Ring Removal

Safest techniques for removing an entrapped ring from a finger, toe, or penis are reviewed and outlined in this guideline taking into account the metal composition of the rings in question that need to be removed to avoid tissue ischaemia with potential permanent tissue necrosis. 

The most common reason for ring removal is swelling. Swelling can be caused by multiple reasons like trauma, allergic reactions, pregnancy, cardiac/renal failure or venous thromboembolism. Although, uncommon, penile entrapment has been described after patients place various constriction devices around the penis or scrotum to maintain or enhance an erection. 

Elasticated band wrap technique

For valuable rings not requiring emergency removal this approach is acceptable. In general, inexpensive soft metal or plastics rings should be cut off because this procedure can be carried out quickly without analgesia/nerve blocks. Warn the patient that the removal of the ring by the elasticated band wrap method is painful and provide analgesia as necessary. 

• Prior to use, cover any open wounds to prevent contamination of equipment and damage to the wound.
• Place one end of the green elasticated band (you can find them on the oxygen masks in ED) under the ring from the proximal to the distal side.
• Wrap the band tightly around the digit overlapping the wrappings so that tissue is not visible. 
• Continue wrapping beyond the PIP joint of the digit.
• Once the wrapping is complete, place some lube around wrapping band and unwrap the proximal end which will gradually remove the entrapped ring. In some patients, rewrapping maybe necessary. 

Ring rescue non-destructive ring removal set technique

For valuable rings not requiring emergency removal this approach is acceptable.

DO NOT USE if there are fractures on affected fingers/toes, tendon or neurovascular injury (not recommended).

• Prior to use, cover any open wounds to prevent contamination of equipment and damage to the wound. 
• Apply the ring rescue device over the affected finger. Ensure the device location is correct (against the ring, but not overtop). Close the pressure valve by turning clockwise. Pump the device until the needle is in the light blue zone. Allow the device to work for about 5 minutes with hand elevated before opening the pressure valve to release pressure. Remove the device by gently wiggling it from the finger. 
• Apply the supplied lubricant on the affected area. 
• Immediately attempt to remove ring using twist and pull or rocking motions. 

If these procedures are unsuccessful proceed with the cutting or breaking of the entrapped ring. 

Soft metal or plastic rings

Soft metal (gold, silver, copper or tin) or plastics rings can be cut in ED with a manual operated ring cutter or electric ring cutters. Become familiar in how to use the individual ring cutter utilised 

Manual ring cutter

Apply the saw blade wheel to the ring and turn it, the friction of the ring cutting process generates heat that in turn can cause discomfort and burn the patient skin. To reduce this risk, water should be used during this process to reduce the heat of the metal being cut. 

Hard metal

Hard metal (steel or titanium) rings can be cut in ED with electric ring cutters. Become familiar in how to use the individual ring cutter utilised 

Electric ring cutters (GEM II or Black & Decker)

If you utilise the GEM II make sure you use the carbide cutting disc (blue colour). If you utilise the Black & Decker it only has one type of disc for all rings.

With the electric ring cutters it is important that the blade wheel is running before it touches the ring to prevent damage to the blades. Do not place undue pressure to the running blades to fasten the process as it will cause damage to the blades themselves. Be patient. The friction of the ring cutting process generates heat that in turn can cause discomfort and burn the patient skin. To reduce this risk, water should be used during this process to reduce the heat of the metal being cut 

Tungsten carbide or ceramic: These rings can be shattered in ED with a set of locking pliers. Prior to use, cover any open wounds to prevent metal particles from entering and causing contamination / damage. 

• Cover remaining of hand with a glove with the affected finger cut off to fit around and to reduce skin damage from shattering pieces to the remaining fingers. 
• Place a towel underneath affected hand with enough overlap to cover hand/pliers when pressure is applied. 
• Wear eye protection and gloves.  o Using the locking pliers fit around width of ring, when tight place towel over hand and pliers to apply locking pressure. If ring does not shatter, turn the lock of the pliers clockwise a tiny bit and try again until ring shatters. 
• Inspect hand for any potential injuries post-removal and treat accordingly 

Post-procedure 

Removal of a ring can cause soft tissue trauma, including bruising or small cuts. After ring removal, clean digit, toe or penis and dress it if necessary. Re-evaluate neurovascular status. If there is clinical suspicion for digital/toe fracture then xray accordingly. For digital/toe swelling, instruct patient to keep affected limb elevated and ice it for the next 3 days (for 20 minutes every 4 hours). Advice patient not to wear another ring on affected finger/toe until the pain and swelling has completely resolved. Verify tetanus status and give prophylaxis as required. Patients with penile rings should be able to void normally before discharge 

Indications for speciality consultation 

After ring removal from a finger or toe, consultations with plastics or orthopaedics surgeon is warranted for the following findings: 

• Persistent signs of ischaemia
• Open fracture
• Open joint dislocation
• Fracture with dislocation
• Unstable fracture
• Tendon injury
• Digital nerve injury 

Emergency urology consultation is indicated for patients with penile ring entrapment and signs of penile ischaemia or necrosis. Urgent urology consultation is also granted if post-removal of ring there is persistent ischaemia, difficulty voiding, or deep ulceration with potential involvement of the urethra or cutaneous urethral fistula.