Hair Tourniquet

Hair Tourniquet

 

Simple answers are always better than complicated ones. Often we get caught focusing on the complex and can forget that Basics are the Best (ex, Pediatric Shock Index, Optimize Chest Compressions, and Penicillin for Pneumonia)! Often, I have found myself knee deep in complicated decisions only to be recued by a straightforward answer. One such scenario is the “Hair Tourniquet Syndrome” case… is there a simple answer or do I have to perform surgery?

 

Hair Tourniquet Syndrome

  • Caused by more than just Hair.
    • We have discussed the unique situation of Metal Band Tourniquet.
    • Hair – one study did show that 95% of cases were due to hair. [Claudet, 2010]
    • Fine thread
    • Thin rubber bands
    • Many advocate for this condition to be termed “constricting tourniquet” or “hair-thread tourniquet.” [Plesa, 2015]
  • Circumferential constriction can lead to substantial injury.
    • Lymphatic drainage is initial obstructed, leading to edema.
    • Increasing edema eventually impedes venous flow.
    • Venous obstruction further increases swelling and can eventually obstruct arterial blood flow… that leads to badness.
      • Tissue necrosis
      • Infection
      • Non-healing ulcer
      • Osteomyelitis
      • Amputation
    • Process can take hours, days, weeks, or even months.
      • May go undetected, especially in the very young (who’s discomfort is often difficult to decipher – consider this in the fussy/crying infant).
      • The swollen tissue can obscure the etiology!
        • As the process continues, the hair/thread cuts into the skin.
        • The skin can scar, cover over the thread, and obscure the etiology.
      • Often involves distal appendages in the young. [Barton, 1988]
        • Toes – 43%
        • External Genitalia – 33%
        • Fingers – 24%

 

Hair Tourniquet Syndrome – Management Options

  • Need to remove the constricting band as soon as possible.
  • Unwind the Thread
    • Certainly, if caught early enough, you may be able to simple unwind the thread.
    • Occasionally, using a curved needle to get under the thread can assist in this.
    • Need to ensure that the entire amount is removed and that no residual constrictive portion remains.
  • Depilatory Cream [O’Gorman, 2011; Plesa, 2015]
    • Cream with thioglycolate and calcium hydroxide or sodium hydroxide (Brand Name = NAIR)
      • The thioglycolate will break down the disulfide bonds of keratin, dissolving the hair.
      • The alkaline component assists with penetration into the hair.
    • Found to dissolve hair within 2.5 minutes and 8 minutes (depending on hair thickness). [Plesa, 2015]
    • The manufacturer does not recommend application on open skin… so a deep laceration may not be the best place to apply it.
    • Can cause skin irritation and even minor burns (it is an alkali).
    • DOES NOT dissolve cotton, polyester, or rayon threads. [Plesa, 2015].
  •  Incise the Thread
    • Toe/Finger
      • A DORSAL incision, along the long axis, down to the bone of the digit is recommended. [Barton, 1988; Serour, 2003]
      • Lateral incisions may injury nerve or blood vessel.
      • Incision along long axis may incise extensor tendon, but should not affect the tendon’s function.
      • Incision down to the bone should ensure transection of the constrictive thread.
    • Penis
      • Low threshold for surgical exploration
      • Incision needs to avoid the urethra in the corpus spongiosum.
      • Incise on one of the lateral, inferior aspects between the corpus cavernosum and the corpus spongiosum. [Barton, 1988]

Hair Tourniquet Syndrome – Management Plan

This is submitted as a reasonable option…

  1. Treat pain! (remember even neonates feel pain!)
    • Topical anesthetic may help initially.
      • This will also help if an incision is needed.
    • Could also consider a digital block.
  2. Can you grasp the thread?
    • If able, carefully remove it and ensure no residual material remains.
    • This can be challenging with small digits and swollen tissues.
  3. Is there a deep laceration?
    • Applying topical depilatory cream may cause more pain, so may want to proceed directly to incision.
  4. Unable to grasp/unwind, but no deep laceration, then apply Depilatory Cream.
    • Since the majority of the threads will be hair, application of depilatory cream is reasonable.
    • The cream should work within 10 minutes.
    • After 10 minutes, rub the area and rinse with water.  If no improvement, proceed to incision.
  5. Incise
    • Consider surrounding structures!
    • Consultation for surgical exploration is required if there is any concern that there is continued constriction.
  6. Topical antibiotic cream if there is evidence of skin breakdown.
  7. Close Follow-up is appropriate.
    • If evidence of vascular compromise, consider emergent Consultation.
    • If good cap refill and improvement after management, close follow-up as outpatient is reasonable.

 

References

Plesa JA1, Shoup K2, Manole MD3, Hickey RW3. Effect of a depilatory agent on cotton, polyester, and rayon versus human hair in a laboratory setting. Ann Emerg Med. 2015 Mar;65(3):256-9. PMID: 25240921. [PubMed] [Read by QxMD]

Bannier MA1, Miedema CJ. Hair tourniquet syndrome. Eur J Pediatr. 2013 Feb;172(2):277. PMID: 23117472. [PubMed] [Read by QxMD]

Alvarez-Pérez A1, Mateo S, Fernández-Redondo V, Toribio J. Hair-thread tourniquet syndrome: a hidden hazard. Pediatr Dermatol. 2013 Jul-Aug;30(4):e61-2. PMID: 22938208. [PubMed] [Read by QxMD]

O’Gorman A1, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care. 2011 Mar;27(3):203-4. PMID: 21378520. [PubMed] [Read by QxMD]

Arch Pediatr. 2010 May;17(5):474-9. PMID: 20338735. [PubMed] [Read by QxMD]

Serour F1, Gorenstein A. Treatment of the toe tourniquet syndrome in infants. Pediatr Surg Int. 2003 Oct;19(8):598-600. PMID: 14551712. [PubMed] [Read by QxMD]

Barton DJ1, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome . Pediatrics. 1988 Dec;82(6):925-8. PMID: 3186385. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. January 2, 2018

    […] adds toes are the most common body parts affected by tourniquet syndrome, and it can lead to swelling. It is also often unnoticed because infants tend to wear socks for a long duration of […]

  2. January 2, 2018

    […] adds toes are the most common body parts affected by tourniquet syndrome, and it can lead to swelling. It is also often unnoticed because infants tend to wear socks for a long duration of […]

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