Ring removal

Overview

Entrapped penile ring.

• 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.
• Typically on fingers, but may occasionally be on other body parts (e.g., penile ring)

Indications

• Should be preemptively removed in the ED 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

• No absolute contraindications

Equipment Needed

• Dependent on technique (see below)

Procedure

Image showing string removal setup (Procedure 1). Note that the string loops should optimally be closer together and start closer to the ring itself.

Image showing manual ring cutter with guard correctly placed between the ring and the skin.

Lubrication Removal

Typically the first attempt, unless already attempted by patient

• Suitable lubricants: mild soap and water, lubricating jelly (e.g., K-Y jelly), safe oils
• Apply between ring and underlying skin
• Once lubricated, attempt to remove the ring

String Removal

• Consider pre-lubrication (see above)
• Possible equipment to use: large diameter nylon suture (with needle cut off), other thin string, venous tourniquet
• Described Procedure 1:
  • Insert string under ring with majority of string left on distal side of ring
    • Wrap the string around the finger ensuring little-to-no space between each time around (should provide maximal constriction of the finger without causing injury)
    • Using the proximate end of the sting (proximate to the ring), slowly unwrap the sting
      • This should provide a cork-screw-type mechanism that moves the ring distally while compressing the tissues underneath
• Described Procedure 2:
  • Place one or more strings underneath the ring
    • Use as traction to pull and remove ring from body-part

Ring Cutter Removal

• Use a manual or electric ring cutter
  • If using an electric ring cutter, stop frequently to check for heat buildup to prevent burns
• Warn patient this is a destructive procedure for the ring
• Place the guard between the ring and the skin
  • Normally supplied with and frequently connected to the cutting device
• Use the circular blade to cut, ensuring the guard is in place and will prevent tissue injury if/when the device fully cuts through the ring
• Make one or two (if ring is hard to bend) cuts, as necessary
  • May consider using plyers or similar to bend ring after one cut, if helpful
• Remove ring

Last Resort Measures

Heightened risk for injury to underlying tissues

• This is for rarer cases, where the ring cutter blade is not sufficient to cut through the ring material
  • For example, high-strength materials such as tungsten and titanium rings
• Consider other resources (e.g., from fire EMS or facilities management, depending on local protocols)
  • For example, hydraulic cutting tools or more power (e.g., Dremel with diamond crusted blade)
• May need to fashion makeshift guard for between ring and body-part
• If using an automatic rotating blade, stop frequently to check for heat buildup to prevent burns

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.