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Elisabeth P. Moore, MD; Tania D. Strout, PhD, RN, Crying MS; John R. Saucier, MD Department of Emergency Medicine, Surprise patients with the with painful Maine Medical Center, truth about pain & aging Portland (Drs. Moore, Strout, and Saucier); Stephen Thielke, MD, MSPH, MA toes Tufts University School of Medicine (Drs. Strout 4 ways to listen to and Saucier) this audiocast: Our patient’s sleepless

. 1. Go to jfponline.com sought care for [email protected] 2. Visit www. their infant’s mysteriously Department EDITOR myjfpmobile.com/1112 Richard P. Usatine, MD 3. Scan this QR code to injured toes. University of Texas Health Science Center listen to the at San Antonio audiocast on your smart phone The authors reported no A well-developed and previously potential conflict of interest 4. Text “PAIN” to relevant to this article. 25827 from your healthy infant was brought to our emer- mobile phone and gency department (ED) by her parents, who follow the prompt. said that their child was experiencing sig- nificant toe pain. Two reddened, swollen toes (FIGURE) were immediately identifiable on the left foot. The patient’s parents denied INSTANT poll any trauma or unusual activity involving How long do you keep patients on oral the infant. anticoagulation to prevent recurrence of venous thromboembolism? ● What is your diagnosis?

● how would you TREAT THIS Online exclusive PATIENT? • CLINICAL INQUIRIES What are the benefits and risks of IUDs in adolescents? Figure Two reddened and swollen Photo rounds Friday  toes Test your diagnostic skills. P Physician’s Briefing News  HO T O

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OF : John John : Get updates from us on R . . S Facebook and Twitter aucier, www.facebook.com/JFamPract http://twitter.com/JFamPract MD

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Diagnosis: How best to remove tourniquet the tourniquet Upon close inspection, we discovered hair Methods of tourniquet removal include un- thread tourniquets constricting the fourth wrapping, cutting, or dissolving the hair with and fifth toes on the baby’s left foot. commercial agents such as Hair tourniquet syndrome primarily af- Nair (Church & Dwight Co, Inc, Princeton, fects in the first few months of life. NJ).2,10-12 The average age of occurrence is 4 months, z Unwrapping. In cases where the tour- a time when maternal postpartum hair loss niquet is easily visualized and minimal (telogen effluvium) is at its maximum.1,2 It is edema is present, simply unwrapping the worth noting, however, that this syndrome constricting hair may be successful. This can has also been observed in toddlers and be accomplished by identifying a loose end of adolescents.3 the hair, grasping the free end with a pinch- z Toes are most frequently involved, al- ing instrument such as a hemostat or forceps, though cases of hair tourniquets affecting the and carefully unwrapping the hair from the fingers, penis, labia, clitoris and uvula have appendage1,11 (strength of recommendation been reported.2-7 Infants may be brought to [SOR]: B). the office or ED with irritability or crying, or z Cutting. If cutting the hair is necessary with an erythematous extremity. due to the presence of mild to moderate ede- Infantile hair ma or failure of the unwrapping technique, tourniquets may Why tourniquets are overlooked a blunt probe may be inserted between the be overlooked Infantile tourniquets may be overlooked be- hair and the appendage to protect soft tissues because of the cause of the fine nature of human hair, the from the cutting implement. Once the probe fine nature of swelling of the involved appendage (which has been inserted, the tourniquet may be human hair and can hide the tourniquet itself), and the pres- cut using scissors or a #11 scalpel blade ap- the swelling that ence of baby booties, footed pajamas, and plied to the surface of the blunt instrument1,11 may hide the mittens that may obscure injured digits from (SOR: C). Alternative instrumentation, in- tourniquet itself. view. cluding a #12 Bard Parker curved scalpel These tourniquets can cause significant blade and a Littauer suture-removal scissor, morbidity if they are not quickly identified may be useful when the tourniquet is too and removed. The tensile strength of human tightly wound to allow for insertion of a blunt hair is quite strong, allowing for strangula- probe instrument (SOR: C). tion and even amputation of appendages. z Dissolving. A commercially available The repetitive motion of hands and feet in- depilatory agent, such as Nair, may be useful side boot­ies or mittens allows constriction for mild cases, but would not be appropriate to increase. when a tourniquet has cut into the skin. Cal- As this tightening occurs, the tourniquet cium thioglycolate, a common depilatory ac- may cause constrictive lymphatic obstruc- tive ingredient, breaks down disulfide bonds tion, edema of the involved soft tissues, and in keratin, thereby weakening hair strands. secondary vascular obstruction of venous Chemical agents containing calcium thiogly- outflow and arterial perfusion.5,8,9 Tourni- colate should be used with caution, as kera- quets can also cut through skin, injuring tin is also present in the epidermis and use of deeper tissues. these agents may cause irritation to the skin. In most instances, the damaged tissue will rapidly reperfuse once the offending When an incisional approach tourniquet is unraveled or removed. How- is needed ever, some cases may result in epithelializa- At times, epithelialization over the tourni- tion over the tourniquet, , necrosis, quet or severe swelling of a digit may neces- and gangrene leading to amputation. Quick sitate an incisional approach. If there is any recognition of the condition and immediate doubt about whether you can completely removal of the constricting tourniquet are key remove all of the strands of the tourniquet, to saving the injured appendage. an incision into the digit itself must be made

676 The Journal of Family Practice | November 2012 | Vol 61, No 11 Hair tourniquet syndrome

to disrupt constriction. Historically, a digital hair, tourniquets may be comprised of multi- nerve block has been the preferred mode of ple . That’s why it’s important to careful- analgesia; however, recent evidence suggests ly inspect the area to be sure that all strands that less invasive pain management strate- have been removed. Thorough treatment gies, such as a sucrose pacifier, EMLA cream, should include consideration of , or ZAP topical analgesia gel may be effective13 tetanus , and the need for (SOR: A). antibiotics1,2,11 (SOR: B). If you must use this approach, you’ll need to consider the placement of the digi- Relief for our young patient tal neurovascular bundles of the fingers and To remove our patient’s hair tourniquets, we toes, located at approximately the 2, 4, 8, and carefully cut the fibers with hooked Littauer 10 o’clock positions. Following sterile prepa- suture-removal scissors and unwrapped ration and draping, a longitudinal incision the hair. Damage to the plantar aspect of should be made at either the 3 or 9 o’clock po- both toes was significant enough that we sition, thus locating it between neurovascular had to cut through the soft tissue and into bundles1,11 (SOR: B). the flexor tendon to completely remove the Alternatively, a longitudinal incision can hair. No sutures were required as the wound be made directly over the extensor tendon, edges were well approximated without located dorsally at 12 o’clock. Any resulting closure. tendon laceration would be parallel to the We cleaned and dressed the injured toes Tell parents to tendon fibers, and could be expected to heal and arranged for close follow-up. The pa- turn mittens and with splinting and wound care1,11,14 (SOR: B). tient’s recovery was uneventful. booties inside Prior to initiating treatment, parents z To avoid hair tourniquet syndrome, out to check for or caregivers should be warned about the counsel parents to turn mittens and boo- loose hairs and potential for bleeding and pain during the ties inside out to check for loose hairs. Also, to make sure procedure. advise parents to make sure there aren’t any there aren’t any hairs wrapped around their baby’s fingers or hairs wrapped Extreme cases may require surgery toes. Vigilance on the part of health care pro- around the Surgical consultation may be required in ex- viders can provide quick recognition and ap- baby’s fingers treme cases of edema, neurovascular com- propriate treatment of this condition. JFP or toes. promise, necrosis, amputation, or failure to 2 completely remove the tourniquet. Correspondence z Other factors to keep in mind. While Tania D. Strout, PhD, RN, MS, Director of Research, Department of Emergency Medicine, Maine Medical Center, classically described as consisting of a single 47 Bramhall Street, Portland, ME 04102; [email protected]

References 1. Loiselle JM, Cronan KM. Hair tourniquet removal. In: King 2003;24:325-326. C, Henretig FM, eds. Textbook of Pediatric Emergency Proce- 8. Rich MA, Keating MA. Hair tourniquet syndrome of the clito- dures. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; ris. J Urol. 1999;162:190-191. 2008:1065-1069. 9. Sylwestrzak MS, Fischer BF, Fischer H. Recurrent clitoral tour- 2. Strahlman RS. Toe tourniquet syndrome in association with niquet syndrome. . 2000;105:866-867. maternal hair loss. Pediatrics. 2003;111:685-687. 3. Bacon JL, Burgis JT. Hair thread tourniquet syndrome in ado- 10. Douglass DD. Dissolving hair wrapped around an infant’s lescents: a presentation and review of the literature. J Pediatr digit. J Pediatr. 1977;91:162. Adolesc Gynecol. 2005;18:155-156. 11. Cardriche D. Hair tourniquet removal. Available at: http:// 4. Badawy H, Soliman A, Ouf A, et al. Progressive hair coil penile emedicine.medscape.com/article/1348969-overview. Updat- tourniquet syndrome: multicenter experience with 25 cases. ed January 30, 2012. Accessed October 3, 2012. J Pediatr Surg. 2010;45:1514-1518. 12. Peckler B, Hsu CK. Tourniquet syndrome: a review of con- 5. Kuo JH, Smith LM, Berkowitz CD. A hair tourniquet resulting stricting band removal. J Emerg Med. 2001;20:253-262. in strangulation and amputation of the clitoris. Obstet Gynecol. 13. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in new- 2002;99:939-941. born infants undergoing painful procedures. Cochrane Data- 6. McNeal RM, Cruickshank JC. Strangulation of the uvula by base Syst Rev. 2010;(1):CD001069. hair wrapping. Clin Pediatr (Phila). 1987;26:599-600. 14. Barton DJ, Sloan GM, Nichter LS, et al. Hair-thread tourniquet 7. Krishna S, Paul RI. Hair tourniquet of the uvula. J Emerg Med. syndrome. Pediatrics. 1988;82:925-928.

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