How to Remove a Tight Ring
John C. Elfar
David J. Ciufo
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.
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).
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
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.
Apply lubricant such as soap or surgical lubricating jelly in the area of obstruction, as well as around and distal to the ring, then rotate the ring to coat the undersurface.
Once the ring and finger are sufficiently lubricated, an attempt to slide the ring past the obstructing region can be made.
Rotating the ring while sliding it distally is the most successful strategy.