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Crying infant with painful toes



Our patient's sleepless parents sought care for their infant's mysteriously injured toes.
Crying infant
with painful
Our patient’s sleepless
parents sought care for
their infant’s mysteriously
injured toes.
A well-developed and previously
healthy infant was brought to our emer-
gency department (ED) by her parents, who
said that their child was experiencing sig-
ni cant toe pain. Two reddened, swollen
toes (FIGURE) were immediately identi able
on the left foot.  e patient’s parents denied
any trauma or unusual activity involving
the infant.
Elisabeth P. Moore, MD;
Tania D. Strout, PhD, RN,
MS; John R. Saucier, MD
Department of
Emergency Medicine,
Maine Medical Center,
Portland (Drs. Moore,
Strout, and Saucier);
Tufts University School
of Medicine (Drs. Strout
and Saucier)
Richard P. Usatine, MD
University of Texas
Health Science Center
at San Antonio
The authors reported no
potential con ict of interest
relevant to this article.
Two reddened and swollen
Filler for p.675:
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VOL 61, NO 11
Hair tourniquet
Upon close inspection, we discovered hair
thread tourniquets constricting the fourth
and  fth toes on the baby’s left foot.
Hair tourniquet syndrome primarily af-
fects infants in the  rst few months of life.
e average age of occurrence is 4 months,
a time when maternal postpartum hair loss
(telogen e uvium) is at its maximum.1,2 It is
worth noting, however, that this syndrome
has also been observed in toddlers and
Toes are most frequently involved, al-
though cases of hair tourniquets a ecting the
ngers, penis, labia, clitoris and uvula have
been reported.2-7 Infants may be brought to
the o ce or ED with irritability or crying, or
with an erythematous extremity.
Why tourniquets are overlooked
Infantile tourniquets may be overlooked be-
cause of the  ne nature of human hair, the
swelling of the involved appendage (which
can hide the tourniquet itself), and the pres-
ence of baby booties, footed pajamas, and
mittens that may obscure injured digits from
ese tourniquets can cause signi cant
morbidity if they are not quickly identi ed
and removed.  e tensile strength of hu-
man hair is quite strong, potentially leading
to strangulation and even amputation of ap-
pendages.  e repetitive motion of hands
and feet inside boot ies or mittens allows con-
striction to increase.
As this tightening occurs, the tourniquet
may cause constrictive lymphatic obstruc-
tion, edema of the involved soft tissues, and
secondary vascular obstruction of venous
out ow and arterial perfusion.5,8,9 Tourni-
quets can also cut through skin, injuring
deeper tissues.
In most instances, the damaged tissue
will rapidly reperfuse once the o ending
tourniquet is unraveled or removed. How-
ever, some cases may result in epithelializa-
tion over the tourniquet, ischemia, necrosis,
and gangrene leading to amputation. Quick
recognition of the condition and immediate
removal of the constricting tourniquet are key
to saving the injured appendage.
How best to remove
the tourniquet
Methods of tourniquet removal include un-
wrapping, cutting, or dissolving the hair with
commercial hair removal agents such as
Nair (Church & Dwight Co, Inc, Princeton,
Unwrapping. In cases where the tour-
niquet is easily visualized and minimal
edema is present, simply unwrapping the
constricting hair may be successful.  is can
be accomplished by identifying a loose end of
the hair, grasping the free end with a pinch-
ing instrument such as a hemostat or forceps,
and carefully unwrapping the hair from the
appendage1,11 (strength of recommendation
[SOR]: B).
Cutting. If cutting the hair is necessary
due to the presence of mild to moderate ede-
ma or failure of the unwrapping technique,
a blunt probe may be inserted between the
hair and the appendage to protect soft tissues
from the cutting implement. Once the probe
has been inserted, the tourniquet may be
cut using scissors or a #11 scalpel blade ap-
plied to the surface of the blunt instrument1,11
(SOR: C). Alternative instrumentation, in-
cluding a #12 Bard Parker curved scalpel
blade and a Littauer suture-removal scissor,
may be useful when the tourniquet is too
tightly wound to allow for insertion of a blunt
probe instrument (SOR: C).
Dissolving. A commercially available
depilatory agent, such as Nair, may be useful
for mild cases, but would not be appropriate
when a tourniquet has cut into the skin. Cal-
cium thioglycolate, a common depilatory ac-
tive ingredient, breaks down disul de bonds
in keratin, thereby weakening hair strands.
Chemical agents containing calcium thiogly-
colate should be used with caution, as kera-
tin is also present in the epidermis and use of
these agents may cause irritation to the skin.
When an incisional approach
is needed
At times, epithelialization over the tourni-
quet or severe swelling of a digit may neces-
sitate an incisional approach. If there is any
doubt about whether you can completely
remove all of the strands of the tourniquet,
an incision into the digit itself must be made
Infantile hair
tourniquets may
be overlooked
because of the
ne nature of
human hair and
the swelling that
may hide the
tourniquet itself.
to disrupt constriction. Historically, a digital
nerve block has been the preferred mode of
analgesia; however, recent evidence suggests
that less invasive pain management strate-
gies, such as a sucrose paci er, EMLA cream,
or ZAP topical analgesia gel may be e ective13
(SOR: A).
If you must use this approach, you’ll
need to consider the placement of the digi-
tal neurovascular bundles of the  ngers and
toes, located at approximately the 2, 4, 8, and
10 o’clock positions. Following sterile prepa-
ration and draping, a longitudinal incision
should be made at either the 3 or 9 o’clock po-
sition, thus locating it between neurovascular
bundles1,11 (SOR: B).
Alternatively, a longitudinal incision can
be made directly over the extensor tendon,
located dorsally at 12 o’clock. Any resulting
tendon laceration would be parallel to the
tendon  bers, and could be expected to heal
with splinting and wound care1,11,14 (SOR: B).
Prior to initiating treatment, parents
or caregivers should be warned about the
potential for bleeding and pain during the
Extreme cases may require surgery
Surgical consultation may be required in ex-
treme cases of edema, neurovascular com-
promise, necrosis, amputation, or failure to
completely remove the tourniquet.2
Other factors to keep in mind. While
classically described as consisting of a single
hair, tourniquets may be comprised of multi-
ple hairs.  at’s why it’s important to careful-
ly inspect the area to be sure that all strands
have been removed.  orough treatment
should include consideration of child abuse,
tetanus immunization, and the need for
antibiotics1,2,11 (SOR: B).
Relief for our young patient
To remove our patient’s hair tourniquets, we
carefully cut the  bers with hooked Littauer
suture-removal scissors and unwrapped
the hair. Damage to the plantar aspect of
both toes was signi cant enough that we
had to cut through the soft tissue and into
the  exor tendon to completely remove the
hair. No sutures were required as the wound
edges were well approximated without
We cleaned and dressed the injured toes
and arranged for close follow-up.  e pa-
tient’s recovery was uneventful.
To avoid hair tourniquet syndrome,
counsel parents to turn mittens and boo-
ties inside out to check for loose hairs. Also,
advise parents to make sure there aren’t any
hairs wrapped around their baby’s  ngers or
toes. Vigilance on the part of health care pro-
viders can provide quick recognition and ap-
propriate treatment of this condition.
Tania D. Strout, PhD, RN, MS, Director of Research,
Department of Emergency Medicine, Maine Medical Center,
47 Bramhall Street, Portland, ME 04102;
Tell parents to
turn mittens and
booties inside
out to check for
loose hairs and
to make sure
there aren’t any
hairs wrapped
around the
baby’s  ngers
or toes.
1. Loiselle JM, Cronan KM. Hair tourniquet removal. In: King
C, Henretig FM, eds. Textbook of Pediatric Emergency Proce-
dures. 2nd ed. Philadelphia,Pa: Lippincott Williams & Wilkins;
2. Strahlman RS. Toe tourniquet syndrome in association with
maternal hair loss. Pediatrics. 2003;111:685-687.
3. Bacon JL, Burgis JT. Hair thread tourniquet syndrome in ado-
lescents: a presentation and review of the literature. J Pediatr
Adolesc Gynecol. 2005;18:155-156.
4. Badawy H, Soliman A, Ouf A, et al. Progressive hair coil penile
tourniquet syndrome: multicenter experience with 25 cases.
J Pediatr Surg. 2010;45:1514-1518.
5. Kuo JH, Smith LM, Berkowitz CD. A hair tourniquet resulting
in strangulation and amputation of the clitoris. Obstet Gynecol.
6. McNeal RM, Cruickshank JC. Strangulation of the uvula by
hair wrapping. Clin Pediatr (Phila). 1987;26:599-600.
7. Krishna S, Paul RI. Hair tourniquet of the uvula. J Emerg Med.
8. Rich MA, Keating MA. Hair tourniquet syndrome of the clito-
ris. J Urol. 1999;162:190-191.
9. Sylwestrzak MS, Fischer BF, Fischer H. Recurrent clitoral tour-
niquet syndrome. Pediatrics. 2000;105:866-867.
10. Douglass DD. Dissolving hair wrapped around an infant’s
digit. J Pediatr. 1977;91:162.
11. Cardriche D. Hair tourniquet removal. Available at: http:// Updat-
ed January 30, 2012. Accessed October 3, 2012.
12. Peckler B, Hsu CK. Tourniquet syndrome: a review of con-
stricting band removal. J Emerg Med. 2001;20:253-262.
13. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in new-
born infants undergoing painful procedures. Cochrane Data-
base Syst Rev. 2010;(1):CD001069.
14. Barton DJ, Sloan GM, Nichter LS, et al. Hair-thread tourniquet
syndrome. Pediatrics. 1988;82:925-928.
... The infant is often presented for evaluation with a complaint of unexplained fussiness and inconsolable crying. Swelling, erythema, tenderness to the touch, and annular constrictions on the affected body part are the hallmark signs of this Box 1. 3. To evaluate for swelling or erythema, caregivers should remove an infant's socks and mittens every 2 to 4 hours while the infant is awake or with diaper changes (Moore, Strout, & Saucier, 2012;Strahlman, 2003). ...
... 4. Caregivers should inspect the infant's fingers and toes at bath time to ensure that no encircling strands are present (Moore, Strout, & Saucier, 2012;Shankar et al., 2012). ...
... In cases of extensive tissue damage, ulceration, tissue infection, or osteomyelitis, necrosis or amputation may result. With early recognition and rapid and effective treatment, pain should be remedied with little to no resulting sequelae (Moore, Strout, & Saucier, 2012;Shankar et al., 2012). Parental reassurance regarding outcomes and education to prevent further incidence is an important discussion in the acute setting and during follow-up. ...
Hair-thread tourniquets are a rare occurrence but result in significant injury as a hair or thread wraps around a digit, resulting in tissue swelling, pain, or possible tissue ischemia. This condition is often overlooked in the differential diagnosis for a fussy infant. Awareness of this condition will help nurses and other clinicians identify and treat the condition. Some simple prevention strategies can help parents and other caregivers mitigate risk.
Penile hair tourniquet syndrome is an uncommon syndrome characterized by progressive penile strangulation by a hair tie. Complications reported include urethrocutaneous fistula, complete urethral transection, penile gangrene, and penile amputation. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion for early diagnosis. Twenty-five children presenting with different degrees of hair coil penile strangulation syndrome have been operated on in the period from 2000 to 2007 in 2 tertiary care centers in the city of Alexandria. Eighteen boys had complete transection of the urethra at the coronal sulcus. Seven boys had partial transection of the ventral wall of the urethra at the coronal sulcus. Repair of the penis was done in all children in a single stage. The mean age of boys is 3 years and 9 months (2-5 years). The mean follow-up is 20.7 (6-48) months. Urethral catheter was left for a mean of 5.5 (4-7) days. In the mean follow-up period, we had 4 complications in the form of 2 tiny urethrocutaneous fistulas and 2 anastomotic urethral strictures. The fistulae were closed surgically after the primary surgery by 1 year in the 2 cases, with no recurrence. Urethral strictures were managed by endoscopic visual urethrotomy, with no recurrence. Penile tourniquet syndrome can cause serious penile complications. Awareness of this rare syndrome can help in preventing such complications. Being familiar with the surgical reconstruction guarantees high success rate.
We have witnessed six cases of the hair-thread tourniquet syndrome, an entity characterized by strangulation of an appendage (toes, fingers, or external genitalia) by hair or hair-like fibers in the pediatric population. All six of our cases were in infants, 12 days to 5 months of age. The offending fibers were hair in three of the four patients with toe injuries and synthetic fibers from mittens in the finger cases. All six patients were treated by immediate removal of the constricting fibers, and, in spite of the worrisome appearance of the tissue distal to the constriction, all six eventually healed without significant tissue loss. A review of the literature indicated 60 similar cases of this type reported, 24 involving toes, 14 involving fingers, and 22 involving genitals. The majority of the toe and external genitalia cases were caused by hair, whereas the majority of finger strangulations were caused by thread from mittens. At greatest risk for strangulation are the middle finger and third toe, followed by the index finger and second toe. Patients with finger or penile involvement were more likely to suffer significant complications from the injuries than those patients with toe involvement. Based on our own experience and that described in the literature, we recommend prompt removal of the offending fiber, followed by prolonged conservative management of the damaged distal tissue, in the hope of maximal tissue salvage. Increased physician awareness of this syndrome is mandatory for prevention, diagnosis, and early treatment.
A 13-month-old male presented with a hair wrapped around his uvula. The entwined hair subsequently caused autoamputation of the distal uvula. Although a non-accidental etiology has been suggested for some cases of hair strangulation of appendages, this case indicates accidental strangulation of body parts is possible.
Sporadic reports have appeared in the literature that call attention to the strangulation of appendages by errant strands of human hair. The condition is called the hair tourniquet syndrome and typically involves the digits and genitalia of infants and children.’-6 Constrictive injuries of fingers and toes are more common, although strangulation of the penis and rarely the clitoris has also been reported. We describe a case of a hair tourniquet ensnaring the clitoris. Prompt recognition and early treatment are essential to avoid the potential complications of ischemic necrosis and autoamputation. A 5-year-old girl presented to the emergency department with a chief complaint of vaginal pain. Examination revealed a swollen and tender clitoris. There was no history of trauma, vaginal discharge, allergy, insect bite or urinary tract infection. Diagnosis was nonspecific vaginal inflammation and the child was referred to the primary care physician for additional treatment. However, the genital swelling increased and vaginal bleeding developed during the next 24 hours. Irritative urinary symptoms of progressive frequency, dysuria and incontinence also began. The local physician encountered a tender bleeding clitoris with marked swelling of the labia minora. The patient was referred for pediatric urology consultation. She was examined under anesthesia because of anxiety and severe discomfort while awake. An engorged hemorrhagic clitoris and edema of the labia minora were noted (see figure). A single strand of the patient’s hair was wrapped around the clitoris and embedded in the edematous tissue just beneath the clitoral hood. The hair tourniquet partially amputated the right superficial margin of the clitoral body. The tourniquet was removed with a fine toothed forceps and scissors. Hyperemia of the clitoris developed immediately after its removal. Pain and voiding symptoms improved immediately, and swelling of the labia and clitoris resolved completely during the next 24 to 48 hours. The genitalia had an essentially normal prepubertal appearance on routine examination 1 week later.
A constricting band causing tourniquet syndrome is a common problem that can cause much frustration and pain for both the patient and practitioner. The following review classifies and describes the different aspects of the treatment of this condition. We also describe a policy and procedure for the motorized removal of large bands by using a high revolutions per minute cutting device.
Hair tourniquet syndrome involves fibers of hair or thread wrapped around an appendage producing tissue necrosis. Appendages commonly involved include the toe, finger, and penis. We report a hair tourniquet resulting in amputation of the clitoris. An adolescent presented with a 4-year history of intermittent genital pain that increased in severity over the preceding 5 days. Physical examination revealed a necrotic clitoris surrounded by a black hair. During the examination, the tissue fell off resulting in immediate improvement in the patient's pain. We report a case of a clitoral hair tourniquet syndrome leading to autoamputation of the clitoris. A high index of suspicion for this condition is important because of the potential consequences of delayed treatment.
Increased hair loss a few months after delivering an infant is a common postpartum condition known as telogen effluvium. A much less common condition involving young infants is the hair-thread tourniquet syndrome, or toe tourniquet syndrome, which involves hair or thread becoming so tightly wrapped around an appendage that pain, injury, and sometimes loss of the appendage result. This case report is the first known description of the hair-thread tourniquet syndrome in association with maternal telogen effluvium. A literature review shows that accidental cases involving human hair almost always involve the toes, and usually occur at the age when mothers are experiencing excessive hair loss. This association is significant in that anticipatory guidance of new parents experiencing rapid hair loss may prevent cases of the toe tourniquet syndrome and its associated morbidity.