Use of the Figueiredo Technique for The Treatment of Ring Avulsion Injury: A Case Report

A Ring Avulsion Injury results from trauma in which the skin of the digit is avulsed, causing exposure of deeper structures, and can be associated with neurovascular, tendon, joint and bone injuries. These injuries are usually severe and present difficulties in choosing the most effective treatment in each case. In order to maintain the digit in these cases, it was necessary to use techniques such as reimplantation or the transfer of flaps for bone coverage, which require a specialized team and a hospital center structured for microsurgical procedures. With this in mind, this study sought to show the results obtained from the treatment of a case of complete Ring Avulsion Injury of the fourth finger of the right hand using the Figueredo Technique (FT). This is a low-complexity, highly effective and low-cost option for repairing injuries with extensive exposure of the soft and bony parts of the phalanges. This avoids amputation of the dislocated area.

Avulsion injuries caused by the ring result in avulsion of the skin and subcutaneous tissue of the digit, exposing deeper structures and can be associated with neurovascular, tendon, joint and bone injuries [1,2]. In the traumatized segment, it is common for the circulation of the skin and subcutaneous tissue to be compromised, so it is difficult to accurately determine the viability of that site in order to institute treatment. Thus, Ring Avulsion Injuries represent a major challenge for hand surgeons,with the outcomein most cases being amputation of the digit [3-5]. Given all the difficulties and the lack of clear definitions in the literature regarding the best treatmentoption for theseinjuries, this studyaims to reporton the process and results of treating a case of Ring Avulsion Injury using the Figueiredo Technique (FT) [6].

A 23-year-old male patient suffereda complete Ring Avulsion Injury(Urbaniak tipe I) of the 4th finger of his righthand, with no bone damage and exposure of all the flexor and extensor tendons. Extensive surgical debridement was performed to remove devitalized tissue, exhaustive cleaning and application of the Figueiredo Technique (Figure 1).

Figure 1: Application of Figueiredo Technique.

The following day, he was discharged from hospital and released for outpatient follow-up, with the external dressing changed every 10 days. After 33 days, the prosthesis loosened spontaneously (Figure 2).

Figure 2:Mature granulation tissues after loosening the prosthesis.

The patient was readmitted for a new approach and signs of tissue memory were observed, with the formation of skin folds on the affected phalanges and a large amount of granulation tissue, making it feasible to perform a total skin grafton the lesion, using the volar region of the homolateral wrist as the donor area (Figure 3). The patient was discharged from hospital the following day and was advised to return every 10 days for reassessment.

Figure 3: Total skin grafting.

129 days after the trauma, the range of motion in the metacarpophalangeal joint was 90° flexion and 0° extension, in the proximal interphalangeal joint 900° flexion and 00° extension and in the distal interphalangeal joint 400° flexionand 00° extension, with a satisfactory functional result given the severity of the injury (Figure 4).

Figure 4:Final result after treatment

Complete ring avulsion injuries are serious and maintaining the digit in these cases required techniques such as replantation or the transfer of flaps for bone coverage [7]. To carry out these procedures, a specialized team and a hospital with an adequate structure for microsurgical procedures are needed, which is not the case in most of Brazil [8,9]. In addition, the severity of the injuries and the exposure of noble tissues such as bones, tendons and vascular-nervous bundles make it difficult to integrate the flaps, often leading to necrosis and treatment failure. Because of these difficulties, surgeons end up opting for amputation of the digit in most cases. The Figueredo Technique, on the other hand, provides low-complexity, highly effective and low-cost treatment for repairing large lesions with extensive exposure of the soft tissue and bone of the phalanges, avoiding amputation of the digit [6]. Another advantage is that it can be performed by any properly trained surgeon/orthopedist, without the need for a professional specializing in microsurgery. The purpose of this new technique is to wrap the entire lesion with a polypropylene prosthesis, a material that is sufficiently resistant to protect the lesion site against painful stimuli and external forces until healing by second intention takes place, but which should not be so rigid as to cause tissue deformities. Therefore, the material that proved to be the most suitable, as it is sterile, low-cost and easily.

accessible in surgical centers throughout the countryman sterile saline bag [6]. The prosthesis should be cut out according to the size and shape of the lesion. The digit should be completely surrounded by the prosthesis, which will have a cone shape once its two ends are joined, and then sutured to the healthy edges of the lesion, forming an occlusive dressing [6]. In this way, as well as providing mechanical protection, the prosthesis prevents the outflow of the exudate formed, which bathes and nourishes the underlying structures, including bones, tendons, vessels and nerves, maintaining their immediate viability. Gradually, this exudate will be replaced by fibrin tissue, with its characteristic yellowish color, which will gradually give way to granulation tissue and lead to total epithelialization of the lesion. This whole process can be observed through the translucent prosthesis, which makes it easier to monitor the healing process. The time it takes for granulation tissue to form varies according to the extent of the lesion, the loss of soft tissue, the presence/absence of an associated infectious process, among other factors inherent to each lesion. In view of this, it is important to periodically reassess the patient.

In the case described, we opted for grafting on mature granulation tissue in a digit recovered from the acute trauma through FT. On the volar side of the lesion, healing occurred more quickly due to the large vascularization of the area, and because of this characteristic, there was complete epithelialization of a larger area under the prosthesis. It is important to emphasize that FT only promotes soft tissue regeneration, so the final length of the digits directly related to bone loss [6]. In cases where there is no bone loss, the original length is maintained in its entirety, with minor deformities depending on the severity of the injury, as occurred in the case above. The functionality of the digit after complete treatment was satisfactory given the severity of the injury. The rehabilitation process is crucial to achieving an arc of movement that is close to normal and that guarantees functionality of the digit, highlighting the importance of physiotherapy. From this perspective, it is possible to conclude that the Figueredo Technique has proved to be a solution for ring avulsion lesions which, to this day, represent a major challenge when it comes to deciding how best to manage them. As such, the technique has established itself as a simple, easy-to-perform, low-cost option with excellent functional and aesthetic results.

Conflict Of Interest

The authors declare that they have no conflict of interest.

Financial Support

There was no financial support from public, commercial or non-profit sources.