If you are coming up with a list of causes of the inconsolable infant, the presence of a hair tourniquet falls very close to the bottom, along with corneal abrasions and hernias. As usual, one of my children* kindly volunteered her own experience as a way to spread the knowledge.
What is a hair tourniquet?
You can find the first documented case report of hair tourniquet syndrome hidden amongst the latest evidence for the treatment and prevention of cholera in an 1832 edition of the Lancet. Dr G. reported a case of a strand of hair forming a constricting band around the penis leading to ischaemia. In the same way that surgeons use an elastic band to create a bloodless field, a thin piece of thread or a long hair may wrap around a digit leading to necrosis.
Cases have been mainly been reported in young infants and incidence probably increases by about 3 months of age as maternal post-partum hair loss kicks in.
Telogen effluvium is not just the name of prog-rock band from the 1970s but also the term for postpartum related hair loss. Many pregnant mothers are complimented on the fullness of their hair, little knowing that it will fall out around three months after birth. According to DermNet NZ around 85% of hair follicles are in the growth, or anagen, phase of development and 15% are in the resting, or telogen, phase. These telogen hairs have a club bulb at the base and are pushed out as the result of new hair growth. So, paradoxically, the increase in hair fall postpartum is actually a sign of regrowth.
As they cut through skin and are buried in the surrounding oedematous tissue they can be hard to find and so may be missed. If present for some time they can be covered by a layer of new skin growth making them even tougher to diagnose and remove.
Where might they be found?
Case reports abound of digital auto-strangulation (predominantly toes) as well as reports of hairs around the labia, clitoris, and penis. Indeed, hair has been used as a means of female genital mutilation since time began. Exceedingly rare cases involving hair tourniquets around the uvula and circumvallate papillae have also been recorded in the literature.
An extensive literature search by Mat Saad et al. found 210 case reports in the literature – 44.2% involved the penis, 40.4% involved the toes, 8.57% involved the fingers with all other sites accounting for 6.83% of cases.
What are the risks of leaving them alone?
Prolonged ischaemia and tissue necrosis leading to auto-amputation have been widely reported.
How can you get rid of them?
In order to restore circulation to the encircled appendage, the tourniquet needs to be completely removed. Sometimes this can be done in the emergency department but if there is any doubt as to whether any remains then the child should be taken to theatre. Here the surgeon usually makes a longitudinal incision down to the bone ( at 3, 6, or 9 o’clock) to ensure complete removal. In the case of penile strangulation then the specialist will have to (carefully) cut down between corpus spongiosum and cavernosum. Take look at this Trick of the Trade from Academic Life in Emergency Medicine that suggests using a cutting needle rather than a scalpel.
Rather than unwind, or incise, there is another option – depilatory cream.
They work by breaking down the keratin in hair, and thus will not work if the tourniquet is caused by a thread. Applying a small amount to the groove cut by the hair for around ten minutes is followed by a gentle wash in warm water. This leads to the immediate resolution of symptoms. Of course, those cases in the literature are victims of positive reporting (who is going to submit a case report to a journal when the technique hasn’t worked?) but it is a painless method to try. Finding depilatory cream in the emergency department is another matter. Toothed forceps are often just sharp enough to slide under the hair tourniquet and strong enough to break the offending strand. Once circumferential skin breakdown has occurred though, these things really can become difficult to be confident you have removed completely, especially if the tourniquet is blonde.
What was the outcome?
Fortunately, these hairs and threads were pretty easy to untangle, leaving little Rosie with the full complement of toes.
- No children were actually harmed in the writing of this post.
Alruwaili N, Alshehri HA, Halimeh B. Hair tourniquet syndrome: Successful management with a painless technique. International Journal of Pediatrics and Adolescent Medicine. 2015 Mar 31;2(1):34-7.
Dr. G (1832) Ligature of the penis. Lancet II: 136
Golshevsky J, Chuen J, Tung PH. Hair‐thread tourniquet syndrome. Journal of paediatrics and child health. 2005 Mar 1;41(3):154-5.
Kurup HV, Gnanapavan M, McSweeney L. Hair‐tourniquet syndrome: Unwind or incise?. Emergency Medicine Australasia. 2006 Aug 1;18(4):415-.
O’Gorman A, Ratnapalan S. Hair tourniquet management. Pediatric emergency care. 2011 Mar 1;27(3):203-4.
Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Annals of plastic surgery. 2006 Oct 1;57(4):447-52.
Thomas AJ, Timmons JW, Perlmutter AD. Progressive penile amputation: tourniquet injury secondary to hair. Urology. 1977 Jan 1;9(1):42-4.
Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003 Mar 1;111(3):685-7.