How to Remove a Tight Ring



How to Remove a Tight Ring


John C. Elfar

David J. Ciufo



INTRODUCTION



  • Constrictive rings are a common problem encountered in acute care settings.


  • A tight ring may occur either in isolation or in the setting of trauma.


  • Constricting items may include metal hardware (nuts and washers) in addition to jewelry.


  • Patients often try home-based methods of removal before presentation.


  • The hand is often the dependent portion of the upper extremity, predisposing it to swelling in the setting of trauma or edema due to medical diagnoses.


  • Edema coupled with outflow obstruction leads to a cycle of increasing venous congestion.


  • Arterial obstruction can lead to digital ischemia in severe cases.


  • Rings should prophylactically be removed in the setting of upper extremity trauma.


EVALUATION



  • Identification of potentially constricting jewelry is a critical first step in the setting of trauma.


  • Previous attempts at removal and duration of constriction are important elements of a thorough history.


  • Neurologic and vascular examination of the entire extremity is critical, along with documentation of the examination findings, before and after removal of constricting devices.


  • A focused neurologic and vascular examination of the affected digit should be performed.



  • The type of material causing constriction may affect the management (soft vs. hard metal vs. ceramic or stone).


PATIENT MANAGEMENT



  • Attempts to remove a ring are sometimes destructive of the ring itself, and patients should be warned of this possibility.


  • If vascular status is compromised (absent capillary refill, mottling of the digit), the ring should be removed emergently.


  • Provide a field block if indicated for the patient to better tolerate removal.



    • This should be avoided if removal methods would benefit from protective sensation for feedback from the patient.


    • Injection of local anesthetic should be performed with caution because this could add fluid and increase swelling of the affected digit.


  • Efforts should be made to repeat imaging studies after removal to avoid missed injuries to the affected digit.


  • Rings should never be left in place under splints or other forms of immobilization.


  • Avoid intravenous access in an injured extremity when possible.


METHODS OF RING REMOVAL


Edema Management



  • Compression of the entire digit by wrapping it with an elastic tourniquet (such as those used for intravenous access) may be used to reduce edema.


  • Ice and elevation may be sufficient to reduce minor edema and allow the ring to slide off.


  • These are some of the simplest methods and often have been attempted before presentation in isolated tight-ring situations.


Lubricants

May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on How to Remove a Tight Ring
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