Hair thread tourniquet syndrome or hair toe tourniquet syndrome or toe tourniquet syndrome is a very uncommon emergency that occurs when a toe is circumferentially strangulated by human hair or some other fiber. It can also affect the fingers or penis, with it being often reported that about 40-50% of cases affect the toes. It generally only happens in infants. The hair thread or fiber becomes so tightly wrapped around the digit that it results in pain, injury and in the worst cases, amputation from the strangulation. The cause is accidental, but on rare occasions child abuse may have to be considered.
The mechanism of the tissue damage is from the constricting effect of the hair causing lymphatic and venous obstruction resulting in oedema and swelling of the tissues. As the tissue swells, a vicious cycle is started to make the tourniquet tighter. Eventually arterial perfusion is limited. The hair can cut through the oedematous skin to be embedded in the subcutaneous tissue. Skin re-epithelialization over the hair can occur. If the arterial flow is interupted for too lengthy a time, there will be tissue damage and death with eventual auto-amputation.
It was first called toe tourniquet syndrome by Quinn in 1971.
It typically presents with pain, a circumferential groove around the toe, oedema, redness of the toe and signs of developing ischaemia. The symptoms may progress rapidly over a number of hours or be more insidious over several months. The infant is usually irritable. Bone erosion and tendon lesions have been reported in some cases, if the strangulation has been longer term. It has been suggested that ultrasound may be useful to diagnose.
Differential diagnosis: ainhum
It is not specifically known why the hair so tightly intertwines around the toe, but wet hair constricts more as it drys so this may be a factor. There are periods of high hair loss in the months following pregnancy (telogen effluvium) and this could be considered a potential risk factor as this peaks around 4 months after the birth, which is a common age for this syndrome to occur at.
Esat et al speculated that the failure to turn socks inside out during washing so as to remove potential hair that may be the problem and advised doing this as a simple preventative measure.
In a 1991 survey of healthcare and child protective services in Miami, USA, 83% of the child welfare workers and 45% of the public health nurses misinterpreted this as intentional injury, raising issues of potential child abuse (Biehler et al). The consensus in the literature is that this is not an intentional injury, thought repeated incidences in the same child may need to be investigated (eg Munchausen by proxy).
Management of Hair Thread Toe Tourniquet Syndrome:
Treatment needs to be prompt to avoid ischaemia and loss of the toe. The offending hair or fiber has to be removed, but this can be difficult as the hair may be covered by epithelisation, necessitating incision. In minor cases, simple unwrapping may be possible
Blunt probe method: used if the hair is not too deeply embedded in the tissues; insert a blunt probe under the hair to elevate and the cut the hair with scalpel or fine scissors.
Incisional method: this will need a digital block; make a deep longitudinal incision on medial or lateral side of the digit, avoiding neurovascular bundles to the cut hair.
Prevention: hygiene measures to prevent accumulation of hair in the infants environment. It has been suggested that turning socks inside out when washing them may be an important preventative measure.
Provided prompt removal of the constricting hair or fibre is done, healing is usually quick, uneventful and outcomes excellent with no long term sequelae.
Hair tourniquet syndrome of the toe (Podiatry Arena)
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