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Case Report
A Case of an Elderly Patient With Rubber Band Syndrome
Erica Amemiya, MD,
*
Kazuhiro Maeda, MD, PhD,
*
,
y
Takayuki Nemoto, MD,
z
Iris Wiederkehr, MD,
x
Takeshi Miyawaki, MD, PhD,
x
Mitsuru Saito, MD, PhD
*
*
Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
y
Hand Surgery Center, The Jikei University School of Medicine, Tokyo, Japan
z
Department of Orthopaedic Surgery, Ota General Hospital, Kawasaki-shi, Japan
x
Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
article info
Article history:
Received for publication March 25, 2021
Accepted in revised form July 6, 2021
Available online 11 August 2021
Key words:
Carpal tunnel syndrome
Circumferential scar
Cognitive impairment
Rubber band
Rubber band syndrome is a relatively rare disease in which a rubber band around a limb becomes
embedded under the skin, resulting in tissue damage. Most reported cases are in children, and its
occurrence in adults is considered extremely rare.We present a case of a 71-year-old patient with
cognitive impairment, in whom a rubber band around the wrist became embedded under the skin. The
examination of the distinctive circumferential scar, ultrasonography, x-ray, and magnetic resonance
imaging led to the diagnosis of rubber band syndrome. To avoid further damage to the tissue, surgical
removal of the band was conducted. When elderly patients with cognitive impairment present with chief
complaints of swelling and contracture in the limbs due to an unknown cause, accompanied by a
circumferential scar on the affected limb, rubber band syndrome should be considered. Due to risk of
deep tissue necrosis, prompt band removal is necessary.
Copyright ©2021, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Rubber band syndrome (RBS) is a relatively rare condition in
which a rubber band around a limb becomes embedded under the
skin, causing tissue damage. Most reported cases are in children,
and its occurrence in adults is considered extremely rare. In this
report, we present the case of a patient with RBS in whom a rubber
band around the wrist became embedded under the skin.
Case Report
The patient was a 71-year-old man, who experienced swelling,
tingling, numbness, and difficulty performing finger movements
using his left hand. Two weeks after the onset of symptoms, the
patient visited a local hospital, where he was diagnosed with
cellulitis and received antimicrobial therapy. However, there was
no improvement in his symptoms, and he was referred to our
hospital 1 month after initial onset of symptoms.
The initial examination showed swelling, induration, and
hypesthesia of the whole left hand. The range of motion for the
affected wrist was flexion of 0
(compared with healthy wrist
flexion of 65
)anddorsalflexion of 60
(compared with healthy
wrist dorsal flexion of 80
), indicating notable restriction in
flexion. The hand was contracted in an intrinsic minus position.
There was no redness or warmth. There was a circumferential
scar on the proximal wrist crease and a skin ulcer on the side of
the palmar joint (Fig. 1). Blood tests indicated a white blood cell
count of 8,290/
m
L with 69% neutrophils, C-reactive protein
level of 0.05 mg/dL, and blood glucose level of 102 mg/dL. There
were no findings indicative of infection or diabetes. Plain radi-
ography confirmed a slight indentation on the radial bone
(Fig. 2). Magnetic resonance imaging (MRI) confirmed edema-
tous changes in the whole hand, entrapment of the median
nerve in the wrist joint, and a cord-like object compressing the
wrist (Fig. 3). This led to the suspicion of constriction of the
wrist joint by a cord-like object; therefore, an emergency sur-
gery was performed.
A zigzag incision was made on the palmar joint side, and 2
rubber bands were found embedded circumferentially under the
skin, matching the scar on the proximal wrist crease. After the
rubber bands were removed and the transverse carpal ligament
was separated, a widespread adhesion of the flexor tendons in the
Declaration of interests: No benefits in any form have been received or will be
received by the authors related directly or indirectly to the subject of this article.
Written informed consent: Written informed consent was obtained from the
patient for publication of this case report and accompanying images.
Corresponding author: Kazuhiro Maeda, MD, PhD, Department of Orthopaedic
Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-
ku, Tokyo 105-8461, Japan.
E-mail address: maeda@jikei.ac.jp (K. Maeda).
Contents lists available at ScienceDirect
Journal of Hand Surgery Global Online
journal homepage: www.JHSGO.org
https://doi.org/10.1016/j.jhsg.2021.07.005
2589-5141/Copyright ©2021, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the
CC BY license (http://creativecommons.org/licenses/by/4.0/).
Journal of Hand Surgery Global Online 3 (2021) 368e372
carpal tunnel was discovered. The median nerve had been
considerably constricted by the rubber bands (Fig. 4), and flexor
tendolysis and median nerve neurolysis were performed. The pa-
tient started rehabilitation with range of motion exercises for the
fingers from the first postoperative day, followed by exercises for
the wrist from the second postoperative week onward. The skin
ulcer epithelialized 3 weeks after surgery. Extensor tendolysis was
scheduled for the third week after surgery; however, the patient
expressed a strong preference for conservative therapy. Therefore,
hand therapy was conducted, and to resolve the remaining intrinsic
minus position of the hand, knuckle bender orthosis was applied,
with which an intrinsic plus position was secured. At 1 year after
surgery, the pain and swelling had subsided completely; however, a
slight numbness remained in the pulp of the thumb and the index,
middle, and ring fingers. The range of motion for the affected/
healthy wrist was as follows: flexion of 47
/65
, dorsal flexion of
66
/80
, pronation of 80
/80
, and supination of 90
/90
. Although
the patient still exhibited some movement restriction on the
affected side compared with the healthy side, his condition had
improved (Fig. 5). Grip strength and pinch strength improved to 9.8
kg and 3.4 kg, respectively, at 1 year after surgery compared with
4.9 kg and 2 kg immediately after surgery. In comparison, the grip
strength of the healthy side was 20.7 kg and the pinch strength was
3.5 kg. Because of the emergency of the situation, no nerve con-
duction studies were performed before surgery. When examined 3
weeks after surgery no nerve conduction was detectable; however,
7 months after surgery nerve conduction velocity became detect-
able and showed a tendency to recover.
Discussion
To date, only few studies have reported on constriction marks
ontheskincausedbyrubberbands.Commonsitesforsuchoc-
currences are the neck, limbs, and the penis. There are several
reported cases of infants and toddlers who accidentally wrapped
a band around their neck.
1
Casesconcerningthelimbsincluded
the use of rubber bands to hold sleeves and socks in place.
2
There
are also a few case reports of rubber bands wrapped around the
penis to prevent incontinence. Hogeboom and Stephens
3
were
the first to report on RBS in 1965; since then, to our knowledge,
there have been 5 reported cases of adults with RBS of the upper
extremity (Tab le 1 ).
1,2,4e6
The affected sites were fingers in 4
cases and the upper arm in 1 case. Since most reported cases are
in children, RBS in adults is considered to be extremely rare.
7
Following the publication of several adult cases in the United
Kingdom in the 1960s, most reports of RBS have been in children
in India.
1,2,4
In India, there is a tradition of tying a rubber band or
a string around the wrist of young children for religious cere-
monies and decorative purposes, which could be a causal factor.
7
The high prevalence of RBS in children, older individuals, and
people with cognitive disability could be because they do not
understand the risk of having a rubber band in place, they have
Figure 1. Preoperative photographs. APalmar view showing a circumferential scar on the proximal wrist crease and a skin ulcer on the side of the palmar joint. BLateral view
showing hand contraction in an intrinsic minus position.
E. Amemiya et al. / Journal of Hand Surgery Global Online 3 (2021) 368e372 369
difficulty communicating, or they are unclear on the process of
injury that could occur because of problems with memory. Since
the patient in the present case underwent emergency surgical
intervention, the patient’s cognitive impairment had not been
assessed before surgery. After surgery, the patient appeared to
have no recollection of wearing a rubber band around his wrist,
Figure 2. Preoperative plain radiographs confirming slight indentation on the radial bone (arrows). AAnteroposterior view. BLateral view.
Figure 3. Preoperative MRI. ASagittal T2-weighted imaging showing edematous changes in the whole hand and a cord-like object (arrowhead) compressing the median nerve
(arrow). BAxial T1-weighted imaging at the level of nerve entrapment showing a cord-like object on the volar side (arrowheads); the median nerve is not visible dueto entrapment.
CAxial T1-weighted imaging at 1 slice distal from image B, showing a cord-like object on the dorsal side (arrowheads), with the median nerve visible on the volar side (arrow).
E. Amemiya et al. / Journal of Hand Surgery Global Online 3 (2021) 368e372370
which suggested a certain degree of cognitive impairment. The
patient’s cognitive status was assessed using the Revised Hase-
gawa Dementia Scale, and he was diagnosed with mild dementia
(19 points on the Revised Hasegawa Dementia Scale). Further-
more, as the patient was not able to reproduce the instructions
given during hand therapy, his performance was evaluated as
having “poor understanding.”In cases of severe cognitive
impairment, where a caregiver is present, a rubber band may be
more likely to be noticed than in people with mild cognitive
impairment who are independent in daily life activities but are
not well integrated into a community.
An acute type of RBS can result in compartment syndrome, and
in some cases, fasciotomy and carpal tunnel release has been per-
formed subsequently.
8
Other reports are all of the chronic type. In
chronic RBS, the rubber bands cut into the soft tissue and the
condition progresses gradually and is mostly painless.
7
Rubber
bands become embedded deeply under the skin through sustained
tensile force, and long-term irritation leads to the development of a
Figure 4. Intraoperative photographs. AThe rubber band constricting the median nerve before removal. BThe actual size of the rubber band after removal.
Figure 5. Postoperative photographs showing range of motion of the wrists at 1 year after surgery. ADorsal flexion of 47/65(affected/healthy wrist) and Bflexion of 66/80.
Table
Five Reported Cases of Adults With RBS of the Upper Extremity
Author Age Sex Location Duration Country
Thurston
1
Unknown (adult) Unknown Finger Unknown United Kingdom
Turney
2
Unknown (adult) Unknown Upper arm Unknown United Kingdom
Dawson-Butterworth et al
4
42 years Male Finger 3 days United Kingdom
Whitaker et al
5
68 years Female Finger Unknown United Kingdom
Maharjan et al
6
Unknown (adult) Unknown Finger Unknown Nepal
E. Amemiya et al. / Journal of Hand Surgery Global Online 3 (2021) 368e372 371
linear circumferential scar along the foreign object. It continues to
penetrate the fascia, tendons, neurovascular structure, and osseous
tissue, leading to distal edema, loss of function, infections, and
neurovascular injuries.
7
The depth of impact by rubber bands is
affected by various factors such as the size of the affected site, size
and strength of the rubber bands, and length of the time period
between symptom onset and band removal. The longer the time
period, the deeper the rubber band can reach. A circumferential
scar accompanied by a fistula or ulcer is characteristic of RBS and
has been mentioned in almost all reports. Imaging diagnosis usu-
ally consists of plain radiography, ultrasonography, and MRI.
Because x-ray absorption by the rubber and soft tissue is similar, a
definitive diagnosis is difficult on the basis of radiography imaging
alone. However, in cases where osteolytic indentation or osteo-
myelitis is present, radiography can be used to establish the diag-
nosis.
9
Ultrasonography and MRI are useful for diagnosing
contracture of the soft tissue when the rubber band has penetrated
the tendons and neurovascular structures.
9,10
In all reported cases, the treatment was surgery. During inci-
sion, there is a risk of severing the rubber band; therefore, an S-
shaped or a zig-zag incision is recommended instead of a vertical
incision.
9
The need for amputation of a necrotic finger has been
reported previously; nevertheless, most other cases had a
favorable postoperative course, and a large-scale reconstruction
of tendons, nerves, and bones was not necessary.
6
In the present
case, extensor tendolysis was scheduled at 3 weeks after surgery,
but the patient expressed a strong preference for conservative
therapy, and the operation was not performed. Nevertheless, a
good range of motion was obtained through orthosis fabrication
and rehabilitation.
When elderly patients with cognitive impairment present with
chief complaints of swelling and contracture in the limbs due to an
unknown cause, accompanied by a circumferential scar on the
affected limb, RBS should be considered. In order to establish a
diagnosis, the characteristic circumferential scar, ultrasonography,
and MRI are useful. This syndrome involves the risk of deep tissue
necrosis; thus, an early extraction is necessary.
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