Ring Removal

Thomas C. Arnold, MD
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Subject: Ring Removal

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Introduction

Removal of a tightly lodged ring or ring-like structure from a digit is commonly requested in the clinical or urgent care setting. Reasons for removal range from instant entrapment to gradual constriction after years of wear. Rings should also be removed anytime swelling of the digit is reasonably anticipated such as trauma, envenomation, prolonged illness, skin conditions, surgery, or allergic reaction. As venous outflow is obstructed, the digit becomes increasingly restricted by the ring’s tourniquet effects. This digital swelling can leave the digit tightly and painfully trapped at the base of the proximal phalanx. If not promptly treated, complications of nerve damage, ischemia, and digital gangrene are possible. Because many rings have personal significance and value to the patient, when appropriate, several ring-sparing techniques may be attempted to preserve a treasured artifact. 
Before attempting ring removal, the digit should be inspected for lacerations, assessed for neurologic compromise by a simple two-point discrimination test, and evaluated for distal digital pulses sought with a Doppler flow meter. If evidence of neurovascular compromise is present (i.e., reduced sensory perception or diminished pulses), ring-sparing techniques should not be attempted and the ring should be promptly removed by cutting. After ring removal, neurovascular integrity of the digit should be re-assessed by tactile sensation and capillary refill. Any deficits suggest that prompt consultation with a hand specialist is warranted. 
Initial attempts at ring removal should begin with elevation of the involved extremity to encourage venous and lymphatic drainage. Many times, lubricating the digit with soap, glycerin, or a water-soluble lubricant will allow removal with gentle traction. 

Equipment

  • Manual ring cutter

  • Pliers

  • Curved hemostats

  • Umbilical tape (2 to 4 mm wide) or 0-gauge or larger braided suture

  • Powder-free, latex surgical glove

  • Motorized handheld grinder (such as a Dremel tool)

Indications

  • Removal of a ring or other constricting object from a swollen digit or one that could potentially become compromised

Contraindications

  • In the presence of lacerations or neurovascular compromise, the ring-cutting technique should be employed rather than the more time-consuming ring-sparing options.

The Procedure

String Technique

Step 1
After sufficient elevation of the entrapped digit, use the umbilical tape or braided suture to wrap the digit in a spiral fashion from the distal tip toward the ring. Apply the wrap slowly with sufficient tension to allow the interstitial fluid to move gently under the ring, being careful not to apply it tightly enough to obstruct arterial flow. 
  • PITFALL: Avoid the use of material that is too thin, such as monofilament or thin sutures, because of potential skin damage and decreased effectiveness.

Step 2
Once the wrapping material reaches the ring, the end should be carefully passed beneath the ring. This maneuver may be facilitated by grabbing the umbilical tape end or the suture needle with a small hemostat after passing it under the ring. 
Step 3
Generous lubrication of the wrapped digit should be applied after this is accomplished. Then, with gentle traction distalward on the ring, slowly unwind the wrapping material from under the ring, pushing the ring off the digit as it unwraps. 

Rubber Glove Technique

Step 1
Another method of reducing a markedly swollen digit involves removing a finger from a small, powder-free, latex surgical glove and pulling it onto the swollen digit. (Alternative methods have been described using a penrose drain or rubber/elastic band such as an IV tourniquet in place of the glove finger to reduce the digit edema.) As the edge of the glove finger nears the ring, utilize the small curved hemostats to assist passage of the latex between the ring and the digit. 
  • PITFALL: Use latex-free material in anyone with a possible latex allergy because latex could worsen the swelling.

Step 2
Allow the latex to compress the swollen digit uniformly while elevating the digit above the patient’s head. 
Step 3
Once enough edema has resolved, invert the glove edge above the ring and use it to pull the ring toward the fingertip. Lubrication of the gloved finger at this point will assist removal. 

Ring Cutting Technique

Step 1
Select the thinnest or most accessible portion of the ring for the cutting site. The digit guard of the ring cutter should be passed under the ring at the chosen location and serves to protect the digit from injury during the cutting procedure. (If elevation of the cutting site is necessary for placement of the digit guard, the ring may be compressed slightly with pliers. Careful pressure should be applied 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. This slight lateral compression will displace the neurovascular bundles to the less restricted palmar region and should not compromise their function.) 
  • PITFALL: Avoid excessive trauma and pressure to the digit. Even with mild pressure, the patient must be warned that some discomfort may be experienced.

Step 2
Once proper positioning of the ring cutter is obtained, rotate the blade lever while maintaining adequate pressure to keep the saw engaged into the metal of the ring. Continue rotation of the saw blade until the ring is completely divided. The two ends of the divided ring are then grasped with pliers or hemostats and pulled apart to open the ring and allow its removal. 
  • Pearl: If the object is too thick or tempered for removal by this method (e.g., steel nuts), consider the use of a motorized, handheld circular cutter/grinder (such as a Dremel tool). A silicone rubber band or other similar material should be placed between the skin and the cutting site to protect the underlying tissue.

  • Pearl: Two cuts 180 degrees apart are usually necessary for large or hardened objects.

Complications

  • Injury to the underlying skin, lymphatics, and neurovascular bundle.

  • Fracture of the proximal phalanx or disruption of the finger joint mechanism.

  • The benefits, risks, and medical necessity of the ring removal should be considered prior to attempting the procedure.

Pediatric Considerations

Consideration should be given to mild sedation and pain control in children experiencing discomfort from this procedure. 

Postprocedure Instructions

A thorough inspection and examination of the finger should be performed after the ring is removed. The chart should document all findings including the presence or absence of two-point discrimination of the digit. Edema of the previously constricted digit should resolve over several hours. 

Coding Information and Supply Sources

There is no specific code for ring removal. Use the appropriate evaluation and management (E/M) code for the visit. 
Ring cutters may be obtained at Chief Supply Co., 10926 David Taylor Dr., Suite 300, Charlotte, NC 28262. Phone: 888-588-8569. Web site: http://www.chiefsupply.com/home.asp
Electric and manual versions are available from the Shor International Corporation, 20 Parkway West, Mt. Vernon, NY 10552. Phone: 914-667-1100. Web site: http://shorinternational.com/RingTools.htm

Bibliography

Gallahue FE, Carter WA. Ring tourniquet syndrome. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill;  2004:311–312.
Hiew LY, Juma A. A novel method of ring removal from a swollen finger. Br J Plastic Surg.  2000;53:173–174. [View Abstract]
Inoue S, Akazawa S, Fukuda H, et al. Another simple method for ring removal. Am Soc Anesthesiol .  1995;83(5):1133–1134. [View Abstract]
Mizrahi S, Lunski I. A simplified method for ring removal from an edematous finger. Am J Surg.  1986;151:412–413. [View Abstract]
Paterson P, Khanna A. A novel method of ring removal from a swollen finger. Br J Plast Surg .  2001;54:182. [View Abstract]
Thilagarajah M. An improved method of ring removal. J Hand Surg Br.  1999;24:118–119. [View Abstract]
Witz R. Ring removal. Nurse Pract .  2002;27(2):54. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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