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146 Chapter 32
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Figure 32-1. Radiographs of this digit show radiopacity of injected
latex material. (Radiograph courtesy of Dr. Fraser J. Leversedge.)
injections between these creases usually result in more superficial wounds.
l Radiopaque substances or free air can be localized using radio-
graphs (Figure 32-1).
l Start IV antibiotics to include a first-generation cephalosporin
and an aminoglycoside to prevent secondary infection.
l Liver function, blood urea nitrogen (BUN), and creatinine
should be monitored because some injectables are toxic to the
liver and cause hematuria.
l Consult a hand surgeon immediately for evaluation and man-
agement.
Definitive Treatment (Refer to Hand Specialist)
l Urgent surgical debridement (preferably within 6 hours of
injury) might be required.
Acute Treatment
Injection Injuries 147
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l Neurovascular injury and tissue necrosis can be severe enough
to necessitate amputation.
Potential Problems
l Neurovascular injury, necrosis, fibrosis, or infection can neces-
sitate amputation.
l Secondary infection can occur.
SUGGESTED READING
American College of Emergency Physicians. Clinical policy for the initial approach
to patients presenting with penetrating extremity trauma. Ann Emerg Med.
1999;33(5):612-636.
Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and
meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect
Dis. 2001;1(3) :175-188.
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chapter
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33
RING AVULSION INJURIES
Injury to the ring finger from a ring avulsion is not only problematic cosmetically, the function and sensibility of the ring finger
are important for gripping and holding objects. These injuries range
from superficial soft tissue injuries to complete degloving of the soft
tissue from bone.
Mechanism of Injury
l The ring catches on a hook, basketball net, or another object
and strangulates the finger; or the ring is too tight because of
swelling (Figure 33-1).
l The same type of injury can be caused if the finger is caught by
a string or rope (eg, sailing).
l Classification is based on vascular damage:
t Class I: adequate circulation
t Class II: inadequate circulation (requires vascular repair)
t Class III: complete degloving (requires replantation)
l If the ring is still present, remove it (Appendix E).
l Determine whether there is compromised perfusion:
t Capillary refill
t Digital Allen test
t Doppler digital vessels
l Recognize that digital vessel disruption can occur, even with-
out skin laceration.
Evaluation
149
150 Chapter 33
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Figure 33-1. This edematous digit was strangulated by a ring
left in place following an injury. (Photo courtesy of Dr. Fraser J.
Leversedge.)
l Assess extent and location of additional soft tissue injury
(nerves, vessels, tendons, bone).
l Radiographs: AP, lateral, and oblique radiographs of the digit
are needed to determine whether a fracture, dislocation, or subluxation occurred.
l Keep the digit warm with gentle irrigation of the wound and
wrap it in gauze soaked in warm saline.
Acute Treatment
Ring Avulsion Injuries 151
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l Do not ligate or cauterize digital vessels before speaking with a
hand surgeon; this will hinder microvascular repair.
l Even if the injury is Class I, leave the skin laceration open to
prevent constriction of blood vessels.
Definitive Treatment (Refer to Hand Specialist)
l These injuries are often worse than they appear. Even if circula-
tion appears to be adequate, arterial thrombosis and progressive ischemia is possible, and the patient should be seen by a
hand surgeon as soon as possible for complete evaluation.
l If perfusion is compromised (or there is any question of it), call
a hand surgeon immediately; this may require urgent vascular
repair.
Potential Problems
l Progressive ischemia from vascular disruption can necessitate
amputation.
l Even with urgent surgical treatment, patients might have
altered sensation (paresthesias, hyperesthesias) or motion (tendon scarring, joint fusion, skin contracture).
SUGGESTED READING
Kay S, Werntz J, Wolff TW. Ring avulsion injuries: classification and prognosis.
J Hand Surg [Am]. 1989;14(2 Pt 1):204-213.
Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion inju-
ries. J Hand Surg [Am]. 1981;6(1):25-30.
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Section VII
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Gunshot Wounds,
Burns, and Frostbite
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chapter
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34
GUNSHOT WOUNDS
Because of the compact tissue volumes and intricate anatomy in
the hand, gunshot wounds to the hand can cause devastating injuries. Often, multiple structures are injured, and the treatment is complicated by balancing a need for immobilization of some injuries (eg,
fractures), with a need for early motion of others (eg, tendon repairs).
Thorough assessment of potentially injured structures and appropriate initial treatment are the goals of the acute management period.
Mechanism of Injury
l Gunshot wounds cause tissue damage because of both penetra-
tion and blast injury.
l Extent of damage is proportional to energy of injury: small
handguns or BB guns are “low energy,” while rifles and larger
caliber handguns are “high energy” and tend to cause more
damage.
l Shotguns disperse pellets and other debris, and usually cause
the worst injuries.
l Determine entry and exit sites of bullet, and use possible tra-
jectory to anticipate structures that might have been injured
(Figure 34-1).
l Note areas of skin loss or laceration.
l A thorough exam will help identify vascular compromise (do
not miss a palmar arch or other vessel injury), tendon injuries,
or nerve deficits.
Evaluation
155
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