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Hair Tourniquet Removal

  • Author: Daniel J Lumbrezer, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Nov 21, 2014
 

Overview

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, vaginal labium, ear lobe, umbilicus, or nipple.[2, 3, 4, 5] In a review of 210 cases of hair-thread tourniquet syndrome, 44% involved the penis, 40% the toes, 8.7% fingers, and another 6.8% represented other sites, including external female genitalia and the uvula.[6]

Human hair is extremely thin and, hence, easily overlooked, especially when a patient presents with a foreign body reaction and local swelling.[7] Once constricted over an appendage, reepithelialization may occur, which may further obscure the hair or thread below an overlying skin bridge.[8] Hair has high tensile strength and the ability to stretch when wet and contract or tighten as it dries.[7] 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.[9] The tissue injury from constricting bands may be caused by ischemic compression of blood vessels and the direct cutting action of the tourniquet.[8] This mechanism is capable disrupting not only soft tissues, but even bone.[6] Constrictive scarring, flexion deformity, even urocutaneous fistulae, may complicate healing post release.[10]

Most cases of hair wrapping occur in young children; the age range of finger wrapping is 4 days to 19 months, and penile involvement is 4 months to 6 years.[11] Labial and clitoral wrapping have been described in an older age group (7-13 y).[12] Case reports have documented 80- and 84-year-old men with involved extremities.[13, 14] The younger age group, especially infants younger than 4 months, is thought to be more at risk because this is the period during which 90% of mothers experience excessive postpartum hair loss, called telogen effluvium.[15] Most cases of hair tourniquet syndrome are deemed accidental, but intentional cases consistent with child abuse have been cited in the literature.[16]

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 preventable with prompt diagnosis. Maintain a high index of suspicion when confronted with such presentations.

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Indications

Removal 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.[17]

Cases requiring surgical debridement have been described.[6, 18] When formation of excessive granulation tissue or involution under edematous skin is present, consider surgical referral.

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Contraindications

No absolute contraindications exist to the removal of a hair or thread tourniquet.

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.

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Anesthesia

Topical agents, local infiltration of anesthetic, nerve blocks, and moderate sedation can be used singly or in combination.

The choice of technique may vary depending on the clinician’s skill, the appendage involved, and the age and cooperation level of the patient.

Immobilization techniques may be required.

For more information on anesthetic administration techniques, see the following articles:

  • Topical Anesthesia
  • Infiltrative Administration of Local Anesthetic Agen ts
  • Procedural Sedation
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Equipment

Unwrapping method requires the following:

  • Gloves
  • Pincer instrument, if necessary (eg, fine-tipped forceps, hemostat)

Cutting method requires the following:

  • Gloves
  • Local or regional anesthesia materials
  • Scalpel blade, No. 11
  • Povidone-iodine (eg, Betadine) solution
  • Fine-tipped forceps
  • Ear wax curette
  • Fine-tipped hemostat
  • Blunt probe
  • Fine-tipped scissors

Depilatory method requires the following:

  • Gloves
  • Commercial depilatory cream
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Positioning

Positioning varies based on the body parts involved. Any position that maximizes exposure of the involved appendage or body part while maximizing patient comfort is recommended.

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Technique

Unwrapping method

This technique is likely to be successful in cases with minimal edema and clear access to the constricting fibers.

Look closely to identify a free end of the hair or thread.

Grasp the free end, then slowly pull and unwind the hair from the appendage using gloved fingers or a pincer instrument (eg, fine-tipped forceps, hemostat).

If no free end is visible, but a hair knot is visible, break the knot off the strand at one end using fine-tipped forceps, and then unwrap the hair as described.[8]

The unwrapping method may require multiple attempts, as the hair strand may break apart during removal or multiple hair strands may be involved.

Cutting method

Blunt probe method

This method is likely to be successful in cases in which the constricting band is not too deeply embedded in the soft tissue.

Gently wedge a blunt probe or metal earwax curette between the skin and the hair. Insertion is facilitated when performed in a proximal-to-distal direction while applying traction to the skin, allowing the hair to penetrate less deeply.[8] See images below.

The blunt probe method. The blunt probe method.
This illustration shows removal of a penile tourni This illustration shows removal of a penile tourniquet using the blunt probe method.

Cut the hair with fine-tipped scissors or a No. 11 scalpel blade directed against the surface of the probe or curette so as to protect the underlying skin. Alternatively, lift a strand of hair gently away from the skin with the upturned scalpel blade until the hair is divided.[2]

Once divided, the hair can be removed using the simple unwrapping method described above.

Incisional approach for digital involvement

This approach is the most invasive and should be reserved for severe cases of digital involvement.

A digital nerve block is recommended.

The involved area must be adequately sterilized with povidone-iodine solution and draped in the usual manner with close adherence to sterile protocol throughout the procedure.

Once the area is anesthetized and prepared, make an incision using a No. 11 scalpel blade at either the 3-o'clock or 9-o'clock position of the digit. See image below.

In this figure, the blade is in the 9-o'clock posi In this figure, the blade is in the 9-o'clock position. The dorsal alternative approach is also indicated.

The incision should be made longitudinally, with the blade perpendicular to the strand and skin surface, going from proximal to distal, and deep to bone to ensure incision of the fiber.[8]

The importance of the 3-o’clock and 9-o’clock positions is that they tend to avoid the dorsal and ventral neurovascular bundles of the digits. See image below for cross-section.

This cross-section of the finger illustrates the 3 This cross-section of the finger illustrates the 3-o'clock and 9-o'clock positions as well as the alternative dorsal approach for digital tourniquet removal.

An alternative incision site is along the dorsal aspect or 12-o’clock position (see image above).[11] A dorsal longitudinal incision parallel to the extensor tendon fibers is thought to heal well with splinting and general wound care.[8]

Incisional approach for penile involvement

This approach is the most invasive and should be reserved for severe cases of penile involvement.

A dorsal nerve block with or without topical anesthetic is recommended.

The area involved must be adequately sterilized with povidone-iodine solution and draped in the usual manner with close adherence to sterile protocol throughout the procedure.

The recommended site for the incision is the inferolateral surface at the 4-o’clock or 8-o’clock position, as these sites are ideal for minimizing risk of injury to the dorsal neurovascular structures of the penis. See image below.

To avoid the deep structures, the incision must be 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-o'clock and 8-o'clock positions. The dorsal neurovascular bundle is not compromised by these approaches.

The incision should be made longitudinally, staying in the deep penile fascia between the corpus cavernosum and spongiosum.[19]

The deep fascia of the penis is relatively tough. In light of this, the clinician may elect to make light incisions along the initial incision, slightly deeper with each stroke, with the goal of cutting the constricting band without penetrating the fascial layer into the lumen of the corpora.[8]

Depilatory method

Although such use is off-label, chemical depilatories are easy and painless to use, relinquishing the need for anesthetic agents.[17]

Standard chemical depilatory agents (eg, Nair) are thioglycolate-based and work to disrupt the chemical bonds of hair keratin, causing the hair to break in half. The limitation, hence, is that they work for hair tourniquets but not thread tourniquets.

Chemical depilatories should not be used on broken skin.

The manufacturer’s instructions recommend that a small site be tested before use 24 hours prior to the main application to assess for irritation or allergic reactions. This should not preclude the use of depilatory creams in emergent situations.

Apply the depilatory cream to the region of the hair tourniquet, with specific attention to the knotted area, and wait the time indicated on the product (typically, 3-10 min) for complete hair breakage.[2]

After the specified time has passed, wash off the depilatory cream with soap and water.

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Pearls

Always document neurovascular status, tendon function, or both after the procedure.

If the skin or distal structures have been lacerated or compromised by the tourniquet or its removal, appropriate tetanus wound prophylaxis should be provided.

A urology consultation should be obtained immediately in all cases of hair tourniquet that involve the penis.

Surgical consultation may be necessary in cases involving significant tissue edema, distorted anatomy, necrosis, or uncertainty about the completeness of the removal.

Antibiotic therapy should be considered for patients who are immunocompromised, have diabetes, or have contaminated wounds.[2]

Very young, preverbal children with constricting bands should be evaluated for child neglect or abuse.[16]

Urgent follow-up is required.

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Complications

Prolonged ischemia, the cutting action of the tourniquet, or the removal incision may all cause damage to the neurovascular structures of the involved appendage. The incisional approach is most fraught with risk for the complication of injury and poses the additional risk of damage to underlying structures. Incisional removal of hair tourniquets from the penis could damage the corpus callosum, corpus spongiosum, or urethra. The incisional approach on the digits may involve injury to the dorsal or palmar neurovascular bundles or flexor tendons when using the 3-o’clock or 9-o’clock incisions. Although the dorsal incision alternative should spare these digital structures, the extensor tendon or the tendon sheath may be damaged, the latter resulting in tenosynovitis.[8]

As with all procedures, if the skin is penetrated, either by the constricting band or an incision, bleeding and infection are known risks.

The use of commercial depilatory cream to remove a hair tourniquet may provoke local skin irritation or contact dermatitis.

Among the methods described, the simple unwrapping approach carries the least risk for iatrogenic complication.

Depending on the degree and duration of the constricted appendage, necrosis of distal structures may ensue.

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Contributor Information and Disclosures
Author

Daniel J Lumbrezer, MD Resident Physician, Department of Emergency Medicine, University of Kentucky Chandler Medical Center

Daniel J Lumbrezer, MD is a member of the following medical societies: Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Christopher I Doty, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

Dennis Cardriche, MD Resident Physician, Combined Emergency and Internal Medicine Program, Kings County Hospital, State University of New York Downstate Medical Center; Assistant Clinical Instructor; State University of New York Downstate School of Medicine

Dennis Cardriche, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Sivathasan N, Vijayarajan L. Hair-thread tourniquet syndrome: a case report and literature review. Case Rep Med. 2012. 2012:171368. [Medline]. [Full Text].

  2. Peckler B, Hsu CK. Tourniquet syndrome: a review of constricting band removal. J Emerg Med. 2001 Apr. 20(3):253-62. [Medline].

  3. Schneider K, Kennebeck S, Madden L, Campbell A. Hair tourniquet of the circumvallate papillae: a potentially "hairy" situation. Pediatr Emerg Care. 2013 Aug. 29(8):924-5. [Medline].

  4. Hickey BA, Gulati S, Maripuri SN. Hair toe tourniquet syndrome in a four-year-old boy. J Emerg Med. 2013 Feb. 44(2):358-9. [Medline].

  5. Dua A, Jamshidi R, Lal DR. Labial hair tourniquet: unusual complication of an unrepaired genital laceration. Pediatr Emerg Care. 2013 Jul. 29(7):829-30. [Medline].

  6. Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg. 2006 Oct. 57(4):447-52. [Medline].

  7. Bangroo AK, Chauhan S. Hair tourniquet syndrome (Case Report). Indian Assoc Pediatr Surg. 2005. 10(1):55-56.

  8. Loiselle J, Cook RT. Henretig FM, King C. Textbook of Pediatric Emergency Procedures. Baltimore, Md: Williams and Wilkins; 1997.

  9. Bothner J. Hair entrapment removal techniques. UpToDate. August 20, 2003.

  10. Liow RY, Budny P, Regan PJ. Hair thread tourniquet syndrome. J Accid Emerg Med. 1996 Mar. 13(2):138-9. [Medline]. [Full Text].

  11. Barton DJ, Sloan GM, Nichter LS, et al. Hair-thread tourniquet syndrome . Pediatrics. 1988 Dec. 82(6):925-8. [Medline].

  12. Bacon JL, Burgis JT. Hair thread tourniquet syndrome in adolescents: a presentation and review of the literature. J Pediatr Adolesc Gynecol. 2005 Jun. 18(3):155-6. [Medline].

  13. Miller RR, Baker WE, Brandeis GH. Hair-thread tourniquet syndrome in a cognitively impaired nursing home resident. Adv Skin Wound Care. 2004 Sep. 17(7):351-2. [Medline].

  14. Srinivasaiah N, Yalamuri R, Vetrivel S, Irwin L. Limb tourniquet syndrome - A cautionary tale. Injury Extra. Apr 2008. 39:140-42. [Full Text].

  15. Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003 Mar. 111(3):685-7. [Medline].

  16. Johnson CF. Constricting bands. Manifestations of possible child abuse. Case reports and a review. Clin Pediatr (Phila). 1988 Sep. 27(9):439-44. [Medline].

  17. O'Gorman A, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care. 2011 Mar. 27(3):203-4. [Medline].

  18. Okeke LI. Thread embedded into penile tissue over time as an unusual hair thread tourniquet injury to the penis: a case report. J Med Case Rep. 2008 Jul 16. 2:230. [Medline]. [Full Text].

  19. Kerry RL, Chapman DD. Strangulation of appendages by hair and thread. J Pediatr Surg. 1973 Feb. 8(1):23-7. [Medline].

 
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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-o'clock 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-o'clock and 8-o'clock positions. The dorsal neurovascular bundle is not compromised by these approaches.
 
 
 
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