Background
Hair tourniquet syndrome is a rare clinical phenomenon that involves hair, thread, or similar material becoming so tightly wrapped around an appendage that it results in pain, injury, and, sometimes, loss of the appendage. [1] Essentially, any appendage may be involved, including a toe, wrist, penis, scrotum, tongue, uvula, vaginal labium, ear lobe, umbilicus, or nipple. [2, 3, 4, 5, 6] In a meta-analysis review of 210 cases of hair-thread tourniquet syndrome, 44.2% involved the penis, 40.4% the toes, 8.6% fingers, and another 6.8% represented other sites. [7]
Human hair is extremely thin and, hence, easily overlooked, especially when a patient presents with a foreign body reaction and local swelling. [8] Once constricted over an appendage, reepithelialization may occur if the offending fiber is not removed in a timely fashion. This may further obscure the hair or thread below an overlying skin bridge, making recognition more difficult. [9] Hair has high tensile strength and the ability to stretch when wet and contract or tighten as it dries. [8] The wrapping of the offending fiber or hair around a digit is thought to be caused by repetitive movement of the appendage in a confined area, such as hands in mittens or feet in pajamas. [10] The tissue injury from constricting bands may be caused by ischemic compression of blood vessels and the direct cutting action of the tourniquet. [9] In addition to soft-tissue damage, this mechanism is even capable of disrupting bone. [7] Complications such as constrictive scarring, flexion deformity, and even urocutaneous fistulae may affect healing post release. [11]
Most cases of hair wrapping occur in young children. The most often observed age range of reported cases of finger wrapping is in the first days of life up to 19 months, and penile involvement is 4 months to 6 years. [12] Labial and clitoral wrapping have been described in an older age group (age 7-13 years). [13] Case reports have documented 80- and 84-year-old men with involved extremities. [14, 15] Hair tourniquet syndrome can be observed across all ages. The younger age group, especially infants younger than 4 months, is thought to be more at risk because 90% of mothers experience excessive postpartum hair loss, called telogen effluvium. [16] Most cases of hair tourniquet syndrome are deemed accidental, but intentional cases consistent with child abuse have been cited in the literature. [17]
Although the affected patient can present in several ways, the classic presentation is that of the inconsolable infant. The diagnosis can be made after identification of a swollen and painful appendage with sharp circumferential demarcation from normal tissue proximally. Hair tourniquet syndrome confers an inherent risk of loss of function and autoamputation. However, it is easily treatable and long-term effects are largely preventable with prompt diagnosis. Clinicians should maintain a high index of suspicion when confronted with such presentations.
Indications
Removal of the offending fiber is indicated in all cases of hair or thread tourniquet syndrome and should be implemented as early as possible.
Adequately visualized constricting bands with little or no tissue edema are good candidates for the unwrapping technique.
Cases associated with mild-to-moderate edema are candidates for the blunt probe cutting technique.
In cases in which other techniques have failed, when the swelling is so severe that the constricting band is not visible, or when epithelialization has occurred, the incisional approach should be implemented.
The use of depilatory creams is a safe alternative to instrumentation and can be done with minimal discomfort, while taking care and using caution on the application to the skin of the penis; it should be avoided when it involves the vagina and mucosal surfaces, as this could lead to burns or irritation. [18, 19]
Cases requiring surgical debridement have been described. [7, 20] When formation of excessive granulation tissue or involution under edematous skin is present, consider urgent surgical referral.
Contraindications
No absolute contraindications exist to the removal of a hair or thread tourniquet. Conversely, removal is required to prevent morbidity.
Relative contraindications are approach-specific. Bleeding diathesis for the incisional approach and/or history of allergic reaction to depilatory creams are relative contraindications and may be an indication to choose one approach over another; however, this should never be a reason to withhold or postpone urgent treatment.
-
In this figure, the blade is in the 9-o'clock position. The dorsal alternative approach is also indicated.
-
The blunt probe method.
-
This illustration shows removal of a penile tourniquet using the blunt probe method.
-
This cross-section of the finger illustrates the 3- and 9-o'clock positions as well as the alternative dorsal approach for digital tourniquet removal.
-
To avoid the deep structures, the incision must be kept within the deep fascia of the penis. This figure illustrates the importance of the 4- and 8-o'clock positions. The dorsal neurovascular bundle is not compromised by these approaches.
