Ring removal

Overview

• Rings can pose a significant threat to body parts after an injury. When body parts with rings begin to swell, the ring acts as a tourniquet and prevents blood and lymph from returning to circulation.
• With severe swelling, the restriction of the ring can lead to necrosis and amputation of the affected tissues.

Indications

• Should be preemptively removed in the ER for patients with any significant limb injury, infection, or need for IVF
• Other indications for ring removal include:
• Swelling
• Cyanosis
• Need for proximate evaluation
• Numbness or pain
• Difficulty removing the ring
• Required imaging where the ring will cause interference (MRI, etc.)

Contraindications

• There are no absolute contraindications to removing a ring

Equipment Needed

• Dependent on technique (see below)

Procedure

Image showing string removal setup.

Lubrication Removal

A first attempt at ring removal should be made using a lubricant to ease the ring off of the entrapped body part. Suitable lubricants can include mild soap and water, lubricating jelly and skin safe oils. Use any thin and narrow applicator to massage the lubricant between the ring and underlying skin. Once lubricated, attempt to remove the ring.

String Removal

Ring removal may be facilitated by using any kind of string to pull the ring off the body part. This method will work best if the ring is already lubricated. Using a thin string, rubber band, venous tourniquet, or other flexible material, feed one end between the ring and the skin to the opposite edge. Use a series of short, firm pulls in the direction of removal and work your way around the entrapped body part. Alternatively, the string can be wrapped around the body part multiple times in the direction of removal to provide a cork-screw-type path as you pull on the other end of the string.

Ring Cutter Removal

Using either a manual or electric ring cutter, you will remove the ring by cutting in one or two places, damaging the ring. First, place the guard for the ring cutter between the ring and the skin. Then, use the circular blade to cut toward the guard; the guard should be secured to the ring cutter to ensure the blade's trajectory. Once the blade reaches the guard, remove the ring cutter and bend the ring open. If the ring cannot be easily bent, repeat the process on the opposite side of the ring to create two semi-circles and remove them from the entrapped body part.

Last Resort Measures

In rare cases where your ring cutter blade is not sufficient to cut through the ring material, it may be necessary to seek out other resources. This is often the case with high-strength materials such as tungsten and titanium rings. In serious cases, reach out to the OR for possible resources. Depending upon local guidelines and protocols, the fire department may be called to use hydraulic cutting tools to help facilitate removal though this carries significant risks to the underlying tissues.

Complications

• Laceration and abrasion of underlying tissues
• Joint dislocations
• Nerve and vascular damage
• Accidental amputation

See Also

• Hand and finger diagnoses

References

• Reichman, Eric F. Emergency Medicine Procedures. McGraw-Hill, 2013.