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Hair Tourniquet Syndrome: An Unusual Surgical Emergency In Infant

Mohammad Saquib Mallick
Pediatric Surgery Division, Department of Surgery
King Khalid University Hospital, College of Medicine, King Saud University
Riyadh, Saudi Arabia

 

 

Corespondence

 

Dr. Mohammad Saquib Mallick, FRCS - Associate Professor
Consultant Pediatric Surgeon, Division of Pediatric Surgery
Department of Surgery, College of Medicine
King Khalid University Hospital, King Saud University
P.O. Box 7805, Riyadh 11472
Riyadh, Saudi Arabia
Tel: 00966 1 467-1575; Fax: 00966 1 467-9493
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

The hair tourniquet syndrome is a surgical emergency occurring primarily in infants and is characterized by circumferential strangulation of one or more appendages by human hair or fibers. It induces progressive oedema, ischaemia and tissue necrosis and can lead to the auto amputation of digits or other strangulated structures. The prompt diagnosis and treatment of this unusual condition is crucial to prevent damage to or loss of appendage. We report a case of hair tourniquet syndrome affecting second and third right toes of an infant and suggest that awareness of this condition should be increased to prevent its potential complications.

Key words: hair, tourniquet syndrome, infant

 

 

Introduction  

Hair tourniquet syndrome is the term coined to describe the phenomenon caused by a strand of hair tightly wrapped around an appendage. Body parts involved include the finger, toe, penis, clitoris and vulva. It occurs infrequently, and the incidence is not known. The etiology is usually described as accidental [1]. Increased physician awareness of this syndrome is mandatory for recognition and early treatment to prevent tissue damage or auto amputation. We report an unusual case of hair tourniquet syndrome where a hair cheese wired through the skin and soft tissue of second and third toe of an infant. We have also reviewed the published literatures on this infrequent but important pediatric condition.

Case report

A 3-month old baby girl presented to accident and emergency department with swelling and red discoloration of the right second and third toes of unknown hours of duration ( fig. 1,2). Mother had noticed the swelling and redness while removing the sock of right foot. On examination, the infant was febrile and there were no signs of clinical upset. Inspection of toes revealed a circumferential constriction and deep cut at the level of metatarsal joint of right second toe with much swelling and redness distally. The right third toe appeared to have a constriction band again at metatarsal joint but with little obvious oedema and erythema distally. Capillary refill appeared to be brisk at the tip of second toe.

hair tourniquet 1

Fig. 1. Showing erythema and oedema of the second right toe due to hair tourniquet syndrome 

To avoid further circulatory embarrassment, the infant was taken to the operating theatre. Multiple twisted hairs were found deeply embedded in the subcutaneous tissue at the base of the second and third right toes. A short longitudinal deep incision over the area of strangulation on the dorsal aspect of the toes was made for complete transection of the constricting hairs. The hairs were removed completely. This was followed by an improvement in the circulation of the toes, although swelling persisted. The wound was cleaned with betadine and normal saline but not sutured. A dressing with antibacterial ointment was applied to the toes. The wound healed completely without any complication. At one year follow-up the child is doing well with normal looking right second and third toes without any residual constriction and functional problems of the involved digits.

hair tourniquet 2

Fig. 2. Showing the hair has cut through the oedematous skin of right second and third toes 

Discussion

The term hair thread tourniquet syndrome was coined in 1908 by Barton et al [2] in which a strand of hair or a thread or fiber encircling an appendage causes ischemic strangulation. The body parts involved in this syndrome includes toe, finger, penis, clitoris and vulva. This syndrome typically occurs in infant. The finger and toe strangulation mostly occur in first couple months of life, penile tourniquet has been described with an age range of 4 months to 6 years [2, 3]. The labial or clitoral strangulation has been described in much older children [4, 5].

The etiology of these conditions is believed to be accidental in most cases but child abuse must be considered in selected cases [6]. There was no suggestion of non-accidental injury in our patient. In the cases of toes and genital appendages, they are mostly caused by hair, while in the fingers, they are mostly caused by a loose thread from mittens [2, 7]. Hair is postulated to become a tourniquet due to its high tensile strength and its ability to wrap around the tissue [8].

The mechanism of the injury is due to the tourniquet effect of the hair or fiber, which causes lymphatic obstruction, oedema of the tissue and swelling. A vicious circle is started as the more the tissue swells, the tighter the tourniquet becomes. Secondary venous congestion follows, and ultimately arterial perfusion is impaired. The tourniquet of hair can cut through the oedematous skin and becomes deeply embedded in the subcutaneous tissue, as in this case. Re-epithelialization of the skin over the hair or fiber can occur, hence obscuring the offending hair or fiber altogether [9]. This process may progress rapidly over hours or more insidiously over months.

The only presenting symptom may be irritability, so the index of suspicion needs to be high. Most often it is the discovery of swelling or discoloration of the appendage noted by mother or caretakers while changing the infant’s clothing or during bathing, that bring the problem to attention. Prompt recognition of the tourniquet effect and complete removal of the offending constricting agent are crucial to restore the circulation and to prevent damage to or loss of the appendage [11]. We would advise urgent wound exploration and complete release of the constricting hairs or fibers’ in the operating theatre under general anaesthesia to prevent tissue damage or auto amputation. A simple longitudinal incision along the digit (either mid dorsal or lateral aspect of the toe or the fingers) is safe and effective for complete removal of the constricting hairs or fibres [7, 11].

A conservative measures like removal of the constricting hairs or fibers’ with a fine scissors or forceps or applying the depilatory cream to weaken the fibres [2], seems inappropriate as the hair fibers’ are not always easy to see and may cut through the oedematous skin to become deeply embedded in the subcutaneous tissue. There are many reported cases where the strangulation was not fully released in the first attempt in the accident and emergency department and later on required surgical exploration for complete release of the constriction [2, 7, 9, 10].

In conclusion, hair tourniquet syndrome is an unusual surgical emergency. Early diagnosis and prompt treatment can prevent loss of appendages and save the patient from unwanted complications. This case is presented to increase the awareness of this syndrome to pediatric emergency physicians, young surgeons and other professionals providing health care to the infants and children.

 

 

 

REFERENCES 

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