Introductions

Definition

sudden pull on a finger ring results in severe soft tissue

injury ranging from circumferential soft tissue laceration
to complete amputation

skin, nerves, vessels are often damaged

Epidemiology
o

incidence

150,000 incidents of amputations and degloving

in the US per year

5% of upper limb injuries

location

usually only involves 1 digit (with ring)

risk factors

working with machinery

wearing a ring

Mechanism
o

patients catch their wedding band or other finger ring on moving machinery or protruding object

long segment of macro- and microscopic vascular injury from crushing, shearing and avulsion

Prognosis
o

outcomes of injury

extent of injury is greater than what it appears to be

poor prognosis because of long segment vascular injury

treatment outcomes

advances in interposition graft techniques have improved results with ring avulsion
replantation

Anatomy
Muscles
o

avulsed digits are devoid of muscles and will survive >12h if cooled

Skin
o

skin is the finger's strongest soft tissue

once the skin tears, the remaining tissue quickly degloves

Biomechanics
o

Urbaniak Class I injuries at 80N of traction force

Urbaniak Class III injuries at 154N of traction force

Standard wedding band (3mm wide, regardless of alloy) will not open at 1000N

Classification
Urbaniak Classification
Class

Description

Treatment

Class I

Circulation adequate

Standard bone and soft tissue

care

Class II

Circulation inadequate

Vessel repair

Class III

Complete degloving or complete amputation

Amputation

Images

Kay, Werntz and Wolff Classification

Class

Description

Treatment

Class I

Circulation adequate

Standard bone and soft tissue

repair

Class II

Arterial compromise only

Vessel repair

Class III

Inadequate circulation with bone, tendon, or

nerve injury.

Amputation

Class IV

Complete degloving or complete amputation.

Amputation

Images

Presentation
History
o

may have history of working with machinery, getting caught in door

Symptoms
o

pain

bleeding

lack of sensation at tip

Physical exam
o

inspection

irrigate wound and inspect for visible avulsed vessel, nerve, tendon, damaged skin edges

staggered injury pattern

proximal skin avulsion (from PIPJ to base of digit)

distal bone fracture or dislocation (distal to PIPJ, often at DIPJ level)

Imaging
Radiographs
o

recommended views

Xray both segments (the amputated part, if present, and the remaining digit)

Treatment
Initial

place amputated part, if present, in bag with saline-moistened gauze, followed by bag of ice water

antibiotics and tetanus prophylaxis

Operative
o

replantation +/- vein graft, DIPJ fusion

indications

disruption of venous drainage only

disruption of venous and arterial flow (requires revascularization)

requires intact PIPJ and FDS insertion

contraindication

complete amputation (especially distal to PIPJ and FDS insertion) is relative

contraindication to replantation

outcomes

survival

lower overall survival for avulsed digits replantation (60%) than finger
replantation in general (90%)

lower survival for complete (66%) vs incomplete avulsion replantation (78%)

lower survival for avulsed thumb (68%) than finger (78%) replantation

surgeons more likely to attempt technically difficult avulsed thumb

replantation where conditions not favorable because of importance
of thumb to hand function (unlike other digits, where revision
amputation would be performed instead)

sensibility

most achieve protective sensibility (2PD 9mm)

better sensibility with incomplete avulsion replantation (8mm) than complete

(10mm)

range of motion

average total arc of motion (TAM) of 170-200 degrees

better TAM with incomplete avulsion replantation (199 degrees) than

complete (174 degrees)

revision amputation

indications

complete degloving

bony injury with nerve and vessel injury

bony amputation proximal to FDS insertion or proximal to PIPJ

replantation likely to leave poor hand function

consider revision amputation or ray amputation

Surgical Technique
Replantation/revascularization
o

approach

under operating microscope mid-lateral approach to digit

technique

arteries

thorough debridement of nonviable tissue

thorough arterial debridement (inadequate debridement leads to failure)

repair using vein grafts because of significant vascular damage

may need another step-down vein graft because of difficulty in arterial size
matching (small artery, large vein graft)

may reroute arterial pedicle from adjacent digit

veins

repair at least 2 veins

important factor in revascularization failure

bone

disadvantage is this sacrifices major artery from adjacent digit

skin

if amputation occurs at DIPJ, perform primary arthrodesis of DIPJ

perform full-thickness skin grafts or venous flaps to prevent tight closure or may
utilize commercially available synthetic acellular dermal matrix.

Complications
Complications of replantation
o

cold intolerance (70%)

revascularization/replantation failure

factors include

most significant factor is repair of <2 veins

vascular damage up to digital pulp

smoking and level of bone injury have not been found to affect survival

flexion contracture

malunion

revision surgery

Complications of revision amputation

o

Hyperaesthesia

Patterns of Prehensile Hand

Function
Efficient prehensile function depends on a multitude of factors, the most important of which are:
l. Mobility of the first CMC joint and, to a lesser extent, of the fourth and fifth MCP joints
2. Relative rigidity of the second and third CMC joints
3. Stability of the longitudinal linger and thumb arches
4. Balanced synergism and antagonism between the long extrinsic muscles and the hand intrinsic
muscles
5. Adequate senSOl)' input from all areas of the hand
6. The precise relationships among the length, mobility, and position of each digital ray.
Dua pola berbeda pada pergerakan tangan : Power grip dan precision grip. Hal tersebut merupakan
dasar dari pergerakan memegang dan stabilisasi. Power grip adalah pegangan kuat yang dilakukan
dengan fleksi jari-jari
Precision grip involves the manipulation of small objects between the thumb and the flexor aspects
of the fingers in a finely controlled manner (Fig. 14-24B). The \vrist position varies so as to
increasethe manipulative range. The fingers arc generally in a semiflexed position, and the thumb is
palmadyabducted and opposed. Certain prehensile activities involve both power and precision grips
(Fig. 14-25).As a refinement of Napier's classification, Landsmeer (I962) suggested that the precision
gripbe termed "precision handling" because it involves no forceful gripping of the object and is a
dynamic process without a static phase. In both power grip and precision handling, full opposition of
the thumb to the ring and little fingers is obtained via palmar displacement of the metacarpals of
thesedigits.
A variant of precision handling is the often used "dynamic tripod" (Capenec 1956), wherein the

thumb, index finger, and middle finger have a d)'namic action, \vorking in close synergy for precision
handling of the object, while the ring and little lingers are used largely for support and static control
(Fig. 14-26). A further refinement is pinching a small object between the thumb and index finger.
Such maneuvers are commonl).' classified as tip pinch, palmar pinch, lateral (or key) pinch, and
pulp (or ulnar) pinch, depending on the parts of the phalanges brought to bear on the object being
handled
(Fig. 14-27). Another important distinction between power grip and precision handling is the
fundamentally different position of the thumb in each postme. In the power grip, the thumb is
adducted; in precision handling, it is pal marly abducted (Fig. 14-24). The relationship of the hand to
the forearm also differs strikingly. In the power grip (Fig. 14-2411), the hand is usually deviated
ulnarly and the wrist is held approximately in a neutral position so that the long axis of the thumb
coincides with that of the forearm.
In this wa)', pronation and supination can be transmitted from the forearm to th~ object. In precision
handling (Fig. I4-24B), the hand is generally held midway between wrist radial and ulnar deviation,
and the wrist is markedly reflected in the posture of the thumb. When the demand for prectSion
is minimuj or abscI1L. the thumb is wrapped over the dorsum of the middle phalanges of the digits
and
acts purely as a reinforcing mechanism. \Vhen an el cment of precision is required in what is
predominately
a power grip, slich as the fencing gl"ip (Fig. 14-28;\), the thumb is adducted and aligned with the
long axis of the cylinder so that, by means of small adjustrnents of posture, it can control 1hl:
direction
in which the force is being applied. Al the other extreme of the power grip range is the coal-hammer
grip (Fig. 14-28B), the crudest form of prehensile function, where the thumb is wholly occupied in
reinforcing
the clamping action or the digits. An example of this exlreme in an empty hand is the
bunched fist (Fig. 14-28Cl. Rotating the thumb into an opposing position is a requirement of almost
every hand function, whether it be a strong grip or a delicate precision pinch. In some inslances,
howcver, the thumb may
not be involvcd at all, as in the hook grip in which the fingers are ncxcd so that their pads lie parallel
and slighlly away from the p,t1m, together forming a hook. This posture requires relatively little
muscle
activity to maintain and is used when precision requirements arc minimal and when power must be
exerted continuously for long periods. Functionally, the hook grip pattern has limited potential and is
not used ver~v often. An example of its use is to carry an aoache case or a suitcase b.y its handle. In
contrast,
the individual whose hand intrinsic muscles are paralyzed or severely weakened relics on the
hook grasp 1'01' all functional task completion. The hook grasp is the only grasp pattern available
when
the hand intrinsics arc not working.