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Multiple finger avulsion with rare form of injury: A case of sufficient circulation but with pulley injury

Published:January 10, 2023DOI:https://doi.org/10.1016/j.jcot.2023.102104
      Dear Editor
      Finger avulsion injury is a rare trauma, and most cases are associated with a ring worn of one of the fingers. In the Urbaniak classification
      • Urbaniak J.R.
      • Evans J.P.
      • Bright D.S.
      Microvascular management of ring avulsion injuries.
      —widely used for the classification of finger avulsion injury—Class 1 injuries tend to have good treatment outcomes, thus, there is paucity of reports in the literature.
      We report a 28-year-old male with finger avulsion injuries classified as Class 1 when considered in the Urbaniak classification, injured when his hand accidently slipped while carrying a heavy object. Distally based avulsed flaps of widths between 10 and 15 mm were observed on the right index, middle, and ring fingers. The length of the avulsed flap was the longest in the middle finger, from the fingertip to the volar side of the metacarpophalangeal joint (Fig. 1A). Fortunately, circulation was adequate in all fingers and there was no nerve injury. For the index and ring fingers, the connective tissue of the avulsed flaps were removed, and pedicled skin graft was performed. The A3, A4, and part of the A2 pulley were injured on the middle finger, and a bowstring effect was seen. Therefore, the pulleys were immediately reconstructed using flexor digitorum superficialis (Fig. 1B). The pedicled skin graft was also performed on the middle finger (Fig. 1C). The skin graft was completely engrafted. Because cutaneous contracture became apparent during rehabilitation (Fig. 1D), the contracture was released with digitolateral flap at 2 months and 5 months after the injury. A year after the injury, he had regained full range of motion and grip (Fig. 1E.F) and the bowstring effect was not observable.
      Fig. 1
      Fig. 1A: Distally based avulsed flaps with widths of between 10 and 15 mm were observed on the right index, middle, and ring fingers. The length of the avulsed flap was the longest in the middle finger, from the fingertip to the volar side of the metacarpophalangeal joint. B: The pulley was immediately reconstructed using flexor digitorum superficialis. C: Pedicled skin graft was also performed on the index, middle, and ring fingers. D: The skin graft was completely engrafted, but cutaneous contracture became apparent during rehabilitation. E.F: A year after the injury, he had regained full range of motion and grip. Hand in extension.
      Urbaniak et al. describe a Class 1 ring injury as having sufficient circulation in the finger. Soft tissue injuries can be accompanied by varying degrees of avulsion of the surrounding skin as well as damage to the flexor tendons, extensor tendons, pulley, volar plates, etc.
      • Urbaniak J.R.
      • Evans J.P.
      • Bright D.S.
      Microvascular management of ring avulsion injuries.
      In the review by Ravinder et al., the frequency of Urbaniak Class 1 among ring avulsion patients is as low as 9% (54/572 patients). Moreover, most of these are reports of patients with very good outcomes, with only skin avulsion and no deep structural injury; therefore, there are few data on patients with deep soft tissue injury in Urbaniak Class 1
      • Bamba R.
      • Malhotra G.
      • Bueno Jr., R.A.
      • Thayer W.P.
      • Shack R.B.
      Ring avulsion injuries: a systematic review.
      . Our case was not associated with a ring and was due to a rare form of injury. There was extensive pulley injury, so immediate reconstruction was performed. Skin grafting was selected on the basis that blood flow to the periphery of the flap could not be expected. A local flap was performed for the cutaneous contracture that became apparent at a later date. There may be other possible surgical/treatment options, but, in this case, appropriate treatment by a hand surgeon is believed to have led to a good outcome. In order to study a more systematic treatment strategy, it is necessary to subdivide Urbaniak Class1 according to the presence or absence of deep structural injury and collect more cases in the future.

      Funding

      None.

      Patient consent

      Informed consent for publication was obtained from the patient in this report.

      Declaration of competing interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgments

      We would like to thank Dr Fumikazu Tamura, and Professor Mitsuru Sekido for useful discussions. We would like to thank Thomas Mayers, Medical English Communications Center, University of Tsukuba, for language revision of this manuscript.

      References

        • Urbaniak J.R.
        • Evans J.P.
        • Bright D.S.
        Microvascular management of ring avulsion injuries.
        J Hand Surg Am. 1981; 6: 25-30
        • Bamba R.
        • Malhotra G.
        • Bueno Jr., R.A.
        • Thayer W.P.
        • Shack R.B.
        Ring avulsion injuries: a systematic review.
        Hand (N Y). 2018; 13: 15-22