Hair Tourniquets

Case

A two month old infant is brought to your office by the parents because of inconsolable crying for 6 hours. The child is breast fed and has been doing well. There is no vomiting, diarrhea, constipation, or increased gas. The mother has not changed her diet and the infant is on no medications. There has been no fever. On physical examination the child is active and screaming. There is no fever. The physical exam is completely normal except for the right third toe is swollen, tender, erythematous, and there is a circumferential indentation proximal to the redness. A thread is seen in the indentation. 

Background

Hair tourniquet syndrome is a relatively rare finding in infants. The infant usually presents with excessive crying or the caretaker notices the redness of the extremity. It is an emergency because failure to remove the tourniquet promptly can lead to pain, ischemia, and a serious infection or necrosis. 

Hair tourniquet syndrome can affect any body part including fingers, toes, external genitalia, tongue, or umbilical stump, but the third toe and third finger are most commonly involved. Hair is more commonly associated with toes and external genitalia while threads are more often found around fingers. There is an association with older frequently washed clothes and the wearing of mittens.  It is believed to be an accidental occurrence, but knots or ligation of larger body parts should raise suspicion for intentional abuse.

Differential Diagnosis

  1. Congenital annular bands
  2. Ainhum – spontaneous dactylitis and autoamputation of a digit. Occurs more often in dark-skinned individuals in tropical climates.

Management & Treatment

  1. Physician awareness of the condition is key to expedite treatment.
  2. Obtain good lighting and complete a full examination on an undressed patient
  3. Removal with a fine scissors and forceps. Unwinding and incising techniques have been described, but one must use caution not to cause further tissue damage.
  4. If unable to remove, OTC depilatory agents (active ingredient calcium thioglycolate) to dissolve hair/thread have been used
  5. May need a surgical procedure and general anesthesia if there is a very deep hair or thread
  6. Early removal leads to complete resolution without long term consequences

Other diagnoses to consider in infants with inconsolable crying

  1. Colic
  2. Infectious diseases- UTI, Otitis media, herpangina, and herpes stomatitis
  3. Trauma 
  4. Eye problems including foreign bodies and corneal abrasions.
  5. Intussusception, constipation, gastroesophageal reflux
  6. CNS lesions
  7. Drug reaction - including DPT immunization
  8. Night terrors
  9. SVT
  10. Idiopathic

References

  1. Barton, David. Sloan,Gerald. Nichter,Larry . Reinisch, John. Hair-Thread Tourniquet Syndrome. Pediatrics Vol.82 No6 December 1988
  2. Strahlman R. S. Toe Tourniquet Syndrome. Pediatrics Vol 111 N0. 3 March 2003 Pg 685
  3. O'Gorman A, Ratnapalan S. “Hair tourniquet management.” Pediatr Emerg Care. 2011 Mar;27(3):203-4.
  4. Onyeama CO, Vitale K, Cochran K, Onyeama GL. “Swelling and redness of the fourth toe in a 3-month-old infant.” Pediatr Rev. 2011 Jun;32(6):253-5.