Basics
Description
- Primary constricting band: A band tightened around an appendage causes swelling and pain (e.g., a hair knotted around a toddlers toe).
- Secondary constricting band: Injury or disease process that causes swelling and edema as a result of tightness against the band (e.g., impacted ring with an underlying fracture of the finger)
- Untreated, the constricting band may become embedded and interrupt skin integrity.
- Tourniquet syndrome occurs when anything causes a constriction and there is distal tissue effect.
In the preverbal child, a constricting band may be a manifestation of child abuse or neglect. It should also be considered as a cause of inconsolable crying.
The cognitively impaired nursing home resident or Alzheimer patient may be unable to give an indication of injury or pain.
Etiology
Tourniquet syndrome may result from allergic, dermatologic, iatrogenic, endocrinologic, infectious, malignant, metabolic, physiologic, or traumatic conditions, or it may be related to pregnancy.
Diagnosis
Signs and Symptoms
- A constricting band with swollen tissue and skin of an appendage, most commonly involving a finger
- Other locations include wrist, ankle, toe, umbilicus, earlobe, nipple, septum or nares of nose, penis, scrotum, vagina, labia, uvula, or tongue.
- Pain on manipulation of the appendage or constricting band
History
Usually straightforward but in nonverbal populations it can be a cause of unidentified pain. An inconsolable crying infant may be having pain due to a hair tourniquet.
Physical Exam
- Evaluate area of concern.
- If evaluating an inconsolable infant or agitated nonverbal adult, assess fingers, toes, and genitalia.
Essential Workup
- Primary constricting band: Diagnosis made by history and physical exam with special attention to neurovascular status.
- Secondary constricting band: Diagnosis of underlying pathology may depend on results of imaging and lab test results.
Diagnosis Tests & Interpretation
Lab
- Usually not indicated for acute treatment
- Measurement of electrolytes, BUN, and creatinine; thyroid function tests; and Tzanck smear of vesicular lesions may be useful in identifying the underlying diagnosis.
Imaging
Plain films for evaluation of underlying fracture or residual foreign body after band removal
Differential Diagnosis
Any condition causing marked swelling and edema predisposing to the tourniquet syndrome
Treatment
Pre-Hospital
Remove rings and other potential constricting bands before development of tourniquet syndrome:
- Particularly in regions of extremity trauma
Initial Stabilization/Therapy
Pain management or procedural sedation as needed
Ed Treatment/Procedures
- Removal of the constricting band either by advancing the band distally or by division
- These adjuvant methods may be used alone or in combination:
- Elevation of the affected extremity may decrease vascular congestion.
- Cooling the extremity with ice or cold water may reduce edema and erythema.
- Lubrication with soap or mineral oil may allow slippage over an inflamed or edematous area.
- Digital block with 1 " 2% lidocaine without epinephrine decreases the discomfort of removal and manipulation of an underlying injury.
- A digital block may; however, increase local swelling. Consider regional blocks.
- Gauze or a needle holder may be used to manipulate the band.
- The distal swollen finger, especially the proximal interphalangeal joint, is an important obstacle in constricting band removal.
- Distal to proximal edema reduction by sequential compression:
- Self-adherent tape is wrapped from distal to proximal to form a smooth and decompressed area over which the band is advanced.
- A Penrose surgical drain or a finger cut from a small glove is stretched to fit over the distal swelling before attempted removal.
- With lubrication, the proximal end of the drain is pulled under the ring to form a cuff around the ring; the cuff with distal traction applied advances the band over the decompressed area.
- Suture material (no. 0 silk, dental floss, or umbilical tape) is wrapped under tension in a tight layer advancing over the edema in a distal-to-proximal direction; the proximal tail of the suture material or floss is tucked under the ring; with lubrication, the tail under tension is pulled distally and unwound, forcing the ring over the layered suture material and decompressed area.
- Constricting band removal by division:
- Scissors may be used to 1st lift and then cut the offending fibrous band constricting a toddlers toe or penis.
- A no. 11 scalpel blade with cutting edge up may be sufficient to cut constricting bands formed by hair, fibers, or plastic ties.
- A topical commercially available depilatory agent may be used to divide a tourniquet formed by a suspected hair obscured by local edema.
- A handheld wire cutter/stripper may divide small-girth metallic rings with minimal discomfort to the underlying injury; this type of removal may; however, impart a crush defect to the ring, making repair difficult.
- A long-handled bolt cutter, available in most operating rooms or hospital engineering departments, may be used to divide large-girth or broad-sized rings:
- Long handles provide the significant mechanical advantage needed to cut large rings.
- The reinforced cutting blades may not easily fit through a constricting band with adjacent swollen tissue and skin.
- A standard hand-powered, medically approved ring cutter (Steinmann pin cutter with a MacDonald elevator) may be used to divide small-girth metallic constricting bands made of soft metals (gold/silver)
- This method has the advantage of a cleaner cut for subsequent repair of the ring.
- The disadvantage is that the handheld ring cutter is labor-intensive and may aggravate the pain of an underlying injury.
- A motorized high-RPM cutting device may be used to rapidly divide constricting bands irrespective of girth and size of the ring; it may be DC- or AC-powered or pneumatically driven in the operating suite.
- Cutting procedure:
- The initial cut is made on the band on the volar aspect of the extremity.
- A tenaculum may be used to spread the band in softer metals.
- For a 2nd cut, the band should be rotated 180 ° on the extremity, allowing the 2nd cut on the band over the volar aspect of the extremity.
- Motorized cutting:
- Remove flammable solvents from the work area.
- Protective eyewear should be worn by everyone present, including the patient.
- Place a thin aluminum splint (shaped to the curvature of the ring) between the patient's skin and the ring as a shield to protect underlying tissue.
- Cool splint and cutting surface with ice water irrigations before and during the cutting procedure.
- Limit cutting with motorized device to 5 sec with max. intervals of 60 " 90 sec between ice water irrigations to avoid producing local excessive heat.
- Depilatory cream:
- Can be used if suspected constriction is caused by hair in place of "unwinding or excising " the hair.
- Swelling of tissues heaped up around the hair may obscure the hair tourniquet leaving only a visible crease with the underlying hair buried below.
- Depilatory cream applied to the crease may release the hair tourniquet within 10 min.
- Postdivision care:
- Underlying injuries should be irrigated thoroughly to remove metallic dust and avoid foreign-body reaction and granuloma formation.
- Tetanus prophylaxis should be provided if indicated.
Medication
- Tetanus prophylaxis: Tetanus toxoid 0.5 mL IM
- No medications are typically required unless evidence of or at risk for infection
First Line
- Cefazolin: 1 g IV/IM (peds: 20 " 40 mg/kg IV/IM single dose in ED) and
- Cephalexin: 500 mg PO (peds: 25 " 50 mg/kg/d) QID for 7 days.
- Amoxicillin/clavulanate: 875/125 mg PO (peds: 25 mg/kg/d) BID for 7 days
- Erythromycin: 333 mg PO TID (peds: 40 mg/kg/d q6h for 7 days)
Second Line
- If patient is penicillin allergic:
- EES: 800 mg PO, then 400 mg PO q6h for 7 days or
- Clindamycin: 300 mg PO q6h for 7 days
Follow-Up
Disposition
Admission Criteria
- Neurovascular compromise or injury requiring surgical repair
- Concomitant infection or necrosis
- Investigation of abuse and or neglect
Discharge Criteria
Successful band removal with restoration of circulation.
Issues for Referral
Wounds at high risk for infection should have close follow-up in 1 " 2 days.
Followup Recommendations
Return to the ED for increasing pain, numbness, tingling, redness, swelling drainage, fevers, or other changes in clinical presentation.
Pearls and Pitfalls
- Failure to completely examine the fingers, toes, and genitalia of the irritable infant
- The hair causing a hair tourniquet may be obscured by edema and heaped up tissue and skin.
- Rings must be removed early after trauma to the distal extremity.
Additional Reading
- Hoffman RJ, Wang VJ, Scarfone RJ. Fleisher and Ludwigs 5-minute Pediatric Emergency Medicine Consult. Lippincott Williams & Wilkins; 2011.
- O 'Gorman A, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care. 2011;27(3):203 " 204.
- Peckler B, Hsu CK. Tourniquet syndrome: A review of constricting band removal. J Emerg Med. 2001;20(3):253 " 262.
- Rosen P, Chan TC,
Vilke GM, et al. Atlas of Emergency Procedures. St. Louis,
MO: Mosby; 2001. - Sung S, Hsu CK, O 'Rouke K. Resident training in constricting band removal: Motorized cutting. Ann Emerg Med. 2007;50(3):Sup:S76.
Codes
ICD9
- 959.5 Finger injury
- 959.7 Knee, leg, ankle, and foot injury
ICD10
- S60.448A External constriction of other finger, initial encounter
- S60.449A External constriction of unspecified finger, initial encounter
- S90.446A External constriction, unspecified lesser toe(s), initial encounter
- S90.443A External constriction, unspecified great toe, initial encounter
- S60.440A External constriction of right index finger, initial encounter
- S60.441A External constriction of left index finger, initial encounter
- S60.442A External constriction of right middle finger, initial encounter
- S60.443A External constriction of left middle finger, initial encounter
- S60.444A External constriction of right ring finger, initial encounter
- S60.445A External constriction of left ring finger, initial encounter
- S60.446A External constriction of right little finger, initial encounter
- S60.447A External constriction of left little finger, initial encounter
- S90.441A External constriction, right great toe, initial encounter
- S90.442A External constriction, left great toe, initial encounter
- S90.444A External constriction, right lesser toe(s), initial encounter
- S90.445A External constriction, left lesser toe(s), initial encounter
SNOMED
- 248406004 Ring tight on fingers (finding)
- 52011008 Injury of finger (disorder)
- 282776008 Injury of toe (disorder)