10.05 Ring Removal
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agk's Library of Common Simple Emergencies

Presentation
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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 lymph- 
atic drainage, which in turn leads to more 
swelling and further constriction, until venous 
and eventually arterial circulation is comprom- 
ised. 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
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img/cse1005.gif

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