What Is Ring Avulsion

  • Charchita Mishra Bachelor’s of Science - BSc. [Hons] Applied Biomedical Sciences, University of Essex
  • Jenny Lee Master of Chemistry with medicinal Chemistry, The University of Manchester

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Ring avulsion

A sudden pull on your finger, in most cases with a ring on it, leads to the degloving and complete removal of a finger in response to the strong force that hits it. This is a serious injury, usually causing damage to the blood vessels and nerves in the fingers when the ring worn is forcefully pulled off of the finger. Treatment should usually be urgent and follow immediately before tissue death occurs. If reconstruction is not immediately ensued, the damage could be permanent, leading to long-term trauma and significant consequences. 

In this article, we delve further into the causes, issues, treatment options, and preventative measures that one could take in order to avoid ring avulsion injuries. 

Introduction

Commonly occurs in situations where individuals are participating in activities that involve sudden movement or a risk of being entangled with another object moving forcefully. About 150,000 ring avulsion-related incidents are reported per year. Making up for about 5% of upper limb injuries. It usually is a 1 digit injury, i.e., affecting only a single finger or toe. Ranging from it being just a surrounding soft-tissue laceration to a complete amputation. It may also involve the avulsion of neurovascular bundles alongside the additional crushing of the flexor tendon. This poses quite a challenge for hand surgeons, based on the severity of the injury, bringing up the debate of when to entirely amputate the injured digit or perform a replant. 

How does this injury affect the injured?

Depending on the acuteness of the injury, this could lead to traumatic injuries that permanently affect the finger and could leave it expendable. The damage could go up to the soft tissue, muscles, tendons, blood vessels and even up to the bone in some instances

Various classifications have been published on the range of injuries for ring avulsion. The earliest classification fromUrbaniak et al., who framed the three classes:

  • Class 1: Adequate circulation: Treated via standard soft tissue and bone care
  • Class 2: Inadequate circulation: Treated via vessel repair
  • Class 3: Complete amputation: Treated via amputation

Nissenbaum, then added onto this list, modifying Class 2 injuries (Inadequate circulation) to consist also of Class 2A for isolated arterial injuries. 

Kay et al. further included it to have one more class and expanded on Class 2 injuries to include skeletal.

Although acknowledged in the literature, Urbaniak’s classification was initially adopted. 

When the ring on a finger is grabbed onto and tugged on with force, it acts as an ardent ambush. This sometimes causes the skin - the strongest soft tissue of the finger - to get ripped apart. Although strong, the skin is still relatively delicate and quite dainty and can rupture easily.  

What counts as a ring avulsion injury?

When a ring avulsion injury occurs, it could be very obvious based on its symptoms. The severity of the injury determines the intensity of the symptoms and how long they can be prolonged. Some of the symptoms of such an injury are:

  • Pain: Since the finger is almost dislodged from its member, the person can undergo a sharp, throbbing, or intense pain in the region of injury.
  • Bruising: The area of injury also now consists of damaged blood vessels, which cause bleeding underneath the skin via enlarged vessels. This can lead to discolouration and bruising within the area.
  • Swelling and Deformity: The enlarged vessels are brought about due to the inflammation leading to swelling within the arm. Swelling and tissue damage could cause the finger to appear deformed, especially when paired with a severe injury that could have led to the finger being fractured.
  • Restriction in movement and loss in sensation: Pain and swelling make it quite difficult to have any finger motility. Numbness due to nerve damage. 
  • Bleeding and visible tissue damage: In severe cases, a tear in the skin could result in visible bleeding due to an open wound. Further, if the injury deepens into the soft tissues, it could expose ligaments, tendons, or bones. 

Even if, at times, the injury does not appear severe, it is crucial to assess the extent of the damage and seek immediate medical attention if necessary in order to prevent potential complications. Expeditious care is essential in order to accurately analyse the injury, diagnose it, and carry out proper treatment for it. In some instances, expeditious care may narrow down the potential surgical intervention that needs to be done in order to reduce the long-term impact of the injury. 

Treatment

Ring avulsions could lead to bruising, deformity, swelling, and severe pain, amongst other symptoms Upon witnessing any of these, carrying out immediate care is extremely important to avoid permanent damage.

  • Avoid removing the ring: Attempting to take the ring off the injured finger could lead to further irritation and stretching of the tissues, causing increased bleeding and damage. Professional medical intervention is then required. 
  • Elevation and pressure: Applying gentle pressure on the injury to stop the bleeding and ensure clotting. This is done once the injured hand is raised above heart level to try and reduce blood flow and swelling. 

When this basic care does not suffice, the individual afflicted with the injury must be taken to emergency care. The finger must be placed in ice in order to preserve it if it is degloved. This is when surgical intervention is necessary. Followed by rehabilitation, including occupational therapy to regain functional mobility and strength in the affected finger. 

Preventative measures

  • Take off your ring before engaging in risky activities that involve heavy equipment, machinery, sports, or any instances where it could get caught on or pulled by objects.
  • Donning safer alternatives such as breakaway rings or ones made of silicone that are easily broken off when put under pressure. This reduces the risks of them being pulled and severe injury via entanglement.
  • Ensure that the rings you wear fit you well and are not too tight on the finger. Taking them off could lead to nerve bundles that become a ring avulsion injury. They could also increase the chances of causing avulsions during accidents as it would be harder for them to come off when stuck. 

FAQs

What are the common causes of ring avulsion?

Often, this takes place when a ring catches on some sort of equipment, machinery or other such objects, resulting in a forceful and sudden pulling on the finger. Activities such as working with heavy machinery, engaging in sports, or performing tasks involving rotating equipment pose a risk of ring avulsion. This is most likely due to wearing a tightly fitted ring that does not allow for proper circulation, causing it to get stuck.

How should one respond to a ring avulsion injury?

Pressing down on the injury to reduce bleeding and swelling whilst keeping it elevated above heart level, avoiding removing the ring. Thoroughly examine the injury and seek emergency medical intervention if necessary.

What are the treatment options for ring avulsion?

Depending on the severity of the injury, treatment could vary. Ranging from compressions to reduce swelling and blood loss to immediate surgical intervention in tissue and nerve damage or fracture cases. This is done to stabilise the finger, reattach tendons and vessels, and reconstructive surgery to restore finger functionality and motility. Followed by occupational therapy regimens to regain strength in it. 

What are the potential long-term complications of ring avulsion injuries?

Long-term complications of ring avulsion injuries may include permanent damage to tissues, loss of function or sensation in the affected finger, reduced mobility, chronic pain, and, in severe cases, amputation or permanent disfigurement.

How important is immediate medical attention for ring avulsion injuries?

Immediate medical attention is crucial for ring avulsion injuries to assess the severity of the injury, control bleeding, and prevent further damage. Timely treatment significantly impacts the outcome and potential complications associated with these injuries.

Always remember that any injury involving a ring and the potential for entanglement should be taken seriously, and seeking immediate medical care is essential to ensure the best possible outcome.

Conclusion

Ring avulsions, making up only 5% of upper arm-related injuries, are not so common. Yet, it can cause severe long-term consequences and loss of potential mobility and function in the affected digit. It is crucial to wear well-fitted rings and take them off during certain activities that could lead them to get stuck or require them to be pulled off. If injured, the individual must seek prompt medical attention once the injury has been well-examined and the primary care has taken place. Ensure that one wears easily breakable or silicone rings if said person does not remove any jewellery when partaking in any activities to reduce ring avulsion injuries. 

References:

  1. Jones M, Gujral S. Interesting Case Series Ring Avulsion Injuries [Internet]. 2016 [cited 2023 Dec 21]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753839/pdf/eplasty16ic05.pdf
  2. Bamba R, Malhotra G, Bueno Jr RA, Thayer WP. Ring Avulsion Injuries: A Systematic Review. [Internet]. American Association for Hand Surgery. 2018 [cited 2023 Dec 20]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5755869/pdf/10.1177_1558944717692094.pdf
  3. Woon C, Vitale M. Ring Avulsion Injuries [Internet]. Ortho Bullets. 2021 [cited 2023 Dec 20]. Available from: https://www.orthobullets.com/hand/6061/ring-avulsion-injuries
  4. Nothing Is Funny about Ring Avulsion | University of Utah Health [Internet]. healthcare.utah.edu. 2015 [cited 2023 Dec 21]. Available from: https://healthcare.utah.edu/healthfeed/2015/07/nothing-funny-about-ring-avulsion
  5. Brooks D, Buntic RF, Kind GM, Schott K, Buncke GM, Buncke HJ. Ring Avulsion: Injury Pattern, Treatment, and Outcome. Clinics in Plastic Surgery [Internet]. 2007 Apr 1 [cited 2023 Dec 21];34(2):187–95. Available from: https://www.sciencedirect.com/science/article/abs/pii/S009412980600112X
  6. Kay S, Werntz J, Wolff TW. Ring avulsion injuries: Classification and prognosis. The Journal of Hand Surgery. 1989 Mar;14(2):204–13.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Charchita Mishra

Bachelor’s of Science - BSc. [Hons] Applied Biomedical Sciences, University of Essex

There is art to medicine as well as science”, claims the Hippocratic oath. As a medical writer, Charchita aims to combine the two seamlessly. Having founded two newsletters and been President of the Life Sciences Society during the course of completion of her Biomedical Sciences degree, she tries to bring a deep and cohesive understanding of medical concepts. Her passion for science and writing and several years of experience in the two are what make her strive to deliver compelling, well-researched, and informative articles that resonate with the readers.

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