Kids, certainly, love to get themselves into difficult scenarios. We’ve all seen funny photos of kids’ heads wedged between the spindles of a bannister. Occasionally, kids will present to the ED having placed themselves in unusual and unfortunate predicaments (certainly, the adult counterparts are just as adept at this). The question of “why” crosses your mind, but the answer is never as profound as you had wished for… and more importantly, the question is quickly obscured by the more serious question of “how am I going to fix this situation?”

Recently two separate children presented with large metal machine nuts stuck on their fingers proximal to their PIPs. These machine nuts were threaded on the inside and prevented simply sliding off the nut. Unfortunately, we could not just “unscrew” them either. This had the potential to be a very bad day for everyone involved.

Tourniquet Syndrome Basics:

Strangulation injury of a digit (or penis) due to circumferential compression is not uncommon.
Injuries to fingers that have jewelry can lead to swelling that prevents removal of the jewelry.
Kids, as was already stated, do weird things and may put tight fitting objects on their fingers.

The circumferential compression leads to venous engorgement.
This leads to swelling, which further prevents the removal of the object.
Eventually, there is enough pressure to cause arterial compromise, which is suboptimal.
Naturally, because of this potential complication, the ideal is to remove the constrictive object expediently.

Tourniquet Syndrome with Metal Band – Basic Steps

Don’t waste time!
- Start simple therapies out in triage.
  - Apply Ice and Elevate.
  - Give Analgesics.
  - Topical LMX (or LET if you think there are open wounds) can act as both a lubricant and pain reliever.
- If it is a simple, traditional ring, have someone start using the Ring Cutter (perhaps this kid won’t even need a formal room).
Finger Wrap Technique
- On occasion, your ring cutting devices are not readily available… don’t waste time… start wrapping the distal portion of the digit with thick suture (0-0 Nylon), Umbilical Tape, etc.
- By having the proximal end of the string/tape threaded through the underside of the ring, you can often get the ring off without any cutting.
- Even if not successful, it can start to help manipulate the swelling.
Ring Cutters
- Manual or electric are both effective for most standard rings (obviously, the electric is easier to use).
- There are some metals that won’t be affected by a manual ring cutter.
  - Titanium is tough but can be done.
  - Stainless Steel and Tungsten Carbide cannot be cut with manual ring cutter.

Tourniquet Syndrome with Metal Band – Difficult Cases

Unfortunately, most kids won’t come in with a simple gold wedding band that can be easily removed with a traditional ring cutter. Furthermore, the Finger Wrapping technique, while often taught, can be difficult to do with the digit is significantly swollen already. What to do then, when time is precious? Use MORE POWER! {but carefully}

High Speed Rotary Tools (like the Dremel)
- Can easily cut most metals, even stainless steel.
- They actually do not cut skin when touched gently.
- Do get mighty hot.
- Place a protective guard (plastic or metal) between the constricting object and the digit.
- Take frequent breaks to cool with water or use a continuous water irrigation to prevent thermal injury.
- Give the patient safety glasses (sparks will fly) and wear them yourself as well.
- Cutting at two positions 180 degrees apart will allow easy removal
  - In the two cases shown here, a single cut and some gentle torquing of the nut allowed for removal.

Tungsten Carbide is a special metal!
- It actually cannot be cut by even a high speed rotary tool (aka Dremel).
- Fortunately, it is brittle and can be shattered by striking with a hammer or alternating compression points with vice grips.
- View this video on how to deal with Tungsten rings

Moral of the story – keep your Dremel handy… or at least know how to get one quickly.