A single strand of hair or thread may encircle a finger, toe, or the penis, leading to circumferential strangulation of the appendage. Children in their 1st year of life are particularly at risk from inadvertent encirclement by a parent’s hair or loose thread especially within confining clothing. The affected digit appears edematous, erythematous, and painful. If not corrected, vascular compromise or infection can ensue. The differential diagnosis includes insect bites, trauma, cellulitis of the digit, osteomyelitis, or ainhum (dactylosis spontanea), a painful constriction in the base of the 5th toe of unknown etiology followed by spontaneous autoamputation months to years later.
Management and Disposition
Visualization of the constricting material may be difficult. Edema, erythema, and periarticular skin folds may hide the hair or thread. It is imperative to carefully retract the skin around the proximal aspect of the edematous appendage. A magnifying lens may be helpful in identifying the band. Since the removal can be painful, consider a digital or penile block prior to removal. A topical anesthetic may also be applied to assist in reducing local pain. If the tourniquet is deeply embedded, a higher level of sedation may be required to appropriately localize and remove it. For superficial tourniquets that are visible with the naked eye and without significant skin breakdown, chemical hair removers are an appropriate first choice. If the tourniquet is synthetic, chemical removal fails, or there is significant skin breakdown, mechanical removal is indicated. Using a small hemostat, grasp a portion of the material, cut it with a surgical blade, and unwind it. Elevation of the involved digit after removal of the constricting agent provides resolution of the edema and erythema within 2 to 3 days. In some cases, the digit’s blood supply may have been irreversibly compromised. Subspecialty consultation should be considered whenever neurovascular integrity is in question or if the constricting band cannot be visualized and removed. The patient should be reevaluated in 24 hours to assure improvement and need for further surgical consultation or intervention.
In the vast majority of cases, a clear line of demarcation can be identified between the normal tissue and the affected area.
Fussiness or irritability may be the only presenting symptom. Examination for hair tourniquets should be included in the evaluation of any inconsolable infant.
There may be an insidious onset with reepithelialization over the hair tourniquet, leaving it difficult to visualize.
Hair Tourniquet. A strand of hair has encircled the middle toe in two places, causing erythema and swelling. (Photo contributor: Kevin J. Knoop, MD, MS.)
Hair Tourniquet. Erythema distal to the hair tourniquet of the affected toes due to strangulation by the tourniquet. (Photo contributor: Robert W. Hickey, MD.)