Unfortunately, rings sometimes need to be removed emergently. Other times, ring removal is more prudent than emergent, such as when further swelling may occur (i.e., after distal radius fracture), preoperatively, prior to MRI, and postmortem. Allergic reactions, anasarca, digital trauma, age-related changes, late pregnancy, and excessive weight gain are common causes of acute and chronic changes in finger circumference.
Metal rings also need to be removed emergently when placed on the penis and scrotum for sexual purposes and become entrapped. Cutting is generally the first line of management for removal.
Scores of anecdotal reports abound about ring removal techniques and using nonmedical tools that would make MacGyver proud. Ring removal can destroy or preserve the ring, and preserving it is preferred when the ring has sentimental, monetary, or historical value. Ring-destroying techniques include multiple techniques for cutting through the ring.
All rings are not created equal. The Mohs hardness scale is used to quantify the hardness of various materials. Diamonds are ranked 10 on the scale and gold around 3, while cobalt is rated at 5, stainless steel at 5.5 to 6.3, titanium at 7, and tungsten carbide at 8.5 to 9. The material will partially determine the clinician's choice of tools.
The locking-pliers technique, for example, has been used for rings made of tungsten carbide, which is one of the hardest materials; it is nearly impervious to many traditional ring cutters. The Achilles heel of tungsten carbide rings, however, appears to be its carbon lattice structure that behaves like glass. Those rings will shatter rather than bend under pressure. That is where the technique that uses locking pliers such as Vise-Grips comes into play. Repeated application of locking pliers while gradually tightening eventually causes the tungsten to shatter into pieces. This technique appears to be quite effective, but sharp fragments can injure the fingers.
One common ring style, the eternity band, has circumferential stones, which make the ring hard to cut. Prying them apart can result in stones flying everywhere, and two cuts are generally needed. Removing two or more rings from the same finger also create special challenges. Watch a video of ring removal pearls.
Ring-preserving techniques include those that decrease swelling of the finger distal to the ring followed by specific actions to maneuver the ring from the finger. Well-known steps for decreasing edema in injured extremities, RICE (rest, ice, compression, and elevation) are applicable in managing edematous fingers. Other techniques include compressing the finger distal to the ring to reduce edema using dental floss, suture material, umbilical tape, elastic straps from oxygen masks, elastic bands such as Penrose drains, blood-draw tourniquets, Coban self-adhesive wrap, and a novel device called the Ring Rescue Compression Device. Watch a video of the device being used to reduce finger edema.
Using string, umbilical tape, Coban, or elastic bands entails unwinding to progressively pull the ring off the finger distally. Ring rescue techniques call for adding lubrication around the ring once edema has been reduced, followed by four maneuvers to give the operator the best chance of success: corkscrewing the ring, rocking the ring back and forth, applying countertraction on the skin proximal to the ring, and the claw maneuver using the operator's index fingernail to pull the ring distally.
One final pearl for managing swollen fingers is to place a blood pressure cuff on the proximal arm biceps region to decrease systolic blood flow to the hand during removal. The cuff arm tourniquet may buy a little more time if the edematous finger seems to shrink temporarily only to swell up quickly.
Some edematous fingers, however, are not shrinkable to the point needed to allow the ring to be removed. This may be the case with angry fingers resulting from multiple failed ring removal attempts prior to arrival in the emergency department, severely swollen fingers, and significant adipose weight gain. String techniques using narrow material such as dental floss and 00 silk suture can cause tissue damage because of the associated mechanics where contact forces exceed what tissue can sustain. Infections related to this are rare, but cleaning the traumatized areas with chlorhexidine before and after ring removal should be considered, particularly if skin damage already exists or the removal technique is likely to cause skin damage.
Many of the tools used for removing rings can be purchased at hardware stores, and some marketed specifically for removals are not on the FDA website. Using medical equipment off-label or nonmedical tools requires a conversation with patients. Openly acknowledging to your patient that you have limited options and will be using nontraditional tools or equipment off-label is recommended.
Bolt cutters, Dremel tools, and other high-speed cutting disc tools have some risk of injury to the patient. Heat transfer with ring cutters is a major problem, and the risk of burning the patient is great. Unless the patient is obtunded or a digital or metacarpal block has been performed, the patient will usually tell the clinician when he is experiencing heat and associated pain. Burns resulted in one patient after the fire department used a high-speed rotary disc tool despite applying water to prevent overheating. (Photo.)
Burns can be prevented by pulsing the high-speed drill and providing a steady stream of cooling water. Experts recommend grinding for no longer than two seconds, and then stopping to allow heat dissipation for three seconds. A syringe can be used to drip water on the area, but a bag of saline with IV tubing and a 16-gauge catheter to provide a continuous drip is more efficient and prevents multiple interruptions for refilling a syringe.
Using a high-speed drill also creates a risk for sparks, metal particles, and aerosolized dust. Safety glasses and respiratory masks to protect the user and the patient from flying dust and debris are recommended. Tungsten material data safety sheets report that metal powders and dust may cause mechanical eye and skin irritation, and inhalation of powder or dust may cause mild respiratory tract irritation. Interstitial lung disease has been reported in industrial workers exposed to cobalt and tungsten dust. (Respir Med. 2017;129:91; https://bit.ly/3GwZMZJ; Ann Intern Med. 1971;75:709.) Using cutting equipment that minimizes aerosolized dust may be preferrable. Preventing tungsten dust from encountering open wounds is also recommended to prevent tissue reactions.
Dr. Mellick disclosed that he has no relationship with the company that makes the Ring Rescue Compression Device.