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 ...