What is your diagnosis?

An embedded ring with underlying osteomyelitis of the proximal phalanx.

• Pearl: Radiographic findings of osteomyelitis are usually not seen in early disease. Soft tissue swelling can begin 3 days after infection, but periosteal elevation/reaction can take 10-21 days and lytic lesions typically do not show for more than a month [1].

What are additional complications of embedded rings?

Soft tissue injuries include tendon injury, tenosynovitis, abscess, or cellulitis. Neurovascular injuries include ischemia, necrosis, and loss of sensation. A recent literature review of twenty-eight patients gave evidence that ischemia was an unlikely complication although data is sparse [2]. 

What patients are predisposed to ring complications?

All patients with hand swelling, especially those in trauma, should have rings taken off to prevent complications. A recent review showed that embedded rings are not exclusive to the psychiatric population as previously thought [2].

What methods are there to remove rings that are stuck?

The extent of embedment, material of ring associated swelling and involvement of deeper structure are all factors that play into the choice of removal. Consider a digital or larger nerve block when appropriate. Consider the following ideas:

Removing the Ring Intact 

• Substances such as lubricant jelly, soap, or even Windex 

https://www.aliem.com/windex-ring-removal/

• String removal trick

https://www.youtube.com/watch?v=DrDROoJAF4I

• Consider a tourniquet wrap 15 minutes prior

https://www.aliem.com/trick-of-trade-ring-removal-from-finger/

• Use the elastic strap from an oxygen mask to wrap the finger

https://youtu.be/DxoAbK5Pc6w

Destructive Techniques

• Cutting the ring (non hardened steel). Many shears have a ring cutter on their backside

• Hardened steel ring cutter

https://www.youtube.com/watch?v=YKkiFSgy95g&t=301s

https://www.youtube.com/watch?v=2_PA56Y5EOQ

• Tungsten carbide

https://www.youtube.com/watch?v=poM423pewRE

What is your disposition and management?

Consider tetanus immunization status and a local antibiotic ointment or oral antibiotic if there is a superficial infection.

• Pearl: An early consult with a hand surgeon is warranted for any of the following:

-Persistent signs of ischemia

-Open fracture

-Open joint dislocation

-Fracture with dislocation

-Unstable fracture

-Tendon injury (unable to flex or extend the digit)

-Digital nerve injury (loss of distal sensation)

-Osteomyelitis

-Tenosynovitis