of injury was a fall from the top of a wall. There was a deep longitudinal wound of the first two phalanges and the patient underwent emergency surgery. Since there was no nerve or blood vessel injury, we performed skin debridement, exploration and skin
suture. The postoperative course consisted of one day only of school attendance and interruption of leisure activities for three weeks. At one year and three months of follow-up, the patient was pain-free, the Quick DASH was 0/100, range of motion and pulp sensitivity were complete and he presented no cold sensitivity.
2.3. Patient C Female 22-year-old student, non-smoker, right-handed, presented to the emergency department with a lesion of the fourth right finger caused by a pre-weakened ring. The mechanism of injury was unclear. The wound was deep and the patient underwent emergency surgery. Since there was no nerve or blood vessel injury, we performed skin debridement, exploration and skin suture. The postoperative course consisted of a three-night hospital stays and interruption of leisure activities for two weeks. At four and a half years of follow-up, the patient was pain-free, the Quick DASH was 0/100, range of
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
+ Models
CHIMAI-877; No. of Pages 3
A.S. Matheron et al. / Chirurgie de la main xxx (2014) xxx–xxx
motion and pulp sensitivity were complete. However, she presented with cold sensitivity.
3. Discussion Finger ring injuries are no longer limited to ring fingers among married patients. Currently, these injuries affect all fingers including the thumb in increasingly young patients [7], as we also observed in our small clinical series. Studies have been performed to look at how to prevent such serious injuries [8–11]. Children’s toys must now include intentional weak points [12]. Rings for adults can be modified to incorporate invisible weak points that would break before tearing the finger [13]. However, to be effective, this method implies the recalibration of the drill guide for every ring model and also requires the manufacturer to bear the high costs, which explains its very limited uptake. The safety of other ring weakening methods has never been evaluated. Our three cases of injury by pre-weakened rings illustrate this latter process. The ring broke into two pieces during trauma and its edges made a deep, proximal to distal longitudinal skin lesion indicative of a traction mechanism. This mechanism can be likened to that of ring finger injuries caused by iron fences [14]. Even though the lesions caused by these pre-weakened rings in our series were less serious than those caused by conventional rings, they still required surgery, hospitalization, financial costs and were responsible for sequelae such cold sensitivity. This could have been avoided if a manufacturing standard had been in effect. Australia obligated all manufacturers to cap their fences to prevent finger injuries [15]. Why couldn’t the European Union do likewise for ring finger injury prevention by imposing a standard, such as the process described by Dubert et al. [13]?
3
Disclosure of interest Philippe Liverneaux has conflicts of interest with Newclip Technics, Integra, Argomedical. The other authors declare that they have no conflicts of interest concerning this article. References [1] Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25–30. [2] Mitz V. Replantation of the ring finger. Rev Prat 1994;44:2456–60 [In French]. [3] Adani R, Pataia E, Tarallo L, Mugnai R. Results of replantation of 33 ring avulsion amputations. J Hand Surg Am 2013;38:947–56. [4] Barbary S, Dap F, Dautel G. Finger replantation: surgical technique and indications. Chir Main 2013;32:363–72. [5] Chung KC. Invited discussion: long-term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003;51:569. [6] Segret J, Barbary S, Pétry D, Dautel G. Primary ray resection as an alternative to microsurgical replantation in the management of ring finger avulsion. Chir Main 2008;27:202–7 [Article in French]. [7] Sanmartin M, Fernandes F, LaJoie AS, Gupta A. Analysis of prognostic factors in ring avulsion injuries. J Hand Surg Am 2004;29:1028–37. [8] Bevin AG, Chase RA. The management of ring avulsion injuries and associated conditions. Hand Plast Reconstr Surg 1963;32:391–400. [9] Carroll RE. Ring injuries in the hand. Clin Orthop Relat Res 1974;104:175–82. [10] Varela CD. Case report: tang avulsion injuries in a field environment. Military Med 1996;161:308–10. [11] Weil DJ, Wood VE, Fryckman GK. A new class off ring injuries. J Hand Surg Am 1989;14:662–4. [12] Décret no 2010-166 du 22 février 2010. Sécurité des jouets. JORF 2010;46:3476. [13] Dubert T, Diop A, Voeltzel P. An experimental study of ring avulsion injuries and two preventives devices. J Hand Surg Br 2000;25:418–21. [14] Amjadi M, Harries R. Corrugated-iron fence injury to the hand. J Hand Surg Eur Vol 2009;34:809–10. [15] Griffin PA, Robinson DN. Paediatric hand injuries and the galvanized-iron fence. Med J Aust 1989;150:644–5.
Please cite this article in press as: Matheron AS, et al. Can ring finger injuries be prevented by pre-fragilized rings? About three clinical cases. Chir Main (2014), http://dx.doi.org/10.1016/j.main.2014.03.004
