Ring Removal
Susan M. Fuchs
Introduction
Occasionally children try on a parent’s ring or toy jewelry, only to realize that the ring cannot be removed. By the time the child arrives in the emergency department or office, several attempts to remove the ring have often been made, resulting in increased swelling of the affected finger. Another scenario is an adolescent who injures a finger distal to a ring. In these cases, the injury (possibly a fracture) results in swelling that does not allow removal of the ring. With continued swelling, ring removal is often necessary to avoid vascular compromise to a digit. Although this chapter focuses on rings, other round objects (washers, metal nuts) can be treated in a similar manner.
Anatomy and Physiology
The degree of vascular compromise of the finger depends on the magnitude and duration of swelling. Initial swelling is usually due to injury or attempts at ring removal and does not compromise circulation. Further swelling of the finger can result in obstruction of venous and lymphatic drainage, which in turn exacerbates the swelling. The risk of complete obstruction of circulation and gangrene can occur in 10 to 12 hours (1).
Acute swelling of a finger also can result from an allergic reaction, insect bite, or burn to the finger, in which case edema is the primary problem. When a finger is injured due to a fracture or dislocation, the deformity can itself prevent ring removal with or without significant swelling. Compared to those of an adult, the fingers of a young child tend to be chubby, which may further exaggerate the effects of swelling. The time to presentation also will affect the amount of swelling but does not necessarily correlate directly.
Indications
A child often will present with a complaint about a painful finger, whereas an adolescent may be more stoic. Conversely, finger injury may be the initial presentation, only to have ring removal discovered as a secondary problem.
Several methods can be attempted to save the ring; however, if the digit is already ischemic or if a displaced fracture or a dislocation occurs distal to the ring, the ring should be cut off immediately.
Perfusion of the finger is in doubt when it is pale and mottled and has diminished or absent capillary refill. If perfusion is questioned, a pulse oximeter lead can be attached to the fingertip (Chapter 75). If a reading is obtained (a pulse wave form), perfusion is still present (2).
Assuming there is no circulatory compromise to the finger, one factor in determining the best removal method is the type of ring (e.g., plastic versus metal, narrow band versus wide band, inexpensive versus expensive or irreplaceable). It may be easier to cut a plastic ring with a ring cutter than attempt another technique, whereas if the ring is a broad, strong metal band, the string method may be a better starting point, assuming no vascular compromise has occurred.
Equipment
Water-soluble lubricant (e.g., KY jelly or lidocaine jelly if available)
2.0 or 3.0 silk suture, string, or umbilical tape, 20 inches long
Ribbon gauze, 1.25 cm wide, 20 inches long
Rubber band
Hemostats or mosquito clamps
Surgical glove to fit patient
Ring cutter (manual or battery powered)
Elastic tape, 1 inch wide (intravenous tourniquet or Penrose drain)
Blood pressure cuff
Monitoring equipment if conscious sedation has been administered
It is beneficial to have all equipment available for the various methods rather than to begin searching for the ring cutter after other methods fail.
Procedure
Because some of these methods may be upsetting and painful for an infant or child, consideration should be given to (a) letting the parent hold the child during the procedure (Chapter 2), (b) administering a digital block to provide pain relief (Chapter 35), and/or (c) possibly using conscious sedation (Chapter 33).
Before beginning any of the methods described in this chapter, the procedure should be explained to the child and parents, and the equipment demonstrated. Any needles should be shielded from the child’s view. The parent can assist the child in elevating the affected hand. While preparing the equipment, the parent or child should apply ice to the finger for 5 minutes to limit further swelling. The hand and finger are then cleansed with sterile water, with the hand kept elevated as much as possible during the procedure.
Depending on the methods attempted at home or en route to the hospital, the degree of swelling, the duration of swelling, and the desire to preserve the ring, one or more of the following techniques can be performed (see “Indications”).
Glove Method
The finger portion of a surgical glove is placed on the patient’s finger. A portion of the glove is passed underneath the ring using forceps or a hemostat. This portion should be circumferential and long enough to turn inside out and over the ring. This portion of the glove is pulled toward the fingertip. A twisting motion may be necessary. The glove should not be pulled so hard that it rips or the remainder of the glove slips under the ring (Fig. 119.1) (3).
String Pull or Rubber Band Method
With the string pull, one end of the suture (string) or a rubber band is slipped beneath the ring and pulled through until both ends are of equal length. A hemostat may be used to grasp the suture or rubber band under the ring. The ring and distal finger are then lubricated. Both ends of the suture or rubber band are grasped with the clinician’s fingers or a hemostat and pulled in a circular motion. The suture or rubber band should be rotated around to different sections of the ring and pulled along the axis of the finger to gradually advance the ring off (Fig. 119.2) (4,5).
If this method is not successful, a digital block should be administered before the next maneuver. If the block is performed with medication deposited into the web space or via a volar metacarpal approach, no significant additional swelling of the finger should occur.
 Figure 119.1 Glove method of ring removal. |
String Wrap Method (Performed with Suture, Umbilical Tape, or Ribbon Gauze)
With the string wrap, one end of thick silk suture (or umbilical tape or ribbon gauze) is passed under the ring so that 5 inches remains on the proximal side of the finger. A hemostat may be used to slide the suture under the ring. The remaining suture (tape, gauze) is wrapped tightly around the swollen finger beginning just distal to the ring. Each loop of the suture (or umbilical tape) should touch so that no tissue bulges between loops (each loop of gauze should overlap a half width). The wrap should be continued just beyond the proximal interphalangeal joint (PIP) (Figs. 119.3 and 119.4) (1,2,4,6,7,8). When the wrap is complete, the proximal piece of string (under the ring) is pulled toward the fingertip with the clinician’s fingers or a hemostat. As the string (tape, gauze) gradually unwinds, it should ease the ring over the PIP joint and off the
finger. If the string (tape, gauze) was not long enough or the wrapping not tight or close enough, this procedure may have to be repeated (4,7,8).
finger. If the string (tape, gauze) was not long enough or the wrapping not tight or close enough, this procedure may have to be repeated (4,7,8).
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