John W. Chamberlain, M.D., and Maury Soltes, M.D.
Pediatric Surgical Service, Boston City Hospital
ADDRESS: (J.W.C.) 818 Harrison Avenue, Boston 18, Massachusetts.
WRINGER
INJURIES
96
PErnATmcs, July 1961
W
RINGER ARM is the term introduced byMacCollum’ in 1938 to designate the
injury caused to an arm that has been
caught between the rollers of an electric
clothes wringer. According to MacCollum,
sales of these machines increased from
200,000 in 1932 to 1,600,000 in 1936. In
more recent years, the automatic
washer-drier has been gradually replacing the
ma-chine with wringer attachment in
popular-ity; even so, of 4,010,000 washing machines
sold in this country in 1959, over 900,000
had the wringer attachment. Moreover,
these machines are more durable than the
newer fully automatic washers and have a
much longer life, so large numbers of them
are still in use. They continue to be a
haz-ard to toddlers’ upper extremities.
This report is based on a review of 116
cases of wringer injury in children treated
as inpatients at the Boston City Hositpal
from January, 1955, through July, 1960 (Fig.
1). Of this group, 75 (65%) were males. No
patient was under 1 year of age at time of
injury, and 88 (76%) were under 6 years
(Fig. 2). In other words, a large majority of
wringer injuries occur in youngsters old
enough to be inquisitive and to reach and
too young to be aware of the hazard of
get-ting hands caught in a wringer.
A review of our cases and of the literature
was done in an attempt to evaluate the
ad-vantages and disadvantages of compression
dressings in the treatment of these injuries.
We are not sure who first advocated
treat-ment with pressure dressings. MacCollum
did not in 1938. Allen2 did S years later,
ex-plaining that the dressing was “applied to
keep the subcutaneous tissues or graft held
firmly in place and to diminish the amount
of subsequent edema that will occur.” He
stated further that, “the edema may itself
cause further loss of skin by separating the
skin from its source of blood supply.” Since
then, the majority of contributors to the
literature on this subject, and they have
been surprisingly few, have advocated the
use of pressure dressings.
Entin3 in 1955 reported the results of an
investigation of the effect of roller injuries
on the forelegs of dogs and the hind limbs
of rats, using a modification of a commercial
laundry wringer. He found that “the injured
leg invariably developed edema, which
be-came apparent during the first hour and
progressively increased until six to eight
hours after injury when the peak was
reached” and that “at about forty-eight
hours after injury, crusting appeared at the
area of greatest damage, which was usually
at the most proximal part of the limb, where
the rotary action of the rollers persisted
longest.”
These findings agree with what is
oh-served clinically in children suffering from
wringer injuries. More pertinent to our
in-quiry are Entin’s results following the use of
hyaluronidase with and without the use of
compression bandages : “The combined
ef-feet of enzyme and pressure differed from
the use of enzyme alone in that a greater
amount of tissue was lost in tle former.” In
spite of this, Entin recommended the use of
compression dressings in the management
of wringer injuries.
In severe wringer injuries, there are
usu-ally three major elements in the pathology.
The first and most obvious is the area of
skin destruction caused by the bruising,
shearing and burning effect of the rollers
turning over and over at one level,
some-times at the hand, and sometimes at the
axilla, most often just below the elbow. The
damage has been done when the child’s arm
is removed from the wringer. The second
WRINGER ARM 36
32
28
0 24
0
.‘- 20 0
6
.0 E 2
z 8
4
0
955 956 957 958 959 960
28
‘,, 24 0)
0
0
0
a,
.0 E :2
z
---Fic. :3. Diagram illtmstratimig concel)tioml of the
effect of pressure applied over a hematoma.
2 3 4 5 6 7 8 9 0 II 2
Age in Years at Time of Injury
FmG. 2#{149}Age imici(lence of ringer injuries.
Fic. I. Nimniher of children with ‘ringer injtmries,
(:(lniittNl to tIle Bostoti City I lospital, I) ears,
from 1955 throimgh Jmml’, 1960.
stihetmta:ieous tissues pni11eiptlly, but prob-ai)lV also imi niusele, vhieh results from I)r’sstmre of tue rollers. \Ve assume this is chiefly an osmnotie I)resstmre effect, i)ut what-ever its nature the force is ol)viously a
strong one. The third element is the
forma-tiOll of discrete collections of blood, in
con-trast to the diffuse capillary bleeding that
miiay accompany the edema, and \vilieil is edlmSe(l b’V rupture of larger blood vessels.
It is the effect of a pressure dressing on
these last two elements that concerns us.
One of us (J.\V.C.) has long held the
opinion that tile value of pressure dressings results in large meastmre from their splinting effect, vhether 1I)Plie1 to a sprained ankle
OI. over a 51)lit thickness skin graft, that the
32
aceumimlation of fluid in tissue or space as
a result of trauma cannot he avoided with
iresstmre unless drainage is provided, and
that cold alone is the chief deterrent to such
an accumulation of fluid. It is noteworthy,
iml this connection, that IaeCollum, in his 1938 paper, advocated the application of
ice cold magnesium sulfate compresses in
the early treatment of wringer arm injuries. Cope and Moore4 demonstrated that the
ap-plication of pressure dressings to burns, popular during \Vorld \Var II, “does not
(4-feetively limit the interstitial space expan-sion” which they note is “the important
fea-ture of the disordered fluid balance.
The effect of pressure over a hematoma is
more obvious and is a harmful, not a bene-fieial one. As illustrated imi Figure 3, it causes spread of the blood laterally, with undermining of larger areas of skin and diminution of the blood supply to the skin
most centrally located. Incision first and
tilen ap)hcation of pressure would, of
course, prevent this.
\Ve ilad been treating wringer injuries in
the conventional manner, inellm(ling the
Fic. 4A. (P.\V., No. 171:3729). Appearance of eschar 8 (layS after wringer injtmry.
Fic. 4B. Partial sohmtion amid separation of eschar
after application of proteolytic enzyme (l)ehricin 4%, provided b Johnson and Johnson Co.) for
3 clays.
98 WRINGER INJURIES
pressure dressings. Even the areas of skin
abrasion and necrosis were treated by the
exposimre method we use for thermal burns.
Of the 116 eases on which this report is
based, 56 were treated with and 60 without
compression dressings. In the first group,
the injured arm was treated by cleansing,
gauze dressing with petroleum jelly
(Vase-line) to an’ abrasions, a sterile pressure dressing usfng an elastic bandage, and
ele-vation of the arm. In the second group, the
arm was cleansed and elevated on a pillow.
Abrasions and areas of skin more seriously
injured were treated without dressings simply by bathing two or three times a day
with hexachlorophene (pHisoHex). In
gen-eral, no restriction on use of the arm was imposed. It was felt that the pain resulting
from motion would automatically restrict
use of the arm wilen this was desirable. \Vlieml axillarv skin was abraded or severely eontused the arm was maintained in
abduc-tion. Areas of necrotic skin were treated tmsimallv by enzymatic dehridement to
per-mit early grafting (Fig. 4). Sedation, tetanus
antitoxin or toxoid, and antibiotics were
ad-ministered to both groups when thought to
he indicated. Lacerations were sutured at
time of admission.
Of the first group of 56 cases, four
pa-tients (7) required split-thickness skin
grafts and one required multiple operations,
including a tendon graft and osteotomy, on
a severely injured hand. Of the second
group of 60 cases, six patients (10)
re-quired skin grafts, one required incision
and drainage of a hematoma of the hand,
and one required multiple operations on a
hand (Table I). This last patient had been
treated on an oimtpatient basis at another
hospital for 2 weeks and had severe
infec-tion of lacerations of the thumb, index and
middle fingers at the time of admission.
Ex-cept for the two patients with severe hand
injuries, there were no sequelae. \Iany of
the patients showed eechvmosis, but
in-cision and drainage has not been done
ex-cept in one instance. In contrast to this, Lynn and Reed reported aspiration or
in-cision and drainage for approximately 27%
of 423 patients, and MaeCollum reported
that incision and drainage was done for 23
of 116 patients. The average number of
hos-pital days for each group of patients was 8.
If those cases requiring a skin graft and the
two severely injured hand cases are
ex-eluded, the average number of hospital days
is reduced to slightly under 5 for the first
group and to 4.2 for the second.
Since we began treating these patients
without compression dressings, we have
maxi-* Botim I)ati(’m:ts Imad severe injuries of the hammd.
EI(;. 4C. Clean, firm, granulating surface after
6 days of enzyme therapy. Graft sas appliC(1 16 days after injury.
mum eircimmferenee of the injured armil or
forearm following admission in tile more
severely injured patients. All the evidence
to (late agrees with Entin’s findings in
lab-oratory animals and indicates that
maxi-IllUIll swelling is reached within a few hours
of tile time of injury and begins to dimilinisil
within 48 hours. It also agrees with Fraser’s
observations in a ease report of a 6-year-old
girl who was hospitalized 2% hours after
in-jury that “at the time of admission the right
arm was grossly swollen” and “after 48
hours in the hospital the edema was
sub-siding and tile damaged skin was still
in-tact.”
COMMENT
Wringer arm is still a common injury,
)articularly of toddlers. Altilough there is
ample clinical evidence that the application
of a pressure dressing to injured tissue does
not prevent tile formation of edema, such
treatment is still advocated in the treatment
of wringer arm by the great majority of
writers on the subject. Our results have
1)een equally good with and without
pres-sure dressings. The percentage of patients
requiring operative procedures is less than
ill any series yet reported in the literature.
Laboratory and clinical evidence indicates
that most of the swelling has occurred
be-fore there is an opportunity to appiy a
pres-sure dressing. This we feel supports us in
our contention that the application of a
compresion dressing is not indicated. There
is little logic in trying to prevent a swelling
which is already present.
While we have not demonstrated that
compression dressings as applied in our first
group of patients (lid any harm, we have
demonstrated in our second group of eases
that the elimination of the dressing has not
been harmful.
Because our results have been so
imni-formly good, we attempted to compare them
with those reported from other clinics from
tile point of view of treatment, but we
be-lieve there are too many variables to make
such a comparison valid. For example, in
the report of Hausmann and Everett, in one group of 45 patients with wringer arm
injuries, 24 required skin grafts; in a second
group, of 52 patients, 11 required skin
grafts; this resulted in a total of 35 grafts in
97 patients. We performed grafts for 10 and
multiple operations for 2 more of 116
p-tients. The only reasonable explanation is that Hausmann and Everett’s patiellts were
more severely injured than ours. In support
of this is tile fact that there were 20
frac-tures among their cases and only one in ours. Of Lynn and Reed’s5 423 patients, 16%
required skin grafts. Of 419 cases reported
by Lindsey et al.,#{176}13% required grafts or
other reconstructive work. \Vhatever the
reason, there is a significant difference imi
the percentage of patients requirmg
opera-tions in our series and those reported in the
literature.
TABLE I
()mEmctTmoNs wm’rmn AND WITHOUT Pm:EssuI:E l)m:ssmNGs
Pressure Open
Treatni en! Dressings Treatment Total
Ollien-Thiensdm graft 1 (1 10
Incision: and (Iraimmage 0 1 1
Multiple operations* 1 1 2
100 WRINGER INJURIES
SUMMARY
During the 5% years from January 1, 1955,
to August 1, 1960, 116 children with wringer
injuries were admitted to the Boston City
Hospital. Of these, 56 were treated with,
and 60 without, pressure dressings. There
was no significant difference in the
per-centage of cases requiring skin grafting and
other operative procedures. It is concluded
that the application of pressure dressings in
the treatment of these lesions is illogical
and a waste of time and materials.
REFERENCES
1. MacCollum, D. W. : Wringer arm. New Engl.
Med., 218:549, 1938.
2. Allen, H. S.: Wringer im:jlmries of the upper
extremity. Ann. Surg., 113: 1 101, 1941.
3. Entin, M. A. : Roller and wringer injuries. Plast.
Reconstr. Surg., 15:290, 1955.
4. Cope, 0., and Moore, F. I). : The
redistribim-lion of body water and the flimid therapy of
the burned patient. Ann. Surg., 126:1,010,
1947.
5. Lynn, H. B., and Reed, R. C. : \Vringer in-juries. J.A.M.A., 174:108, 1960.
6. MacCollum, D. \\‘., Bernhard, \V. F., and
Banner, R. L. : The treatment of wringer ann
injuries. New Engl. J. Med., 247:750, 1952.
7. Fraser, M. : The wringer injury. Amer. J. Surg., 100:646, 1960.
8. Hausmann, P. F., and Everett, H. II. : Wringer injury. Surgery, 28:71, 1950.
9. Lindsay, \V. K., Thompsomi, H. S., and Fanner,
