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675
JFPONLINE.COM
|
THE JOURNAL OF FAMILY PRACTICE
PHOTO
PHOTO
ROUNDS
ROUNDS
Crying infant
with painful
toes
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.
●
● WHAT IS YOUR DIAGNOSIS?
●
● HOW WOULD YOU TREAT THIS
PATIENT?
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)
Strout@mmc.org
DEPARTMENT EDITOR
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.
FIGURE 1
Two reddened and swollen
toes
PHOTO COURTESY OF: JOHN R. SAUCIER, MD
Filler for p.675:
Insert Web ad
676 THE JOURNAL OF FAMILY PRACTICE
|
NOVEMBER 2012
|
VOL 61, NO 11
PHOTO ROUNDS
PHOTO ROUNDS
Diagnosis:
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
adolescents.3
❚ 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
view.
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,
NJ).2,10-12
❚ 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.
HAIR TOURNIQUET SYNDROME
677
JFPONLINE.COM VOL 61, NO 11
|
NOVEMBER 2012
|
THE JOURNAL OF FAMILY PRACTICE
References
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
procedure.
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
closure.
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.
JFP
JFP
CORRESPONDENCE
Tania D. Strout, PhD, RN, MS, Director of Research,
Department of Emergency Medicine, Maine Medical Center,
47 Bramhall Street, Portland, ME 04102; Strout@mmc.org
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;
2008:1065-1069.
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.
2002;99:939-941.
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.
2003;24:325-326.
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://
emedicine.medscape.com/article/1348969-overview. 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.
