The need to remove a ring is not uncommon in the Emergency Department.1 Patients may present with an initial primary complaint that they can no longer remove a ring or that a ring has become painful. A variety of conditions may necessitate the urgent removal of a ring (e.g., allergic reactions, burns, fractures, increases in total volume status, infection, and swelling from extremity trauma). Swelling of the digit can rapidly progress and cause the ring to become a constricting band and compromise blood flow to the digit (Figure 126-1A). Critically ill patients undergoing admission to intensive care settings or emergency surgery may need to have rings removed urgently. The Emergency Physician’s goal is to remove the ring in a timely manner and not cause additional injury. The information in this chapter applies to rings on the fingers and toes.
The tight ring that cannot be removed. A. The tight ring with distal finger swelling in an unconscious patient. B. After ring removal with a ring cutter. The finger is macerated with an iatrogenic laceration from the ring cutter. (Courtesy of Brian Lin, MD, and www.lacerationrepair.com.)
ANATOMY AND PATHOPHYSIOLOGY
The second through fourth digits receive their blood supply through four vessels (i.e., palmar radial digital arteries, palmar ulnar digital arteries, dorsal radial digital arteries, and 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. Venous return is impeded and swelling ensues when the digit is compressed for prolonged periods by a tight-fitting ring. The swelling results in greater compression and further propagation of this cycle. The increased swelling will eventually impede the arterial supply to the digit in theory.
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. The untreated digit is at risk for infections (e.g., cellulitis, osteomyelitis, and tenosynovitis). The digit viability may be threatened in severe cases. There are several case reports of rings that have become embedded in the soft tissue of the digits.2-6
Most patients will experience pain and seek medical attention prior to the development of severe complications. Patients with an altered mental status, peripheral neuropathies, peripheral vascular disease, psychiatric illness, or other chronic disability may present later with complications.2,3,5,6
Rings are usually removed to prevent ischemia of a digit. Remove a ring if the digit shows any signs of neurovascular compromise (e.g., decreased capillary refill, decreased pulse wave ...