Atlas of Primary Care Procedures, 1st Edition

General Procedures

6

Ring Removal

Few pieces of jewelry carry the personal or societal importance and meaning of finger rings. Unfortunately, digital swelling can leave a finger or toe ring tightly and painfully trapped at the base of the proximal phalanx. Swelling can be caused by local trauma, infections, arthritis, dermatologic conditions, and allergic reactions. As swelling increases, venous outflow from the digit is increasingly restricted by the tourniquet-like effects of the ring. If not promptly treated, possible complications include nerve damage, ischemia, and digital gangrene. Different techniques may be used to remove the ring with no or minimal damage to it.

Before attempting ring removal, assess the involved digit for major lacerations. Assess neurologic compromise using a simple test such as the two-point discrimination test. A Doppler flow meter may also be used to monitor distal digital pulses. If there is evidence of neurovascular compromise (i.e., reduced sensory perception or diminished pulses), the ring should be removed by the fastest method: cutting. In the absence of neurovascular compromise, ring-sparing techniques may be attempted to preserve its integrity. After removal of a ring, neurovascular integrity must be re-evaluated by tactile sensation and capillary refill of the digit. If deficits are found in either area, prompt consultation with a hand specialist is warranted.

Instruct the patient to elevate the involved extremity to encourage venous and lymphatic drainage. Lubricate the digit with soap, glycerin, or a water-soluble lubricant. Sometimes, these measures allow the ring to slide off with gentle traction.

INDICATIONS

  • Removal of a ring from a swollen digit

CONTRAINDICATIONS

  • Use the ring-cutting technique if there are lacerations or neurovascular compromise.

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PROCEDURE

When using the string technique, after elevating the digit, wrap it in a spiral ligature from the tip of the digit to the ring. Two-millimeter umbilical tape or 0-gauge or larger braided suture with a tapered needle is best, but other materials may be used. Perform the wrapping with enough tension so that the interstitial fluid gently moves under the ring but not so tightly as to obstruct arterial flow.

 

(1) Wrap the elevated digit in a spiral ligature with larger braided suture using a tapered needle from the tip of the digit to the ring.

PITFALL: Avoid the use of monofilament or thin sutures because they can tear through the skin.

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In the string technique, the end is then passed beneath the ring, taking care not to pierce the skin. Grabbing the end of the tape or the suture needle with a small hemostat after it passes under the ring may facilitate this maneuver.

 

(2) Pass the end of the suture beneath ring without piercing the skin.

The suture is then slowly unwound from under the ring, pushing the ring forward as it unwraps. Lubricating the suture can further facilitate ring removal by this method.

 

(3) Slowly unwind suture from under the ring, pushing the ring forward as it unwraps.

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When using the rubber glove technique and the involved digit is markedly swollen, remove a “finger” from a small, powder-free, latex surgical glove, and pull it onto the digit. When the rim of the glove finger nears the ring, pass a small, curved forceps under the proximal side of the ring to grasp the latex, and draw it between the ring and the digit. Allow the latex to compress the swollen digit uniformly until the ring can be passed over the lubricated glove and digit.

 

(4) Rubber glove technique.

PITFALL: Watch for latex allergy, which can worsen swelling.

Pick the thinnest, least ornate, or most accessible portion of the ring for the cutting site. The ring cutter is illustrated. The digit guard of the ring cutter is passed under the ring and protects the digit from injury.

 

(5) Ring cutter.

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If elevation of the cutting site on the ring is necessary for passing the digit guard, the ring may be compressed with pliers. Apply pressure to the ring with the jaws of the pliers placed 90 degrees on either side of the cutting site. This converts the ring shape from circular to elliptical, creating a space between the ring and underlying tissues. Compression from the sides tends to displace neurovascular bundles to the less restricted palmar region and, accordingly, should not compromise them.

 

(6) Pick the thinnest portion of the ring as the cutting site, and use pliers if necessary to compress the ring if you cannot pass the digit guard under the site.

PITFALL: Avoid excessive pressure and trauma to the digit. Even with mild pressure, the patient must be warned that that he or she may experience some discomfort.

When cutting the ring, rotate the lever that turns the circular saw blade. Continued rotation of the saw blade severs the ring without cutting the skin.

 

(7) Continually rotate the saw blade using the lever to sever the ring without injuring the skin.

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The two ends of the divided ring are then grasped with pliers or hemostats, and they are pulled apart to open the ring and allow its removal.

 

(8) Grasp the two ends of the divided ring with pliers, and pull them apart to remove the rings from the finger.

If the object is too thick or tempered for removal by this instrument (e.g., steel nuts), consider use of motorized, hand-held cutters with a sharp-edged, circular grinder. It is usually necessary to make two cuts 180 degrees apart, because such rings are usually too hard to bend. Place a Silastic band or a similar material beneath the ring-cutting sites to protect the finger.

 

(9) Use motorized, hand-held cutters with sharp-edged, circular grinders to remove thicker objects from the digit.

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CODING INFORMATION

There is no specific code for ring removal. Use the appropriate evaluation and management (E/M) code for the visit.

INSTRUMENT AND MATERIALS ORDERING

Ring cutters may be obtained at Chief Supply Co., 2468 West 11th Avenue; P.O. Box 22610, Eugene, OR 97402 (phone: 800-824-4338;http://www.chiefssupply.com/ring_cutter.phtml) or from Transcon Sales and Mfg. (Miltex Brand Ring Cutter), 5725 South Main Street, Los Angeles, CA 90037-4171 (Phone: 888-299-8830; http://www.transconmfg.com).

BIBLIOGRAPHY

Edlich RF, Eggleston JM. Ring tourniquet syndrome. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 1985:300–301.

Fasano FJ, Hansen RH. Foreign body granuloma and synovitis of the finger: a hazard of ring removal by the sawing technique. J Hand Surg Am 1987;12:621—623.

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

Hiew LY, Juma A. A novel method of ring removal from a swollen finger. Br J Plastic Surg 2000;53:173–174.

Huss CD. Removing a ring from a swollen finger. In: Driscoll CE, Rakel RE, eds. Patient care procedures for your practice. Oradell, NJ: Medical Economics, 1988.

Mizrahi S, Lunski I. A simplified method for ring removal from an edematous finger. Am J Surg 1986;151:412–413.

Paterson P, Khanna A. A novel method of ring removal from a swollen finger. Br J Plast Surg 2001;54:182.

Thilagarajah M. An improved method of ring removal. J Hand Surg Br 1999;24:118–119.