10.05 Ring Removal

agk’s Library of Common Simple Emergencies

Presentation

A ring has become tight on the patient’s finger after an injury (usually a sprain of the proximal interphalangeal or PIP joint) or after some other cause of swelling, such as a local reaction to a bee sting. Sometimes, tight-fitting rings obstruct lymphatic drainage, causing swelling and further constriction. The patient usually wants the ring removed even if it requires cutting it off, but occasionally a patient has a very personal attachment to the ring and objects to its cutting or removal.

What to do:

Limit further swelling by applying ice and elevating the extremity above the level of the heart.
When a fracture is suspected, order appropriate x rays either before or after removing the ring.
With substantial injuries, a digital or metacarpal block might be necessary to allow for the comfortable removal of the ring.
Usually, lubrication with soap and water along with proximal traction on the skin beneath the ring is enough to help you twist the ring off the finger.
When the ring is too tight to twist off this way, exsanguinate the finger by applying a tightly wrapped spiral of Penrose drain or flat rubber phlebotomy tourniquet tape around the exposed portion of the finger, elevate the hand above the head, wait five minutes and then apply a BP cuff inflated to 200-280 mm Hg as a tourniquet around the upper arm. Wrap the cuff with cotton cast padding to keep the Velcro conection from separating under high pressure, and clamp the tubing to prevent any slow air leak. Remove the tight rubber wrapping from the finger and, leaving the tourniquet in place, again attempt to twist the ring off using soap and water for lubrication.
If the ring is still too tight or there is too much pain to allow for the above techniques, a ring cutter can be used to cut through a narrow ring band. Have the patient grasp a rolled elastic bandage to stabilize the hand and elevate the dorsal side of the ring so it is easier to insert the ring cutter. Once there is one cut completely through the ring, bend the ring apart with pliers placed on either side of this break to allow removal.
If the band is wide or made of hard metal, it will be much easier to cut out a 5mm wedge from the ring using an orthopedic pin cutter. Then take a cast spreader, place it in the slot left by the removal of the wedge and spread the ring open. Alternatively, two cuts may be made on opposite sides of the ring, allowing it to be removed in halves.
Another useful device for removing constricting metal bands is the Dremel Moto-tool with its sharp-edged grinder attachment. Protect the underlying skin with a heat-resistant shield.
Another technique which tends to be rather time-consuming and only moderately effective (but one that can be readily attempted in the field) is the coiled string technique. Slip the end of a string (kite string is good) under the ring and wind a tight single-layer coil down the finger, compressing the swelling as you go. Pull up on the end of the string under the ring, then slide and wiggle the ring down over the coil.
Another string removal technique is to pull a length of string under the ring and tie it into a large loop that you can place around your own wrist. This will allow you to apply traction and slide the string around the circumference of the ring (allowing skin to slip beneath the ring) while you pull the ring off using lubricant as above.
Teach patients how to avoid the vicious cycle of a tourniquet effect by promptly removing rings from injured fingers.

What not to do:

When a patient is expected to have transient swelling of the hand or finger without evidence of vascular compromise, and he requests that the ring not be removed, do not be insistent that you must cut the ring off. If the patient is at all responsible, he can be warned of vascular compromise (pallor, cyanosis, or pain) and instructed to keep his hand elevated and apply cool compresses. He should then be made to understand that he is to return for further care if the circulation does become compromised because of the possible risk of losing his finger. Be understanding and document the patient’s request and your directions.

Discussion:

The constricting effects of a circumferential foreign body can lead to obstruction of lymphatic drainage, which in turn leads to more swelling and further constriction, until venous and eventually arterial circulation is compromised. If you believe that these consequences are inevitable you should be quite direct with the patient about having the ring removed.

References:

Greenspan L: Tourniquet syndrome caused by metallic bands: a new tool for removal. Ann Emerg Med 1982;11:375-378.

Illustration

-----------------------------------------------------
from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
Longwood Information LLC 4822 Quebec St NW Washington DC 20016-3229
1.202.237.0971 fax 1.202.244.8393 electra@clark.net
-----------------------------------------------------

agk’s Library of Common Simple Emergencies is hosted on sdf