Ring removal: an illustrated summary of the literature

Abstract

Objectives: The inability to remove a ring from a finger is a common presentation to Emergency Departments in addition to Orthopaedic and Plastic Surgery Units. This is often complicated by factors including trauma and infection, leading to a superimposed tourniquet effect by the ring, strangulating the subcutaneous tissues. The threat of neurovascular compromise favours early removal of the ring to limit associated morbidity. This article illustrates the common methods within the literature. We offer assessing clinicians an illustrated summary of techniques for removing an incarcerated ring from an extremity and summarise notable considerations to be acknowledged at time of assessment and ring removal. Methods: A literature search using PubMed and Medline was performed to identify all articles written in English on ring removal. Results: The 12 publications included in this illustrated review describing techniques for removal of an incarcerated ring were published between 1991 and 2018 and include modifications to overcome difficulties due to the composition of the ring or severity of the ring incarceration and penile/scrotal ring removal. Conclusion: The ring removal techniques are ring preserving or destructive. The technique used depends on factors including the extent of associated trauma to the digit, evidence of strangulation, ring composition, patient preference and equipment availability. Before an attempt at ring removal, high arm elevation, indirect ice compression of the digit and adequate analgesia maximise chances of success. In cases of strangulation, emergent referral to a specialist is indicated for removal and further management.

Compression Devices as an Alternative Approach After Unsuccessful Ring Removal Attempts

“…Additional benefits to using a CD is the potential for a less traumatic patient experience as well as preservation of a ring which may have sentimental value [6]. Although challenging to quantify, these two metrics are not inconsequential and often the provider-patient discussion is focused solely on whether the ring can be removed and the digit preserved [5][6][7][10][11]. Patient comfort and ring preservation are significant metrics.…”

“…The need for ring removal can result from processes that are systemic, regional, or localized, and can occur acutely or over days to years. Due to the variety of presentations, it is important to assess the cause of a ring becoming stuck [ 6 - 7 ], and like any tool, CDs must be applied only when safe. As with all ring removal techniques, the provider ultimately removes the ring, making proper technique with any tool, and often the integration of several techniques which are important for success.…”

“…Patient comfort and ring preservation are significant metrics. Asher et al recognize this when they state that any future algorithms for ring removal should consider patient input when selecting a removal strategy [ 6 ].…”

“…To further complicate removal, modern ring materials and designs can be challenging to cut with cutting devices [9][10][11]. Also, sometimes missing from the discussion is the sentimental value that jewellery can hold and the loss a patient experiences when jewellery is damaged or destroyed in the process of medical care for their digit [5][6][12][13].…”

“…Several compression techniques have been used to remove rings ranging from the application of strings or elastics to tourniquets [ 2 - 5 ]. This novel device has yet to be included in formal recommendations and algorithms for ring removal with other compression techniques [ 6 - 7 ]. This represents a knowledge to practice gap [ 8 ].…”