Vol 41 # 3 September 2009 - Kma.org.kw

September 2009
KUWAIT MEDICAL JOURNAL 249
Fig. 1: Swelling of the distal phalanx of the right ring finger.
A clear demarcation of the swelling is shown, indicating a
tourniquet like effect.
Fig. 3: The human hair after surgical release
to the appendage involved; for toes, the median
age was four months (range 20 days to 15 months),
for fingers, the median age was three weeks (range
4 days to 19 months), for genitals, the median
age was two years (range 4 months to 6 years) [1] .
Genitals were usually involved in the older age subgroup.
These patients may be irritable or display no
unusual behavior. Child abuse has to be considered
in such a group and a thorough search in history
and physical examination is mandatory to rule out
this possibility. Accidental fiber entrapment is the
most common form compared with the child abuse
form.
Once diagnosed, it is considered an emergency.
Lymphatic drainage is impaired initially leading to
swelling. This is followed by venous impairment and
more edema which later affects the arterial supply
leading to ischemia and then necrosis. This will lead
to auto-amputation [4] . It has to be considered that
epithelium might cover the fiber making it difficult
to recognize. On other extreme, it might cut through
the skin.
The hair is extremely thin and therefore is
overlooked especially with the edema. It stretches
when wet and contracts when it dries causing a more
tight constriction [4] . With regards to management, a
high index of suspicion is required. If the clinician
Fig. 2: The line of demarcation is covered by epithelial debris
is not alert to this possibility, the diagnosis is missed
and devastation is the rule. To avoid circulatory
embarrassment, an immediate conservative
management in the form of soaking the appendages
in a depilatory cream is required. Two problems
arises here: first, the cream will not reach the fibers
if epithelium has been established and second, the
cream will act mainly on the human fibers. Due to
the high failure rate of this line of management, the
surgical approach is advocated by many authors. It
could be simply done with a fine scissor and forceps
under magnification or a deep longitudinal incision
reaching the bone could be made. This ensures the
complete release of all fibers [5] . This entity is also
reported in animals [6] .
Awareness of such entity is required to prevent
the delay and miss appropriate management.
CONCLUSION
Hair–thread tourniquet syndrome is a rare
emergency resulting from circumferential
strangulation of appendages by hair or fibers. If
passed unrecognized, devastating consequences
would almost occur. A high index of suspicion for
this condition is mandatory to avoid unpleasant
consequences of delayed treatment.
REFERENCES
1. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hairthread
tourniquet syndrome. Pediatrics 1988; 82:925-
928.
2. Trocinski DR, Pearigen PD. The crying infant. Emerg
Med Clin North Am 1998; 16:895-910.
3. Miller RR, Baker WE, Brandeis GH. Hair-thread
tourniquet syndrome in a cognitively impaired
nursing home resident. Adv Skin Wound Care 2004;
17:351- 352.
4. Bangroo AK, Chauhan S. Hair tourniquet syndrome.
J Indian Assoc Pediatr Surg 2005; 10:55-56.
5. Haene RA, Loeffler M. Hair tourniquet syndrome in
an infant. J Bone Joint Surg Br 2007; 89:244-245.
6. Hoffer M, Estrin M. Tourniquet Injury: a case report
and review of the literature. J Appl Res Vet Med
2006; 4:67-72.