Correspondence

Use of a Penrose drain to remove an entrapped ring from a finger under emergent conditions

To the Editor,

It is common to encounter a patient featuring an entrapped ring on a markedly swollen finger in the emergency department (ED). It is frequently the case that a patient asks for the ring to not be destroyed during its removal for sentimental and/or monetary value reasons. Thus, preserva- tion of the ring and ensuring that no further damage occurs to the finger constitute a real challenge to ED physicians.

The typical causes of ring entrapment of the finger include trauma, tissue fluid retention, infection, and an allergic reaction in association with the presence of a too- tight ring. The tourniquetlike effect resulting from the progressive swelling of the ring-constricted finger may lead to subsequent ischemia, nerve damage, and eventually, even gangrene [1]. Therefore, early Ring removal is necessary or serious sequelae can result.

Cutting the ring off is a drastic method, but it is also prudent. Even the cutter may fail to cut the hardened ring or injure the finger. In cases of an extremely swollen finger, there may not be a sufficient gap between the ring and the finger to slip in a string [2], a bandage [3], a surgical glove [4], a rubber band [5], or a ribbon [6,7], which have been reported as nondestructive ring removal methods.

Instead of slipping a device under the ring, we used a Penrose drain to eliminate the tissue swelling and allow for effective and expeditious ring removal. A Penrose drain (PD-1) (7/16 x 1/4 x 18 in; Sherwood Davis and Geck, St. Louis, Mo) is applied tightly around the affected finger just distal to the proximal interphalangeal joint (PIPJ). This Pen- rose drain is secured in place to block the refilling of the soft tissue distal to PIPJ. The other Penrose drain (PD-2) is applied with circumferential compression between the distal edge of the entrapped ring and PD-1. The PD-2 needs to be wound tightly and directed proximally toward the incarcerated ring (Fig. 1). Immediately after PD-2 removal, it becomes quite obvious that a reduced level of swelling has been elicited in the finger distal to the ring. If, after this procedure, the edema was not sufficiently reduced for ring removal, it becomes necessary to repeat the procedure using the PD-2 1 or 2 more times. The girth of a finger at the PIPJ is normally the largest for the length

of the finger. Once the ring passes this portion of the finger, it can usually be freely dislodged from the finger (Fig. 2).

The nondestructive techniques reviewed in the literature appear to depend on compression of the finger’s tissue to reduce the edema distal to the impacted ring. Therefore, the effective exsanguination of the finger is the key point for ring removal from an extremely swollen finger. In reality, attempting to eliminate a large proportion of such swelling from the tip of the finger to the distal rim of the impacted ring by 1 compression may be a rather unreasonable expectation [3]. Once the exsanguinated excessive tissue fluid reaches the constricted ring, it forms a bulging soft mass that may actually exacerbate the difficulties of ring removal. Furthermore, attempting to exsanguinate the swollen finger from a proximal to a distal location for the finger is not going to eliminate the edematous tissue because there is no available space in the already swollen finger tip to receive any additional displaced tissue fluid [8,9].

Although application of a blood pressure cuff to the forearm may help to reduce swelling in a swollen finger, we believe that refilling of the proximal part of the finger has already been blocked by the impeding ring. Thus, blocking the volumetric refilling of the tissue proximal to the ring is less effective compared to distal blocking.

Fig. 1 One piece of Penrose drain (PD-1) is applied to the finger just slightly distal to the PIPJ. A mosquito clamp grasps both ends of this Penrose drain firmly. Another Penrose drain (PD-2) is wound around the finger from PD-1 toward the incarcerated ring.

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Correspondence 723

Fig. 2 The ring is dislodged in an undamaged state.

Penrose drain not only provides a relatively wide surface so as to avoid the risk of tissue laceration, but it also features a constant and reliable compression tension despite the possible girth variation of a finger. It is ideal for the reduction of a swollen finger.

Our recommended ring removal method may be used in the presence of an open wound, exclusive of unstable fracture or Joint dislocation to the finger. It provides the dual advantage of assisting with ring removal as well as controlling any bleeding from the finger.

From April 2003 to July 2006, 12 patients were treated with this method at our institution. Trauma was the major causes. Entrapped rings were removed for all patients. One minor complication of superficial abrasion of skin during ring removal was caused by the rather sharp edge of the ring in 1 patient.

We believe that this method features certain distinct advantages not the least of which is that its application results in less trauma to the involved finger and that it avoids damaging a possibly valuable ring.

Tai-Feng Chiu MD Shi-Jye Chu MD

Department of Emergency Medicine Tri-Service General Hospital National Defense Medical Center

Taipei, Taiwan E-mail address: [email protected]

Shyi-Gen Chen MD Shao-Liang Chen MD Tim-Mo Chen MD

Division of Plastic Surgery Department of Surgery

Tri-Service General Hospital National Defense Medical Center

Taipei, Taiwan

doi:10.1016/j.ajem.2006.11.032

References

1. Comtet JJ, Nillems P, Mouret P. Ring injury with bilateral rupture of digital arteries without skin damage. J Hand Surg 1979;4:415 - 6.
2. Mizrahi S, Lunski I. A simplified method for ring removal from an edematous finger. Am J Surg 1986;151:412 - 3.
3. Mullett ST. Ring removal from the oedematous finger. An alternative method. J Hand Surg [Br] 1995;20(4):496.
4. Inoue S, Akazaw S, Fukuda H, et al. Another simple method for ring removal. Anesthesiology 1995;83(5):1133 - 4.
5. McElfresh EC, Peterson-Elijah RC. Removal of a tight ring by the rubber band technique. J Hand Surg [Br] 1991;16B:225 - 6.
6. Hiew LY, Juma A. A Novel method of ring removal from a swollen finger. Br J Plast Surg 2000;53(2):173 - 4.
7. Thilagaragah M. An improved method of ring removal. J Hand Surg [Br] 1999;24B:118 - 9.
8. Frary T. A few brief tips: ring removal. J Am Acad Physician Assist 1990;3:156.
9. Young JR. Unring a finger. Emerg Med 1982;107 - 8.

Acute right ventricular dysfunction after cardioversion or hyperthyroid cardiomyopathy in an unrecognized thyrotoxicosis patient?

To the Editor,

We have read, with great interest, the recently published article by Tsai et al [1] entitled bAcute right ventricular dysfunction after cardioversion in an unrecognized thyro- toxicosis patient,Q and we would like to make some comments about the same.

We agree with Tsai et al [1] that cardiovascular clinical manifestations of hyperthyroidism are frequent and varied, especially Atrial arrhythmias, but heart failure appears only in 6% of these patients [2] and is characterized by myocardial contractility increase, high cardiac output (CO), and low vascular systemic resistances. However, it has been described in uncontrolled hyperthyroidism that HF can deal, infrequently but not exceptionally, with left ventricular contractility depression and low CO, in a kind of so-called hyperthyroid myocardiopathy [3]. This condition may be reversible at long term after treatment [4]. Boccalandro et al

[5] describe the case of a 46-year-old African-American woman with Graves-Basedow’s disease, which presented HF with low CO, left ventricular enlargement, and Severe systolic dysfunction controlled with furosemide, captopril, and digoxin in addition to lugol and metimazole treatment. They documented functional improvement at 5 months and not complete systolic dysfunction recovery at 19 months after having controlled hyperthyroidism. These authors likewise analyzed a series of 23 cases described in the literature, with similar clinical characteristics, composed by 11 men and 12 women. In 19 of them (83%), Graves-Basedow’s disease was the underlined thyroid disease. All of them had left ventricular systolic dysfunction that recovered some weeks or months after having controlled hyperthyroidism. In only

3 cases (13%), left ventricular ejection fraction did not improve over 40%. However, other authors describe 9 cases