Annals of Case Reports (ISSN: 2574-7754)

Article / Case Report

"A Review of Ring Removal Techniques in the Emergency Setting"

Gina Sparacino1*, Robert Ablove2

1Resident Physician, University at Buffalo Internal Medicine, NY, USA

2Department of Orthopaedics and Sports Medicine, UBMD Buffalo, NY, USA

*Corresponding author: Gina Sparacino, Resident Physician, University at Buffalo Internal Medicine, 13450 Bullis Rd, Alden, NY 14004, USA. Tel: +17164789883; Email: ginaspar@buffalo.edu

Received Date: 28 July, 2018; Accepted Date: 14 August, 2018; Published Date: 22 August, 2018

1.       Abstract

Ring entrapment on swollen digits is frequently encountered in urgent and emergent settings. Various removal methods have been described. Special tools and techniques are required to remove rings and bands from fingers in order to prevent finger ischemia and necrosis. Non-cutting removal techniques are preferable, but when unsuccessful, cutting or destructive techniques may be necessary. Techniques are material dependent and directly related to hardness and malleability. We present a case of digital entrapment in the lug hole of a tire, extricated utilizing a Dremel tool and provide a summary of other ring removal techniques.

2.       Keywords: Constricting bands; Digits; Dremel tool; Emergency; Ring removal; Ring cutting; Trauma; Upper extremity

1.       Case Report

An 8-year-old boy placed his non-dominant index finger through the lug hole of a spare tire wheel. The finger became swollen and incarcerated. (Figure 1) Fire rescue evaluated him at the scene and were unable to extricate the finger using lubricant. They used an acetylene torch to remove the wheel segment containing the lug hole and transferred him to a regional hand center for evaluation and treatment.

Upon evaluation the finger was swollen, but well perfused with 2-point discrimination of 4mm. After obtaining informed consent and performing a digital block with 2% polocaine and 0.5% Marcaine, suture wrapping technique was unsuccessful.

Ultimately, a Dremel Multipro tool with a diamond disk blade was utilized to free the incarcerated finger (Robert Bosch Tool Corporation, Mount Prospect, IL). (Figures 2 and 3). A malleable metal tissue protector was placed beneath the bearing to protect the skin from the diamond tip. Ice water irrigation was applied during cutting to mitigate heat generation. We removed a wedge of metal large enough to extricate the finger.

2.       Discussion

Ring removal following trauma is essential to protect from digital ischemia and necrosis. Untreated tourniquet syndrome resulting from a constricting finger bands can cause distal edema, pain, discoloration and ultimately digital compromise [1].

The simplest and least invasive technique for ring removal is the utilization of lubricant.

Surgical lubricant, or a water-soluble gel is typically used [2]. Ice and elevation may also be utilized to reduce swelling and provide mild pain relief [3]. The skin proximal to the ring is gently pulled towards the hand while the ring is gently pulled towards the tip of the finger [2]. When lubricant fails, non-cutting removal techniques are used. Digital block may be used to provide anesthesia [4].

Multiple techniques have been described to remove incarcerated rings without cutting. The suture or winding technique as described by Pomeroy consists of suture thread, dental floss, or tape wrapped circumferentially around the finger from the distal tip of the finger to the ring, which is then wrapped under the ring. The end proximal to the ring is pulled distally while stabilizing the distal suture end. This step usually needs to be repeated several times as the ring is pulled distally. As the string unwinds, the ring is moved distally [2].

A surgical glove may also be used in order to remove ring without damage. Kalkan et al. described cutting one finger of a surgical glove both at the proximal and distal ends to result in a latex cylinder. Surgical lubricant is applied, and the elastic is wedged underneath the ring using forceps. The proximal segment of the latex is then pulled over the ring distally sliding the ring off the digit [5] (Refer to figures 4 and 5).

Ring cutting is employed when conservative treatments are unsuccessful or when open wounds and or fractures are present. Standard ring cutters have a safety guard that is passed beneath the ring to protect the skin from damage. (Refer to figure 6) A serrated toothed saw then cuts the ring over the safety guard. (Refer to figure 7) Steel cutting pliers may also be used to cut rings made of softer metal [5].

Titanium and tungsten carbide rings have become increasingly popular. With tungsten carbide having a hardness rating of 8.5-9.0 scale and titanium having a rating of 6.0 on the 10.0 Moh’s hardness scale, removal with standard cutting techniques is difficult.

Standard ring cutters are unable to cut titanium and tungsten carbide, posing a dilemma when non-cutting techniques fail to remove the ring in the ED [6].

Diamond tipped dental drills may be used to cut through rings made of virtually any material  [7]. Taylor et al. describes a ring removal from a 17-year old’s finger using a dental drill. The tool was described as having an electric motor with rpms reaching up to 25,000 with the circular diamond grinding disc measuring 15 mm in diameter. Cooling irrigation and a protective device beneath the ring are essential.

Locking pliers or vice grips may also be used to break tungsten carbide rings. Rings are removed by progressively tightening the screw of the vice grip. Usually three to four turns are sufficient. The technique can produce small projectiles, so patient and physician shielding including eye protection is necessary. Finger abrasion and laceration can also occur [8].

3.       Conclusion

Emergency physicians are often faced with the challenge of removing constricting bands from patient’s digits following trauma to the upper extremities. It is important to remove rings following trauma in order to prevent ischemia and further digital damage. While non-cutting ring removal methods are often successful including usage of lubricant, suture technique, and glove technique, ring-cutting techniques is necessary when conservative techniques fail. Standard ring cutters are commonly found in most emergency departments, however, problems may arise when a patient present with rings made of very hard material. Diamond tipped dental drills may be employed. Tungsten rings can be fractured using a vice grip or locking pliers. In our case, ring salvage techniques were unsuccessful in extricating a finger from a lug hole. A Dremel tool with a diamond disk blade was used to successfully cut the surrounding wheel and free the finger.

4.       Conflict of Interest

There are no conflicts of interest.


Figure 1: Fire rescue evaluated him at the scene and were unable to extricate the finger using lubricant.



Figures 2,3: Dremel Multipro tool with a diamond disk blade was utilized to free the incarcerated finger (Robert Bosch Tool Corporation, Mount Prospect, IL).



Figures 4,5: Surgical lubricant is applied, and the elastic is wedged underneath the ring using forceps. The proximal segment of the latex is then pulled over the ring distally sliding the ring off the digit.



Figures 6,7: Standard ring cutters have a safety guard that is passed beneath the ring to protect the skin from damage. A serrated toothed saw then cuts the ring over the safety guard.



Citation: Sparacino G, Ablove R (2018) A Review of Ring Removal Techniques in the Emergency Setting. Ann Case Rep: ACRT-200. DOI: 10.29011/2574-7754/100100