para>Use of sharp instruments can put the appendage at risk for further trauma.
MEDICATION
First Line
Over-the-counter depilatory creams (e.g., Nair) have increasingly become the first-line choice of treatment in cases when offending material cannot simply be unwound. A 30-minute application, followed by rinsing the skin, is generally sufficient (3)[C]:
- Depilatory creams may not be effective on synthetic fibers.
Second Line
Wound-associated cellulitis should be treated with appropriate antibiotic coverage (3)[C].
ISSUES FOR REFERRAL
- If the offending material cannot be removed with the above methods, surgical consult may be indicated and removal done under general anesthesia (3).
- After removal, if the appendage does not demonstrate appropriate reperfusion or necrosis is present, prompt surgical consult is warranted. Poor cosmetic outcomes at any point of healing may warrant referral to a plastic surgeon (3).
- If the penis is involved in any of the above scenarios, a urologist should be consulted (4).
ADDITIONAL THERAPIES
- Once the offending material has been removed and good perfusion assured, patients can usually be discharged with an antibiotic ointment (e.g., Polysporin) for topical application (3).
- If the surface of the skin was compromised, tetanus prophylaxis (as age appropriate) should be considered (3).
SURGERY/OTHER PROCEDURES
- In some instances, not all fibers can be visualized and removed with unwinding and depilatory creams alone. This is especially true if the surface skin has reepithelialized over the offending material. In these instances, a surgical incision is recommended (4)[C].
- The appendage should be thoroughly cleaned with a disinfectant solution. A 1% lidocaine, without epinephrine, should be injected with a 25-gauge needle on each side of the digit for a digital block. A no. 11 or no. 15 surgical blade should then be used to create a longitudinal incision over the area of strangulation on the dorsal side of the digit. Some authors recommend that if an incision is required, then cutting to the depth of the bone (in digits) is ideal to ensure all fibers have been dissected (2,3,5)[C].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Most children do not require inpatient monitoring. If necrosis/amputation is present or if after treatment the affected appendage does not show adequate perfusion, then admission for further monitoring and treatment is recommended.
- Most patients are stable at the time of presentation.
IV Fluids
If an infant presents with a history of poor oral intake and infrequent voiding secondary to the discomfort of the hair tourniquet or has signs/symptoms of dehydration on physical exam, then consider IV fluid resuscitation. Severe dehydration is treated with a 20 mL/kg bolus of normal saline, with repeat boluses as needed followed by routine maintenance fluids. Mild to moderate dehydration can usually be managed with oral rehydration.
Nursing
After reperfusion has been assured, nursing should be ordered to check the neurovascular status of the affected areas at frequent, regular intervals (e.g., q2h). Nursing should report any adverse changes in perfusion (e.g., delayed capillary refill), coloration (e.g., increasing paleness/cyanosis), or decreasing sensation.
Discharge Criteria
Once the patient is able to demonstrate adequate, sustained perfusion of the affected area, has adequate pain control with oral medications, and is taking adequate oral intake to maintain hydration, the patient can be safely discharged with close follow-up with primary care provider.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Regular follow-up with primary care provider until the injury site is fully healed.
PATIENT EDUCATION
If the injury site demonstrates increasing pain, decreasing sensation, poor perfusion, or discoloration, the patient should seek prompt medical attention. Medical providers should review prevention strategies with families (discussed earlier).
PROGNOSIS
Prognosis is typically very good in cases when the diagnosis is made early.
COMPLICATIONS
- Amputation of the appendage, cellulitis, scarring, gangrene, poor cosmetic outcome, flexion deformity, tissue loss, permanent neurovascular damage, loss of function
- Penile complications can also include urethral strictures, urethral transection, and urethral fistula formation.
REFERENCES
11 Klusmann A, Lenard HG. Tourniquet syndrome-accident or abuse? Eur J Pediatr. 2004;163(8):495-498; discussion 499.22 Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg. 2006;57(4):447-452.33 O'Gorman A, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care. 2011;27(3):203-204.44 Haddad FS. Penile strangulation by human hair. Report of three cases and review of the literature. Urol Int. 1982;37(6):375-388.55 Serour F, Gorenstein A. Treatment of the toe tourniquet syndrome in infants. Pediatr Surg Int. 2003;19(8):598-600.
ADDITIONAL READING
- Badawy H, Soliman A, Ouf A, et al. Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases. J Pediatr Surg. 2010;45(7):1514-1518.
- Biehler JL, Sieck C, Bonner B, et al. A survey of health care and child protective services provider knowledge regarding the toe tourniquet syndrome. Child Abuse Negl. 1994;18(11):987-993.
- Chegwidden HJ, Poirier MP. Near strangulation as a result of hair tourniquet syndrome. Clin Pediatr (Phila). 2005;44(4):359-361.
- Golshevsky J, Chuen J, Tung PH. Hair-thread tourniquet syndrome. J Paediatr Child Health. 2005;41(3):154-155.
- Hickey BA, Gulati S, Maripuri SN. Hair toe tourniquet syndrome in a four-year-old boy. J Emerg Med. 2013;44(2):358-359.
- Kerry RL, Chapman DD. Strangulation of appendages by hair and thread. J Pediatr Surg. 1973;8(1):23-27.
- Lohana P, Vashishta GN, Price N. Toe-tourniquet syndrome: a diagnostic dilemma! Ann R Coll Surg Engl. 2006;88(4):W6-W8.
- Mackey S, Hettiaratchy S, Dickinson J. Hair-tourniquet syndrome-multiple toes and bilaterality. Eur J Emerg Med. 2005;12(4):191-192.
- Miller RR, Baker WE, Brandeis GH. Hair-thread tourniquet syndrome in a cognitively impaired nursing home resident. Adv Skin Wound Care. 2004;17(7):351-352.
- Peckler B, Hsu CK. Tourniquet syndrome: a review of constricting band removal. J Emerg Med. 2001;20(3):253-262.
- Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003;111(3):685-687.
- Webley JA, Schleif DR, Coleman J. Tourniquet syndrome: an unusual presentation. Ann Emerg Med. 1981;10(9):494-495.
CODES
ICD10
- S30.842A External constriction of penis, initial encounter
- S90.446A External constriction, unspecified lesser toe(s), initial encounter
- S60.449A External constriction of unspecified finger, initial encounter
- S60.349A External constriction of unspecified thumb, initial encounter
- S90.445A External constriction, left lesser toe(s), initial encounter
- S90.444A External constriction, right lesser toe(s), initial encounter
ICD9
- 911.8 Other and unspecified superficial injury of trunk, without mention of infection
- 917.8 Other and unspecified superficial injury of foot and toes, without mention of infection
- 915.8 Other and unspecified superficial injury of fingers without mention of infection
SNOMED
- Constriction in shaft of penis (finding)
- superficial injury of toe (disorder)
- Superficial injury of finger (disorder)
- Superficial injury of little toe (disorder)
- Strangulation of penis (disorder)
CLINICAL PEARLS
- This rare condition requires a high index of suspicion. A poorly consolable infant with no identifiable cause should be examined thoroughly to rule out hair tourniquet syndrome.
- The penis is the most common location affected (44%), followed by toes (40%), then fingers (9%).
- Most cases occur in infancy and early childhood; however, neurologically compromised individuals of any age are at risk.
- Unwinding and depilatory creams should be first-line treatments. Surgical incision may be required to restore blood flow.
- Most cases are not due to child abuse.