The Journal of Emergency Medicine, Vol. 43, No. 1, pp.

9396, 2012
Copyright 2012 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.07.032

Techniques
and Procedures
A METHOD FOR THE REMOVAL OF TUNGSTEN CARBIDE RINGS
Keith A. Allen, MD,* Marco Rizzo, MD, and Annie T. Sadosty, MD
*Department of Emergency Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, Department of Orthopedics, and
Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
Reprint Address: Annie T. Sadosty, MD, Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905

, AbstractBackground: The removal of metal rings

from fingers is a well-described process that often employs
a toothed cutting wheel or bolt cutters to sever the ring
and allow it to be pried open. However, tungsten carbide
(TC) rings are impervious to these traditional ring-cutting
devices. Study Objectives: We sought to describe a method
for removal of TC rings from cadaveric fingers and characterize potential complications of the technique. Methods: On
cadaveric fingers, we placed TC rings and created a snug fit
by injecting a fluorescein and saline solution. The rings were
removed by a controlled crushing technique using a pair of
locking pliers. Fingers were inspected under magnification
and using an LED (light-emitting diode) black light, and
X-ray studies of each finger were obtained. Injuries were
characterized. Results: Six rings were applied and successfully removed from six cadaveric fingers through controlled
ring shatter. After ring removal, two fingers demonstrated
superficial (<1 mm deep) lacerations, one of which had residual debris within the wound. No phalangeal fractures were
identified. Conclusion: Removal of a TC ring can be performed through controlled crushing using locking pliers.
Superficial lacerations and retained debris are potential
complications. 2012 Elsevier Inc.

Nearly as hard as diamonds, TC is widely used in

industry, from cutting tools to machine metals: it is
the metal of which many of the knives that carve metal
are made (1).
The incredible hardness of TC poses a potential problem for people wearing TC rings who require emergent
ring removal, because many of the cutting tools available
in Emergency Departments (EDs) cannot safely and
quickly remove these rings (1). Failure to recognize these
properties may result in unnecessary delays and could
jeopardize digit viability.
Anecdotal and case reports have emerged of lay people and physicians alike using the brittle vulnerabilities
of TC to their advantage by stressing the rings across their
diameters, although no formal shattering method has
been studied (2,3). The purpose of this study was to
evaluate, in a cadaver model, a controlled-shatter technique of TC ring removal and to characterize potential
complications of the technique.

, Keywordstungsten carbide; ring; finger injury; procedure; technique

This is a cadaveric study. As the research does not involve

live human subjects, the Institutional Review Board does
not require protocol review.
Two thawed cadaveric hands of different size were selected. Authors represented the three physician participants.
Six TC rings of different sizes were obtained from an
online vendor. Each of the rings was placed on an appropriately sized cadaveric finger. No cadaveric finger was

MATERIALS AND METHODS

INTRODUCTION
Historically, jewelry has been constructed of soft,
precious metals like gold and silver, or amalgams therefrom. Recently, tungsten carbide (TC) has been used to
fabricate durable and essentially scratch-proof rings.

RECEIVED: 17 March 2011; FINAL SUBMISSION RECEIVED: 21 June 2011;

ACCEPTED: 31 July 2011
93

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Figure 1. Placement of the locking pliers on the ring.

used more than once. Only the ring being tested at the
time was kept on the hand.
To simulate the edema that often precipitates the need
for destructive ring removal, a dilute solution of normal
saline and fluorescein dye was injected into the subcutaneous tissue surrounding the ring. The solution was
prepared by taking two ophthalmic fluorescein strips
(Fluorets, 1 mg fluorescein sodium ophthalmic strips;
Bausch & Lomb, Rochester, NY) and placing them in
10 mL of normal saline. Using a syringe and needle,
the solution was injected until there was enough simulated edema that the ring was no longer removable
through vigorous longitudinal traction. The amount of
solution injected varied between 5.5 and 20 mL.
Once the ring was situated on the finger and the saline
injected, 9-inch locking pliers (Vise-Grip, Irwin Tools,
Wilmington, OH) were closed onto the volar and dorsal
sides of the ring (Figure 1) and adjusted to a snug fit using
the adjustment screw. This type of pliers has the unique
property of gripping to an adjustable amount such that,
once adjusted, no amount of squeezing will further close

K. A. Allen et al.

the bite of the teeth, thereby preventing over-compression

of the structures in between. The pliers were then opened,
removed, and the adjustment screw tightened by one-half
turn. The pliers were then opened, again placed on the
volar and dorsal aspects of the ring and squeezed until
they locked. This process was repeated until the ring
shattered. In the last two trials, we used a quarter turn
beyond two half turns to fine-tune the number of turns
needed to shatter the ring, given that the first four rings
shattered in two to three half-turns. The technique was
performed twice by each of the three physicians.
Once the ring was successfully broken, the resulting
fragments were collected, quantified, and recorded. The
area of skin underlying the ring was closely inspected
under magnification. An LED (light-emitting diode)
black light was used to illuminate the skin to identify
any glowing lacerations highlighted by the fluorescein
dye. Lacerations were characterized and recorded. Photographs were taken of representative fragments and of any
lacerations (Figure 2). Using a C-arm, orthogonal-view
X-ray studies of each finger were also obtained to identify
retained foreign bodies and underlying phalangeal fractures. The collected fragments were counted and roughly
grouped into three categories: large pieces (defined as
representing a major portion of the ring), small pieces
(generally anything larger than 2 mm in their smallest
dimension), and fine particles (anything smaller than
2 mm). The presence or absence of phalangeal fracture
was recorded. The distance that fragments were propelled
during shatter was also informally noted.
RESULTS
Table 1 summarizes the data collected from each ring and
cadaveric finger. All of the rings shattered within three
half-turns of the adjustment screw. Each physician
successfully shattered the rings to which they were
assigned. During shatter, two of the rings propelled large
fragments two meters or more.
Two of the six cadaveric fingers incurred lacerations.
All lacerations were superficial (<1 mm deep). One finger, the first, incurred two superficial lacerations measuring 5 and 1 mm in length. The fourth finger also incurred
a superficial laceration measuring 3.5 mm in length.
Fine metallic particles were seen superficially on the
wounds of the first finger, but no incisive fragments
were identified either visually or on X-ray study. No
phalangeal fractures were identified.
DISCUSSION

Figure 2. Typical fragments produced during shattering.

Both destructive and non-destructive ring removal

techniques abound. The non-destructive techniques
include: lubricated pull, suture reign longitudinal traction,

Tungsten Carbide Ring Removal

95

Table 1. Tungsten Ring Removal Summary Data

Injuries

Fragments

shattering, we recommend that patients and providers

wear eye and face protection and that a drape be placed
to avoid unintended secondary injuries.

Cuts
Ring #

# Turns

Fxs

RFB

Lg

Sm

Fine

1
2
3
4
5
6

3
2
2
2
2.5
2.5

2
0
0
1
0
0

0
0
0
0
0
0

0
0
0
0
0
0

Yes
No
No
No
No
No

4
5
4
4
5
4

13
20
9
4
23
5

Many
Many
Many
Many
Many
Many

Cuts: S = superficial (<1 mm); D = deep (>1 mm); Fxs = phalangeal fractures; RFB = residual foreign body; Lg = large;
Sm = small.

icing, compression, exsanguination, rubber bands, string

technique, and combinations of the above, among others
(49). The previously described destructive techniques
(motorized and manual toothed cutting wheels,
motorized abrasive discs, bolt cutters) will not work on
TC rings (1,4). Although diamond-abrasive discs,
diamond-tipped dental drills, and diamond bur (as seen
in high-speed air turbine hand pieces) can cut TC, they
are not readily available in many EDs (1,10). Although
any of the non-destructive techniques apply to TC ring
removal, when non-destructive approaches fail and
diamond-based cutting devices are unavailable, the
controlled shatter approach is an effective method for
TC ring removal. In our experiment, six rings were
successfully removed from the cadaveric fingers. Preliminarily, the controlled crushing technique seems to be safe,
especially when weighed against the alternative of finger
ischemia.
Although the fragments produced are exceedingly
sharp, the lacerations that occurred in the cadaveric digits
were both minor and superficial. Nonetheless, the number
of rings tested was too low to exclude the possibility that
a more significant laceration could occur. Because the
pliers that were used lock to the adjusted bite depth, no
fractures of the underlying bone occurred. Given that
the tissue that surrounds the bone provides a force buffer
between the rigid pliers and the bone, it is highly unlikely
that the small travel that occurs at the teeth of the pliers
during failure of the ring would transmit enough energy
to the bone to break it. Even with the fingers that did
not incur a laceration, innumerable metallic particles
peppered the finger and surrounding tissue. As these
fragments are produced by failure of the metal along
a crystalline fracture plane, they are exceedingly sharp.
We believe that the hand should be rinsed after ring
removal to eliminate these potentially harmful shards.
Moreover, due to the tendency for pieces to travel with

Limitations
Here, authors represented study participants, and the
potential for bias exists. The major limitation of this pilot
study, however, is that ring removal was performed on
cadaveric hands instead of live human hands. We attempted to simulate the edema that occurs in human hands by
injecting saline into the subcutaneous tissue. It is
unproven whether this model successfully mimics live
human tissue. It remains unclear whether larger numbers
would have demonstrated significant injuries.
CONCLUSION
Due to the hardness of TC, emergent TC ring removal
may prove challenging. As an alternative to previously
described destructive ring-removal techniques, we evaluated a controlled ring-crushing technique in cadavers. By
following the procedures outlined above, TC rings may
be effectively removed. Superficial lacerations and
retained debris are potential complications.
AcknowledgmentsThe authors would like to thank Shaun
Heath and Terry Regnier for their assistance with the study,
and Cyndra Franke for her assistance with manuscript
preparation.

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com/watch?v=poM423pewRE. Accessed June 22, 2010.
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rings. Ann Emerg Med 2001;37:736.
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K. A. Allen et al.

ARTICLE SUMMARY
1. Why is this topic important?
Due to their extreme hardness, tungsten carbide (TC)
rings are not amenable to traditional destructive ring removal techniques.
2. What does this study attempt to show?
Removal of a TC ring can be performed through a controlled crushing technique using locking pliers.
3. What are the key findings?
The controlled crushing technique effectively removes
the TC ring through ring shatter. Superficial lacerations
and retained debris are potential complications.
4. How is patient care impacted?
Emergency physicians should consider using locking
pliers to perform a controlled crushing technique when
faced with the need to remove a TC ring or when other destructive ring-removal techniques prove ineffective. Inspect the digit after removal, given the potential for
lacerations and retained debris.