Chapter 101. Ring Removal

The need to remove a ring is not uncommon in the Emergency Department. 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, 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 and compromise blood flow to the digit. 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 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. 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 are 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 with complications.1,2,4,5

Rings are usually removed to prevent ischemia of a digit. Remove a ring if the digit shows any signs of neurovascular compromise such as decreased capillary refill, decreased pulse wave on pulse oximetry, mottling, paleness, paresthesias, or diminished sensation. 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. Examples include sprains, contusions, fractures, lacerations, crush injuries, and burns. Rings should be removed from all digits on the involved side for any extremity injury above the digits and where edema of the distal extremity 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. A patient may present and request a ring be removed that is tight and can no longer be taken off. Consider the need for urgent ring removal with markedly decreased levels of consciousness and in all critically ill patients, particularly those being admitted to intensive care settings or undergoing emergent surgery.

There are no absolute contraindications to removing a ring. It is important to note that certain techniques may be more applicable than others, depending on the individual patient.

Metacarpal Block

• Povidone iodine or chlorhexidine solution, or an isopropyl alcohol swab
• 3 mL syringe
• 25 or 27 gauge needle, 1 in. long
• 3 to 5 mL local anesthetic solution without epinephrine

Lubricant and Caterpillar Techniques

• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid soap)

String Technique

• String (1-0 silk suture, cotton umbilical string, tracheal tape, Penrose drain, or intravenous tourniquet)
• Mosquito hemostat

Rubber Band Technique

• 3 to 4 mm wide rubber band
• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid soap)
• Mosquito hemostat

Glove Technique

• Rubber gloves
• Lubricant (K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid soap)
• Mosquito hemostat
• Scissors

Ring Cutter Technique

• Ring cutter, manually operated or battery-powered
• Steinman pin cutter if a ring cutter is not available
• Two large hemostats or needle drivers
• Pliers (optional)

Vice-grips Pliers Technique

• Medium size vice-grip pliers

Miscellaneous Supplies

• Ice water
• Penrose drain or IV tourniquet
• Basin or zip-lock bag for ice water

Place the patient sitting upright or in a semi-recumbent position. Position their hand on a bedside procedure table. Explain the procedure to the patient and/or their representative. A signed informed consent is not required for the removal of a ring. Analgesia should be provided in the form of a metacarpal block for patients who are complaining of pain. Refer to Chapter 126 for the complete details regarding a metacarpal block.

The removal of a tight ring should be considered a two-step process: first reduce the edema in the finger, then remove the ring.6 Instruct the patient to elevate the affected hand or foot to reduce edema prior to any attempts at ring removal. Use a finger trap to elevate the affected extremity if the patient has difficulty or cannot keep the extremity elevated. Consider soaking the hand or foot in ice water for 5 to 10 minutes to reduce edema. A Penrose drain, piece of tape, gauze, or elastic bandage can be wrapped around the finger, from distal to proximal, to further reduce swelling.

The simplest and most effective way to remove a ring from a finger is simply to cut the ring using a ring cutter. Reassure the patient that cut rings can be repaired by a jeweler. However, patients may still be reluctant to have expensive rings or rings with sentimental value removed in such a way. The practitioner must consider time, the individual circumstances regarding the entrapment, and which alternative techniques may be effective.

Lubricant Technique

This technique works for mild cases of ring entrapment with minimal swelling and without significant trauma. Many patients will attempt to remove the ring using some type of lubricant at home prior to presenting to the Emergency Department. Despite this, the same technique may also be tried in the Emergency Department prior to attempting other techniques. Liberally apply a lubricant (e.g., K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid soap) to the digit and beneath the ring. Attempt to advance the ring over the PIP joint with steady traction.

Caterpillar Technique

This recently described technique is useful in that it requires no additional materials other than lubricant (Figure 101-1).7 Liberally apply a lubricant to the finger (Figure 101-1A). Slide the ring down the proximal phalanx and just proximal to the PIP joint. Apply and maintain upward pressure on the bottom of the ring (Figure 101-1B). Simultaneously swing the upper portion of the ring distally (Figure 101-1C). Pull the top of the ring over the PIP joint. Apply and maintain downward pressure on the top of the ring (Figure 101-1D). Simultaneously swing the lower portion of the ring distally to free it (Figure 101-1E). Remove the ring from the finger. This “caterpillar motion” allows the ring to be slowly advanced distally and ultimately removed.

String Technique

Several authors have extensively described the string technique and its modifications5,6,8,17 (Figure 101-2). This technique consists of using a “string” to compress the edematous tissue, exsanguinate the digit, and then facilitate the passage of the ring over the PIP joint. This technique should be avoided if the patient has an associated finger laceration, finger fracture, or an embedded ring.8,9

Pass a length of 1-0 silk suture or a piece of string underneath the ring (Figure 101-2A). Avoid monofilament sutures and smaller-size sutures as they may break or inadvertently cut the patient if wound too tightly. Passage of the string or suture may be facilitated with the use of a mosquito hemostat.8–10 Wind the distal portion of the suture tightly around the digit in a closed spiral (Figure 101-2B). There should be no interposition of skin between the turns of the suture material so as to ensure even compression of the skin and soft tissue. Continue the spiral distally to just beyond the PIP joint. Grasp the proximal end of the suture. Unwind the suture while maintaining traction in the distal direction (Figure 101-2C). The ring will be pushed distally as the suture unwinds. The ring is easily removed once it clears the PIP joint (Figure 101-2D).

Other materials—such as umbilical tape, cotton gauze, rubber intravenous tourniquets, or Penrose drains—have also been used.6,11,12 These materials have certain practical advantages. Since they are wider than sutures, shorter lengths and fewer turns are required to encircle the finger. It is easier to wind these materials around the digit without interposition of the skin between the turns (Figure 101-3).

Insert the umbilical tape under the ring, from distal to proximal, with the aid of a mosquito hemostat (Figure 101-3A). Pull 6 to 7 cm of the umbilical tape proximal to the ring (Figure 101-3B). Wind the distal portion of the umbilical tape tightly around the digit in a closed spiral (Figure 101-3C). There should be no interposition of skin between the turns of the umbilical tape. Continue to spiral distally to just beyond the PIP joint (Figure 101-3C). Grasp the proximal end of the umbilical tape. Unwind the proximal end of the umbilical tape while maintaining traction in a distal direction (Figure 101-3D). Continue to unwind the umbilical tape until the ring passes the PIP joint (Figure 101-3E). The ring is easily removed once it clears the PIP joint (Figure 101-3F).

Rubber Band Technique

This technique utilizes a 3 to 4 mm wide rubber band, which is used to apply traction on the ring to facilitate its passage over the PIP joint10 (Figure 101-4). Though success has been reported using rubber bands, this technique should be reserved for less severe ring entrapments. Avoid this technique if the patient has a laceration, a fracture, or an embedded ring.

Lubricate the finger liberally, as described above. Pass the rubber band beneath the ring using a mosquito hemostat (Figures 101-4A & B). Position the rubber band so that equal lengths are on each side of the ring (Figure 101-4C). Insert a finger through both loops of the rubber band (Figure 101-4D). Pull the loops of the rubber band distally while simultaneously moving them circumferentially between the ring and the finger (Figure 101-4D). Continue the motion until the ring is removed (Figure 101-4E).

Glove Technique

This technique has been advocated for use in patients with underlying soft tissue injury to the finger.13,14 Its success is anecdotal. The glove technique uses a finger cut from an appropriately sized rubber glove (Figure 101-5). The glove finger provides mild compression, acts as a barrier to protect damaged soft tissue, and provides a “leading edge” to guide the ring over the damaged tissues. Despite these theoretical advantages, the glove technique may be no more effective than any other in cases of severe finger edema.

Choose a glove that fits the patient snugly. Use the patient's other hand to aid in choosing the right size glove. Cut the finger from a glove to match the finger of the patient (Figure 101-5A). Cut off the tip of the finger of the glove to create a cylinder (Figure 101-5A). Slide the cylinder onto the patient's finger. Advance the proximal portion of the cylinder beneath the ring using a mosquito hemostat (Figure 101-5B). Lubricate the cylinder and the ring with K-Y jelly, Surgilube, petrolatum, mineral oil, or liquid soap. Pull the proximal edges of the latex cylinder distally, with your fingers or mosquito hemostats, to advance the ring distally (Figure 101-5C). Continue to pull on the proximal cylinder until the ring moves past the PIP joint and falls off the finger.

Ring Cutter Technique

The definitive method for ring removal is cutting the ring. The ring should be cut if the patient presents with an underlying injury, severe swelling, an embedded ring, or entrapment with nonjewelry items. Cutting a ring is generally rapid and safe. A ring cutter can be used to cut rings made of gold, plastic, platinum, silver, stainless steel, and titanium.

Many devices will cut rings. The standard rotary ring cutter should be available in every Emergency Department (Figure 101-6). The ring cutter's blade should be periodically inspected and it should be sharp. Battery-powered ring cutters are also available (Figure 101-7) (Mooney & Co., Ashland, OR). The advantage of the powered ring cutters is that they are easy to use, lightweight, fast, powerful, can easily cut nonjewelry items, and do not rely on the strength of the healthcare provider to use them. In the absence of a ring cutter, another medical device that has been used successfully to cut rings is the Steinman pin cutter.15 Our Emergency Department also maintains a sharp pair of diagonal pliers that can be effective at cutting small rings.

Pass the finger guard of the ring cutter between the ring and the digit at the thinnest part of the ring (Figure 101-8). Care should be taken to place the ring cutter correctly and avoid additional injury. The ring may be squeezed using a heavy needle driver, hemostat, or pliers to change its shape from round to oval to facilitate passage of the finger guard (Figure 101-9). This additional distortion of the ring will not further exacerbate the entrapment.15 Lower the cutting blade onto the ring. Turn the turn key to rotate the blade while maintaining pressure on the ring. Continue turning the turn key until the blade completely cuts through the ring. Pry the ring open with two hemostats or needle drivers once it is completely cut through and remove the ring. An alternative to one cut and prying the ring open is to make two cuts on opposite sides of the ring so that it falls apart in two pieces.

If an open wound is present, it should be irrigated with normal saline to remove any small metal fragments that may result from the cutting process. There has been a case report of a foreign body granuloma caused by metal particles left in a finger wound in a patient following ring removal.16

Vice-Grip Pliers Technique

Many rings cannot be removed with the previously described techniques. These rings can be of a material that also cannot be cut with a carbide, diamond, or metal cutting disk on a ring cutter. This includes rings made of ceramics, natural stone (e.g., jade or onyx), and tungsten carbide. These rings can be removed by cracking them into pieces in a controlled fashion using a vice-grip pliers.

A medium-sized vice-grip pliers is usually appropriate for most ring sizes. Open the jaws of the vice-grip pliers. Adjust the tightening screw so that the closed jaws of the vice-grips fit over the ring (Figure 101-10). Close and clamp the vice grip so that the jaws close lightly on the ring. Release the jaws, turn the tightening screw one-quarter of a turn, and reclamp the jaws on the ring. Continue this process of releasing the jaws, turning the tightening screw one-quarter of a turn, and reclamping the jaws on different places of the ring each time until a crack is heard. Keep continuing this process of tightening the jaws and reclamping different areas of the ring until the ring breaks into pieces and falls off.

Patients may rarely present with other heavy circular objects on their digits such as steel rings, nuts, or washers that cannot be removed using a manually operated ring cutter. Powered cutting tools such as heavy-duty saws and bolt cutters may be needed to remove these objects. Battery-powered ring cutters may be ideal in these situations. Power saws and Dremel tools with carbon blades have been used to successfully remove hardened steel rings from a patient's fingers.5 If it becomes necessary to use a powered metal cutting device, additional care should be taken to protect the patient from secondary injury from the cutting element and the heat these powered devices may generate.

Thoroughly examine the finger for any injuries after the ring is removed. Reassess perfusion to the digit by noting the capillary refill time, the color, and the pulse oximeter reading on the affected digit compared to adjacent fingers.

No specific aftercare is required following the ring removal process. Elevation, nonsteroidal anti-inflammatory agents, and local wound care are all that is necessary. Consultation with a Hand Surgeon, Orthopedic Surgeon, Plastic Surgeon, or Podiatrist is recommended in severe cases that include embedded rings, infections, vascular compromise, and/or neurologic compromise. The aftercare is based on any lacerations and/or fractures of the digit. The patient's tetanus immune status should be ascertained and, if the skin is broken, the appropriate tetanus prophylaxis administered. Instruct the patient not to place any rings on the digit until the edema has completely resolved. Place the ring, and any pieces, in a specimen container and return it to the patient.

The direct complications of ring removal are minor compared to the complications that may occur from failure to remove a ring. Direct complications include secondary injury to soft tissues, vascular structures, and nerves and granuloma formation. This can be due to passing objects and instruments under an extremely tight ring or from improperly used instruments to remove the ring.

Ring cutters have their own specific issues. It may cut too slowly. Ensure that you are using the proper cutting technique. The cutting disk may be worn, dull, or the wrong cutting disk for the material. Check that the proper cutting disk is on the ring cutter and that it is not dull or worn. Install fresh batteries or recharge them to maximize the power of the electric ring cutter. The ring, and the patient's finger, can become quite hot and burn the patient. Periodically check the progress and make sure that the ring has not been cut and you are now cutting the finger guard. Using a cutting disk that is dull, worn, or incorrect can generate significant heat. Correct these issues. Submerge the finger in ice water for a few minutes then resume cutting the ring.

Ring removal is a relatively straightforward and simple procedure. In situations in which the ring is extremely difficult to remove, a variety of potential approaches may assure success. Use of the ring cutter is the most reliable and quickest technique. The decision to use a ring cutter should be based upon the urgency with which the ring must be removed and not upon the monetary or sentimental value of the ring.