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Strangulation of appendages by hair and thread
Strangulation of Appendages by Hair and Thread By Robert
L. Kerry and Daniel D. Chapman
T
HIS SERIES OF CASES of strangulation of appendages is reported to call attention to a frequently unrecognized entity, to emphasize its importance, and to recommend a simple method of treatment. The study includes a review of the limited number of cases of strangulation of appendages reported in the literature, as well as a presentation and discussion of cases encountered in the authors’ practices. of an appendage In 1965 Alpert et al.,’ reported three cases of strangulation by hair wrapping, and emphasized that because of the physical characteristics of human hair, its presence as a foreign body may not be recognized and diagnosis may be missed. In 1966, Curran described a case suggesting intentional encirclement of toes by hair, and Feinberg3 emphasized the significance of interdigital friction burns caused by loose elastic protruding into the lumen of an infant’s pajama bootees. Quinn4 in 1971 labeled this condition as the “toe tourniquet syndrome,” pointing out that loose threads from leotard-type garments inadvertently may become wrapped about a child’s toes, and he warned both parents and the garment industry to be aware of this condition. As delay in recognition and institution of proper treatment of this problem can result in loss of part or all of an appendage, it was felt that a clinical review of ten cases seen in the past 3 yr at the St. Joseph Mercy Hospital in Ann Arbor, Mich., would be beneficial. CASE REPORTS Case I: While traveling in Holland, B.J., a &mo-old dark-haired male infant, was found to have a red, swollen right third toe (Fig. IA). The baby was taken to a medical clinic there and the physician diagnosed the condition as strangulation of the toe by hair wrapping. He subsequently unwrapped three turns of light-colored hair from the toe and told the mother that it might take 2-3 wk for the swelling to subside. When she returned to Ann Arbor, increased swelling and blueness occurred in the strangulated portion of the toe. The mother took the child to their pediatrician, who unwound an additional three turns of hair and sought follow-up surgical consultation. No further hair could be seen, although the swelling was so severe it was impossible to be absolutely certain. Because of impending gangrene, it was elected to take the child to the operating room to explore the toe (Fig. 1B). Through an incision with a Bard Parker No. 11 scalpel From the Departmenfs of Surgery and Pediatrics, St. Joseph Mercy Hospital, Ann Arbor, Mich. Supported by the Dowsett Memorial Fund. Robert L. Kerry, M.D.: Clinical Znstrucfor in Surgery, University of Michigan Medical School, Ann Arbor, Mich., and member of the Attending Staff, St. Joseph Mercy Hospital, Ann Arbor, Mich. Daniel D. Chapman, M.D.: Clinical Associate in Pediatrics, Uniaersity of Michigan Medical SchooZ, Ann Arbor, Mich., and member of the Attending Staff, St. Joseph Mercy Hospital, Ann Arbor, Mich. Address for reprint requests: Robert L. Kerry, M.D., Stadium Professional Center, 2311 East Sradium Boulenard, Ann Arbor, Mich. 48104. 0 1973 by Grune 6 Stratton, Inc.
h.mal
Of k?diatric
Surgery,
Vol. 8, No. 1 (February),
1973
23
24
KERRYANDCHAPMAN
Fig. 1. (A) Case 1. Tourniquet injury to third toe. (6) Case 1. Tourniquet injury to third toe showing depth of injury to the flexor tendon and neurovascular bundle. (C) Type and location of the recommended incision for strangulation of the toe and finger.
.blade made on the lateral side of the toe down to the bone, four additional turns of hair were found and cut. (Fig. 1C). The hair had eroded the skin down to the bone and was constricting three of the four neurovascular bundles. By cutting down to the bone, the tourniquet effect was released and the hair was removed without difficulty. Within 2 wk the severe swelling and blueness had subsided, and by 1 mo the toe appeared normal. The mother, a well-educated woman and apparently responsible, was unable to explain how the hair might have become wrapped around the toe. Case 2: K.M., a 7-wk-old boy, was noted to have the right third toe swollen with a proximal constricted area (Fig. 2). The child’s toe had become caught in cotton threads inside his pajama bootee. One complete wind of thread around the toe was removed by the patient’s pediatrician, who then requested follow-up surgical consultation, fearing that additional constriction might be present. To be certain that additional fibers were not still present, an incision with a No. 11 surgical blade was made on the lateral side of the toe between the neurovascular bundles, extending to the bone, so that it would cut and release any constricting band of thread or hair in the area. No additional threads were found but, more important, further constriction and strangulation of the appendage could be ruled out. Minimal injury occurred from the procedure. Within two days the redness and swelling had disappeared and the child had an uneventful postoperative course. Case 3: F.B., a 5-mo-old boy, was brought to the Emergency Room of St. Joseph Mercy Hospital with a 48-hr history of crying of undetermined cause. Booties had been placed on his feet shortly before the crying began. On removal of the booties by the physician, a band of thread was found wrapped around the base of a gangrenous right fifth toe.
STRANGULATION
OF APPENDAGES
25
Fig. 2. Case 2. Tourniquet injury to third toe with minimal injury. Unfortunately, ischemic necrosis and gangrene had already taken place and amputation of the toe was required. Case 4: A.F., a o-wk-old girl, presented to the Emergency Room with redness and swelling of the right third toe for 6 hr. Fine hairs were removed from the constricted area, which included a break in the skin of the toe. Foot hygiene was very poor. Case 5: W.R., a 6-wk-old boy, was found on a well-baby checkup to have mild strangulation of his right second and third toes by hair wrapped in a figure 8, which had been unnoticed by the mother. By careful unwrapping the physician was able to remove the hair and within a few days the minor creases and distal swelling had disappeared. In this case the mother’s hair was relatively short but the boy’s 3-yr-old sister had waistlength hair. Case 6: L.L., a 7-wk-old baby girl, was brought to the Emergency Room by her mother. The child had a hair wrapped numerous times around the left fourth toe, which was swollen and cold. A lateral incision was made in the toe and the hair removed, but the child was admitted to the hospital for observation because of the questionable viability of the distal toe. Two hours after the incision and removal of the hair, capillary fill was noted. Two days later the child was discharged when it became obvious that the toe was viable, although it remained erythematous for several days. Case 7: C.S., a 14-wk-old girl, was found on a routine checkup examination to have a piece of the mother’s long hair wrapped around her second toe, in a crease of the toe. No distal swelling was noted. Three turns unwound easily and there has been no further difficulty. Case 8: E.H., a 6-wk-old boy, was found on a well-baby checkup to have long hair wrapped around the penis, which probably would have been missed except that the pediatrician thought of this possibility upon noting the mother’s very long blond hair. Simple unwinding resolved the problem. Case 9: J.E., a 4-mo-old boy, was found by the pediatrician to have hair wrapped around the penis. The mother reported that the child had a peristent cry and that the penis had appeared swollen for several weeks, but she neglected to notify the physician. Unwinding of the hair resulted in gradual resolution of the problem. The parents appeared to be competent and, as the color of the constricting hair was the same as the mother’s, the only logical explanation seemed to be that some of the mother’s waist-length hair accidentally became wound around the penis while she was dressing the baby. Case 10: J.D., a lo-mo-old boy, was seen in the Emergency Room of St, Joseph Mercy Hospital with a markedly swollen penis and a proximal constricted area about which hair had been wrapped. This hair was unwound in the Emergency Room. The mother admitted to wrapping hair around the penis to control enuresis. The child was seen on follow-up urological evaluation, and it was noted that the unwrapping of the hair resulted in gradual resolution of the swelling.
26
KERRY AND CHAPMAN
CORPUS CAVERNOSUM
URETHRA CORPUS /-SPONOIOSUM
Fig. 3. Type and location of the recommended incision for strangulation of the penis. DISCUSSION The causes of strangulation of appendages are varied, and the condition may occur accidently or purposely from a strand of hair or thread. The foreign body, whether hair or thread, may come from the child’s own clothing or that of others. Children’s clothing, especially that of the leotard type, should be checked for loose strands of thread. Also, occasionally adults who are emotionally disturbed or are attempting to carry out some ethnic practice or superstitious belief may wrap hair or thread around an appendage. A diagnosis of strangulation should be considered when any swollen appendage is seen. In order to make a diagnosis, complete removal of clothing is necessary. It should be emphasized that even though a foreign body may not be seen, if depression or constriction is noted, careful exploration of the appendage with a forceps and a lateral in&ion should be considered. The recommended treatment initially should include the unwinding of any foreign material. Unless one can be completely certain that all the material is removed, a simple lateral incision should be carried out. In the toe this incision should be between the neurovascular bundles, avoiding tendons found on the plantar and dorsal surfaces. The same technique could be used for similar lesions of the finger. In the case of the penis, unwinding is, of course, the first procedure. If any question remains about retained material, an incision should be made at the depressed area on one of the lateral inferior aspects between the corpus cavernosum penis and the corpus spongiosum penis (Fig. 3). Great care should be taken to avoid cutting into the corpus spongiosum penis and the urethra contained therein. An incision here also avoids the main nerve and blood supply on the dorsal surface.
STRANGULATION
27
OF APPENDAGES
Frequent and careful follow-up is indicated in all cases to be certain that all foreign material has been removed, that swelling has subsided, and that the resultant distal injury has healed. CONCLUSION
The purpose of this report is to emphasize the importance of recognizing strangulation of an appendage so that it may be diagnosed and treated before irritation, swelling, and constriction are followed by ischemia, necrosis, and gangrene, and termination by amputation. A simple operative procedure is recommended to be certain that the treatment of the condition resolves the problem. REFERENCES 1. Alpert, J. J., Filler, R., and Glaser, H. H.: Strangulation of an appendage by hair wrapping. N. Eng. J. Med. 273:866, 1965. 2. Curran,
J. P.: Digital strangulation hair wrapping. J. Pediat. 69:137, 1966.
by
3. Feinberg, S. N.: Interdigital friction burns by loose elastic. Amer. J. Dis. Child. 112:476, 1966. 4. Quinn, N. J.: Toe tourniquet
Pediatrics
48 :I&, 1971.
syndrome.
L. Kerry and Daniel D. Chapman
T
HIS SERIES OF CASES of strangulation of appendages is reported to call attention to a frequently unrecognized entity, to emphasize its importance, and to recommend a simple method of treatment. The study includes a review of the limited number of cases of strangulation of appendages reported in the literature, as well as a presentation and discussion of cases encountered in the authors’ practices. of an appendage In 1965 Alpert et al.,’ reported three cases of strangulation by hair wrapping, and emphasized that because of the physical characteristics of human hair, its presence as a foreign body may not be recognized and diagnosis may be missed. In 1966, Curran described a case suggesting intentional encirclement of toes by hair, and Feinberg3 emphasized the significance of interdigital friction burns caused by loose elastic protruding into the lumen of an infant’s pajama bootees. Quinn4 in 1971 labeled this condition as the “toe tourniquet syndrome,” pointing out that loose threads from leotard-type garments inadvertently may become wrapped about a child’s toes, and he warned both parents and the garment industry to be aware of this condition. As delay in recognition and institution of proper treatment of this problem can result in loss of part or all of an appendage, it was felt that a clinical review of ten cases seen in the past 3 yr at the St. Joseph Mercy Hospital in Ann Arbor, Mich., would be beneficial. CASE REPORTS Case I: While traveling in Holland, B.J., a &mo-old dark-haired male infant, was found to have a red, swollen right third toe (Fig. IA). The baby was taken to a medical clinic there and the physician diagnosed the condition as strangulation of the toe by hair wrapping. He subsequently unwrapped three turns of light-colored hair from the toe and told the mother that it might take 2-3 wk for the swelling to subside. When she returned to Ann Arbor, increased swelling and blueness occurred in the strangulated portion of the toe. The mother took the child to their pediatrician, who unwound an additional three turns of hair and sought follow-up surgical consultation. No further hair could be seen, although the swelling was so severe it was impossible to be absolutely certain. Because of impending gangrene, it was elected to take the child to the operating room to explore the toe (Fig. 1B). Through an incision with a Bard Parker No. 11 scalpel From the Departmenfs of Surgery and Pediatrics, St. Joseph Mercy Hospital, Ann Arbor, Mich. Supported by the Dowsett Memorial Fund. Robert L. Kerry, M.D.: Clinical Znstrucfor in Surgery, University of Michigan Medical School, Ann Arbor, Mich., and member of the Attending Staff, St. Joseph Mercy Hospital, Ann Arbor, Mich. Daniel D. Chapman, M.D.: Clinical Associate in Pediatrics, Uniaersity of Michigan Medical SchooZ, Ann Arbor, Mich., and member of the Attending Staff, St. Joseph Mercy Hospital, Ann Arbor, Mich. Address for reprint requests: Robert L. Kerry, M.D., Stadium Professional Center, 2311 East Sradium Boulenard, Ann Arbor, Mich. 48104. 0 1973 by Grune 6 Stratton, Inc.
h.mal
Of k?diatric
Surgery,
Vol. 8, No. 1 (February),
1973
23
24
KERRYANDCHAPMAN
Fig. 1. (A) Case 1. Tourniquet injury to third toe. (6) Case 1. Tourniquet injury to third toe showing depth of injury to the flexor tendon and neurovascular bundle. (C) Type and location of the recommended incision for strangulation of the toe and finger.
.blade made on the lateral side of the toe down to the bone, four additional turns of hair were found and cut. (Fig. 1C). The hair had eroded the skin down to the bone and was constricting three of the four neurovascular bundles. By cutting down to the bone, the tourniquet effect was released and the hair was removed without difficulty. Within 2 wk the severe swelling and blueness had subsided, and by 1 mo the toe appeared normal. The mother, a well-educated woman and apparently responsible, was unable to explain how the hair might have become wrapped around the toe. Case 2: K.M., a 7-wk-old boy, was noted to have the right third toe swollen with a proximal constricted area (Fig. 2). The child’s toe had become caught in cotton threads inside his pajama bootee. One complete wind of thread around the toe was removed by the patient’s pediatrician, who then requested follow-up surgical consultation, fearing that additional constriction might be present. To be certain that additional fibers were not still present, an incision with a No. 11 surgical blade was made on the lateral side of the toe between the neurovascular bundles, extending to the bone, so that it would cut and release any constricting band of thread or hair in the area. No additional threads were found but, more important, further constriction and strangulation of the appendage could be ruled out. Minimal injury occurred from the procedure. Within two days the redness and swelling had disappeared and the child had an uneventful postoperative course. Case 3: F.B., a 5-mo-old boy, was brought to the Emergency Room of St. Joseph Mercy Hospital with a 48-hr history of crying of undetermined cause. Booties had been placed on his feet shortly before the crying began. On removal of the booties by the physician, a band of thread was found wrapped around the base of a gangrenous right fifth toe.
STRANGULATION
OF APPENDAGES
25
Fig. 2. Case 2. Tourniquet injury to third toe with minimal injury. Unfortunately, ischemic necrosis and gangrene had already taken place and amputation of the toe was required. Case 4: A.F., a o-wk-old girl, presented to the Emergency Room with redness and swelling of the right third toe for 6 hr. Fine hairs were removed from the constricted area, which included a break in the skin of the toe. Foot hygiene was very poor. Case 5: W.R., a 6-wk-old boy, was found on a well-baby checkup to have mild strangulation of his right second and third toes by hair wrapped in a figure 8, which had been unnoticed by the mother. By careful unwrapping the physician was able to remove the hair and within a few days the minor creases and distal swelling had disappeared. In this case the mother’s hair was relatively short but the boy’s 3-yr-old sister had waistlength hair. Case 6: L.L., a 7-wk-old baby girl, was brought to the Emergency Room by her mother. The child had a hair wrapped numerous times around the left fourth toe, which was swollen and cold. A lateral incision was made in the toe and the hair removed, but the child was admitted to the hospital for observation because of the questionable viability of the distal toe. Two hours after the incision and removal of the hair, capillary fill was noted. Two days later the child was discharged when it became obvious that the toe was viable, although it remained erythematous for several days. Case 7: C.S., a 14-wk-old girl, was found on a routine checkup examination to have a piece of the mother’s long hair wrapped around her second toe, in a crease of the toe. No distal swelling was noted. Three turns unwound easily and there has been no further difficulty. Case 8: E.H., a 6-wk-old boy, was found on a well-baby checkup to have long hair wrapped around the penis, which probably would have been missed except that the pediatrician thought of this possibility upon noting the mother’s very long blond hair. Simple unwinding resolved the problem. Case 9: J.E., a 4-mo-old boy, was found by the pediatrician to have hair wrapped around the penis. The mother reported that the child had a peristent cry and that the penis had appeared swollen for several weeks, but she neglected to notify the physician. Unwinding of the hair resulted in gradual resolution of the problem. The parents appeared to be competent and, as the color of the constricting hair was the same as the mother’s, the only logical explanation seemed to be that some of the mother’s waist-length hair accidentally became wound around the penis while she was dressing the baby. Case 10: J.D., a lo-mo-old boy, was seen in the Emergency Room of St, Joseph Mercy Hospital with a markedly swollen penis and a proximal constricted area about which hair had been wrapped. This hair was unwound in the Emergency Room. The mother admitted to wrapping hair around the penis to control enuresis. The child was seen on follow-up urological evaluation, and it was noted that the unwrapping of the hair resulted in gradual resolution of the swelling.
26
KERRY AND CHAPMAN
CORPUS CAVERNOSUM
URETHRA CORPUS /-SPONOIOSUM
Fig. 3. Type and location of the recommended incision for strangulation of the penis. DISCUSSION The causes of strangulation of appendages are varied, and the condition may occur accidently or purposely from a strand of hair or thread. The foreign body, whether hair or thread, may come from the child’s own clothing or that of others. Children’s clothing, especially that of the leotard type, should be checked for loose strands of thread. Also, occasionally adults who are emotionally disturbed or are attempting to carry out some ethnic practice or superstitious belief may wrap hair or thread around an appendage. A diagnosis of strangulation should be considered when any swollen appendage is seen. In order to make a diagnosis, complete removal of clothing is necessary. It should be emphasized that even though a foreign body may not be seen, if depression or constriction is noted, careful exploration of the appendage with a forceps and a lateral in&ion should be considered. The recommended treatment initially should include the unwinding of any foreign material. Unless one can be completely certain that all the material is removed, a simple lateral incision should be carried out. In the toe this incision should be between the neurovascular bundles, avoiding tendons found on the plantar and dorsal surfaces. The same technique could be used for similar lesions of the finger. In the case of the penis, unwinding is, of course, the first procedure. If any question remains about retained material, an incision should be made at the depressed area on one of the lateral inferior aspects between the corpus cavernosum penis and the corpus spongiosum penis (Fig. 3). Great care should be taken to avoid cutting into the corpus spongiosum penis and the urethra contained therein. An incision here also avoids the main nerve and blood supply on the dorsal surface.
STRANGULATION
27
OF APPENDAGES
Frequent and careful follow-up is indicated in all cases to be certain that all foreign material has been removed, that swelling has subsided, and that the resultant distal injury has healed. CONCLUSION
The purpose of this report is to emphasize the importance of recognizing strangulation of an appendage so that it may be diagnosed and treated before irritation, swelling, and constriction are followed by ischemia, necrosis, and gangrene, and termination by amputation. A simple operative procedure is recommended to be certain that the treatment of the condition resolves the problem. REFERENCES 1. Alpert, J. J., Filler, R., and Glaser, H. H.: Strangulation of an appendage by hair wrapping. N. Eng. J. Med. 273:866, 1965. 2. Curran,
J. P.: Digital strangulation hair wrapping. J. Pediat. 69:137, 1966.
by
3. Feinberg, S. N.: Interdigital friction burns by loose elastic. Amer. J. Dis. Child. 112:476, 1966. 4. Quinn, N. J.: Toe tourniquet
Pediatrics
48 :I&, 1971.
syndrome.