Trick of the Trade: Hair tourniquet release

From Wikimedia Commons by Dr. James Heilman

A 3 month old baby presents with distal erythema and swelling of one of her toes. A hair tourniquet is identified. Typically one can try manually unwrapping the tourniquet using forceps, but often only part of the tourniquet can be removed. The distal toe remains swollen and erythematous with delayed capillary refill.

As demonstrated by the image above, it can be difficult to identify the hair because of the edema and the thin nature of the hair (especially if the same as the patient's skin color). In a 2006 review of hair tourniquets in the Annals of Plastic Surgery, they recommend incising down to the bone along the lateral edge of the digit to ensure tourniquet release. It seems a bit aggressive...

Trick of the Trade:
Cut the hair tourniquet using a "conventional cutting needle"

I shot a quick video (above) using a thick piece of chicken fat to demonstrate the principles.

This is a tip provided by Dr. Sarah Morris (Univ of Virginia EM resident) in conjunction with Dr. Robert O'Connor (UVA faculty), and Dr. William Woods (UVA faculty). Here are her great pearls:

Key points:
  1. There are different kinds of suture needles. Cutting needles have the sharp edge on the concave side (internal curvature), and reverse cutting needles have the sharp edge on the convex side (external curvature).
  2. Fear the hair tourniquet - complete resolution is more difficult than it seems
  3. Consider a cutting needle to cut through the hair causing the tourniquet and avoid making a large incision.
For a patient we encountered, we used a PC-1 cutting needle to sever the tourniquet. Following this, the hair appeared from the swollen toe and was able to be removed with forceps. The toe regained normal circulation, and skin indentation was improved but not resolved. The parents were instructed to clean the laceration on the plantar surface with soap and water, to follow up for a re-examination, and the child was placed on prophylactic keflex for 3 days.

A literature review suggests incising the hair with a scalpel (making a lateral incision of toe through skin and to the bone) or soaking in deploratory cream if one is unable to reduce the tourniquet with forceps. We are not aware of prior attempts using cutting needles to reduce hair tourniquet.

Removing a tourniquet is essential. Unsuccessful reduction may need operative management and can result in significant complications including digital loss, flexion deformities and amputations. Hair tourniquet removal can be very difficult as the hair eventually cuts through the edematous skin and becomes embedded in the subcutaneous tissue, making the hair virtually invisible. It is not uncommon for a constricting fibrosis to remain after removal of the tourniquet. If the hair tourniquet appears to have been removed, close follow up is needed to ensure a subcutaneous, invisible tourniquet is not present, as these have been known to cause bone erosion in the past.

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. Pubmed .
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