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Picture of the Month
Michelle Wang, DO;
Jennifer Schott, MD;
Walter W. Tunnessen, Jr, MD
From the Good Samaritan Medicine/Pediatrics Residency Program (Dr Wang),
and the Department of Pediatrics, Maricopa Medical Center (Dr Schott), Phoenix,
Ariz; and the American Board of Pediatrics, Chapel Hill, NC (Dr Tunnessen).
Arch Pediatr Adolesc Med. 2001;155:515-516.
TWO FINGERS of a 6-week-old infant were noted to be discolored, "black
and red," following removal of mittens (Figure
1) that had been placed on both hands 48 hours earlier to prevent
involuntary excoriations of the face by his fingernails. The infant's mother
had been advised by her mother-in-law not to trim his fingernails because,
according to Hispanic folklore, it is believed that trimming the fingernails
of an infant younger than 40 days old may result in poor vision. The infant
had exhibited no unusual fussiness or irritability during this time.
The distal phalanx of the left index finger appeared denuded with surrounding
erythema (Figure 2). The distal phalanx
of the right index finger was necrotic distal to a piece of thread attached
circumferentially. Surgical debridement and amputation of the distal phalanx
were required (Figure 3). The third
toe of another infant with an earlier stage of the same problem is shown in Figure 4.
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Figure 1.
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Figure 2.
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Figure 3.
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Figure 4.
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Denouement and Discussion: Hair-Thread Tourniquet Syndrome
Figure 1. The mittens worn by the infant are turned inside out to show the presence
of loose threads.
Figure 2. The distal phalanx of the left index finger is denuded. A circumferential
constriction of the skin is noted below the area of skin loss.
Figure 3. The distal phalanx of the right index finger has been amputated.
Figure 4. The distal portion of the third toe is swollen and erythematous. A
strand of hair is apparent.
Hair-thread tourniquet syndrome is the term coined to describe the phenomenon
caused by a strand of hair or thread tightly wrapped around an appendage.1 The resulting constriction, if not recognized and
promptly removed, may lead to tissue loss or amputation of the affected appendage.
Although infants are most frequently affected by this problem, cases in children
aged 6 years have been reported.1 Hair-thread
tourniquet syndrome crosses cultural, economic, and gender barriers and has
been reported from several countries, including Spain, Greece, France, Australia,
England, and the United States.
Most cases reported in the literature seem to be accidental in nature,
although child abuse must be considered, especially with involvement of the
penis. Hair or loose thread is most prone to wrap around an appendage when
the appendage is confined in a tight-fitting garment. As the hair or thread
wraps around the appendage, lymphatic drainage may be impeded, which results
in swelling, venous outflow obstruction, and eventually, restriction of arterial
flow. Loss of arterial blood supply may lead to loss of the appendage. As
the swelling develops, the constricting band may become imbedded in the tissue
of the appendage or even cut through the skin, making it difficult or impossible
to discern.
In a review of 66 cases from the medical literature, 28 (43%) involved
toes, 16 (24%) involved fingers, and 22 (33%) involved external genitalia.1 The median age of infants with toe involvement
was 4 months (range, 20 days to 15 months), while the median age of infants
with finger involvement was 3 weeks (range, 4 days to 19 months). Hair was
the cause of the constriction in 79% of infants with toe involvement, while
thread was responsible for 80% of the cases involving fingers. The penis was
the appendage constricted in 21 of the 22 reported cases involving genitalia;
hair was the responsible agent in 95% of the cases. The median age of penis
involvement was 2 years (range, 4 months to 6 years).
Infants with hair-thread tourniquet syndrome may be irritable or display
no unusual behavior.2 The digits of infants
with unexplained crying or irritability should be carefully examined for this
problem. Most often it is the discovery of swelling or discoloration of the
appendage noted by caretakers while changing the infant's clothing or during
bathing that brings the problem to attention. Prompt recognition of the tourniquet
effect and removal of the offending constricting agent are critical to prevent
damage to or loss of the appendage. Careful examination of the site of constriction
is necessary to assure that all strands of hair or thread are removed. Surgical
incision may be necessary to assure release of the constricting agent.
As part of anticipatory guidance, parents should be alerted to the danger
of using mittens or booties with loose threads or fibers. Coverings should
not be used on infant's extremities for extended periods of time without careful
inspection of fingers and toes.
AUTHOR INFORMATION
Accepted for publication March 8, 2000.
Reprints: Jennifer Schott, MD, Department of Pediatrics, Maricopa
Medical Center, 2601 E Roosevelt, Phoenix, AZ 85008.
REFERENCES
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1. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome. Pediatrics. 1988;82:925-928.
FREE FULL TEXT
2. Trocinski DR. The crying infant. Emerg Med Clin North Am. 1998;16:895-910.
FULL TEXT
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ISI
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SECTION EDITOR: WALTER W. TUNNESSEN, JR, MD
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
The Thread-Tourniquet Syndrome
SULIMAN
J Hand Surg Eur Vol 2005;30:658-658.
FULL TEXT
Near Strangulation as a Result of Hair Tourniquet Syndrome
Chegwidden and Poirier
CLIN PEDIATR 2005;44:359-361.
ABSTRACT
Toe Tourniquet Syndrome in Association With Maternal Hair Loss
Strahlman
Pediatrics 2003;111:685-687.
ABSTRACT
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