The need to remove rings is not uncommon in the Emergency Department.
Patients may present with an initial primary complaint that they
are no longer able to remove a ring or that a ring has become painful.
A variety of conditions may necessitate the urgent removal of a
ring, including swelling from extremity trauma, infections or burns,
increases in total volume status, and allergic reactions.
Swelling of the digit can rapidly progress, causing the ring to
become a constricting band. Patients who are critically ill and
being admitted to intensive care settings or undergoing emergency
surgery may need to have rings removed urgently. The information
in this chapter applies to rings on the fingers and toes.
The second through fourth digits receive their blood supply through
four vessels: the palmar radial digital arteries, the palmar ulnar
digital arteries, the dorsal radial digital arteries, and the dorsal
ulnar digital arteries. The thumb receives its blood supply from
the dorsalis pollicis and princeps pollicis arteries. Blood returns
from the digits via the dorsal digital veins. When the digit is
compressed for prolonged periods by a tight-fitting ring, which
acts as a tourniquet, venous return is impeded and swelling ensues.
The swelling results in greater compression and further propagation
of this cycle. In theory, the increased swelling will eventually
impede the arterial supply to the digit.
The greatest circumference of the finger is at the proximal interphalangeal
(PIP) joint. Rings usually become entrapped proximal to the PIP
joint. Skin breakdown and tissue necrosis occur if the constricting
ring is not removed. If left untreated, the digit is at risk for
infections such as cellulitis, tenosynovitis, and osteomyelitis.
In severe cases, the digit’s viability may be threatened.
There have been several case reports of rings that have become embedded
in the soft tissue of the digits.1–5
Most patients will experience pain and seek medical attention
prior to the development of severe complications. Patients with
an altered mental status, psychiatric illness, peripheral neuropathies, peripheral
vascular disease, or other chronic disability may present later
Rings are removed to prevent ischemia of a digit. Rings should
be removed whenever patients complain that a ring is causing pain.
Generally, even a tight-fitting ring will not be painful. Rings must
be removed from any injured digit where edema is a possible consequence:
sprains, contusions, fractures, lacerations, crush injuries, and
burns. Rings should be removed from all digits on the involved side
for any hand or foot injury where edema is a possible consequence.
Other nontraumatic conditions that may necessitate emergent ring
removal include infections of the upper or lower extremity, acute
increases in volume status, and allergic reactions. Urgent ring
removal should be considered in patients with markedly decreased
levels of consciousness and in all critically ill patients, particularly
those being admitted to intensive care settings or undergoing emergent