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M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Monday, April 30, 2018

Small Hairs Make Big Cuts (and Consequences)

The hair or thread tourniquet syndrome is a relatively rare condition that has evaded me in the emergency department for several decades, until past year when three cases showed up over six months. This condition has been around for as long as there has been hair or thread and body appendages. In fact, this condition may have first been described in the 1600s. (J Pediatr Adolesc Gynecol 2005;18[3]:155.)

The etiology of this condition seems almost unbelievable. How in the world does a hair get wrapped repeatedly and tightly around an appendage of the body? Some authors expressed the need to consider nonaccidental etiologies more frequently. Stranger things, however, have happened in emergency medicine (e.g., the urinary catheter tying itself in a knot in the bladder of a patient). (APSP J Case Rep 2011;2[3]:21; J Clin Ultrasound 2009;37[6]:360.)

The risks of strangulation and autoamputation of the involved appendage are very real. This condition does not respect age, gender, or appendage. Hair tourniquets of the penis, clitoris, labia minora, teeth, uvula, fingers, toes, and even the larger extremities have been reported in the young and the elderly. They are, however, much more common in infants and young children than they are in adolescents or adults. In fact, a fascinating temporal association has been made between hair tourniquets and the mother's postnatal telogen effluvium, which causes significant maternal hair loss months after the infant's delivery. Consequently, we include hair tourniquets in that long checklist of potential issues afflicting the inconsolable infant. Corneal abrasions and colic may be much more common, but it makes perfect sense to examine all of the infant's appendages for a hair tourniquet.

I have been shocked by how rapidly these hair tourniquets burrow into the chubby subcutaneous tissues, making examination and quick removal nearly impossible. Hair has significant tensile strength, stretches when it's wet, and can be inadvertently tightened when an unsuspecting parent starts tugging on the exposed end of the hair. Furthermore, it can act like a garrote and cut through the soft skin of the infant while becoming increasingly inaccessible. When the health care provider begins to tease out the hair with a needle or forceps, bleeding quickly begins, making visualization even more difficult. Timely removal of the tourniquets is critical to preventing complications. The removal technique can be manual, chemical, or surgical.

Manual removal entails simply finding the free end of the hair or thread and unwinding it. This is often easier said than done. It can also involve using a blunt object such as forceps or an ear wax speculum, pushing it underneath the constricting material, lifting the tourniquet, and then cutting it and removing it. Chemical removal involves the use of depilatory agents that chemically break down hair protein. I have never used this technique, and some have reported that it can be a slow process. The failure rate will be high if the hair is already deeply buried. Most emergency departments don't plan ahead for hair tourniquets by stockpiling depilatory agents.

Surgical removal is sometimes necessary when presentation is late or the hair has rapidly burrowed deep into the subcutaneous tissue, preventing easy access for manual removal or lessening the potential effectiveness of depilatory agents. The surgical technique often requires anesthesia of the appendage, followed by a limited but relatively deep incision to ensure that the hair or thread has been released. In fact, the phrase "cut to the bone" is used on fingers and toes. A no. 11 scalpel blade is inserted at locations that avoid neurovascular bundles, and one goes all the way to the bone before withdrawing the blade. The incision on the penis or clitoris is made to the underlying fascia while being careful not to lacerate the three penile corpora bodies, the urethra, or the dorsal penile nerves. Incisions at the four and eight o'clock positions are recommended.​

Potential complications of the procedure can be trauma to the skin, bleeding, and infection, as well as injury of underlying neurovascular bundles. Contact dermatitis or skin irritation may occur if a depilatory cream is used. Assessment of tetanus immunization status is also recommended. Finally, close follow-up the next day is recommended to assess for continued improvement and absence of ischemia signs or infection.

mellick hair tourniquet.jpg
 

This child had a hair tourniquet deeply embedded in his pinkie.mellick photo 2 with video.JPG

Watch the removal of a hair tourniquet from a child's toe.