Description

• Characterized by the tight wrapping of an appendage such as fingers, toes, or even genitalia with hair or hairlike materials (i.e., synthetic fibers, hair ties, elastic bands), causing the appendage to have interrupted blood flow and resulting ischemia and necrosis
• Appendage strangulation is an emergency and requires rapid diagnosis and treatment. Although typically found in infants, any individual with compromised mentation/communication can be at risk. Digits and the penis are the most common locations, but other potentially affected areas include the scrotum, clitoris, labia minora and majora, and the uvula.
• Extremely rare, although possible involvement of a limb/strangulation at the level of the neck
• Synonym(s): hair-thread tourniquet syndrome, toe tourniquet, finger tourniquet; penile hair tourniquet syndrome; hair coil strangulation

Epidemiology

Incidence
Incidence is unknown. Many cases likely not reported by caregivers and treated at home. Of the reported cases:

• Most common location is the penis (44%), followed by toes (40%), and fingers (9%). The most commonly affected toe is the 3rd toe (32%). About 1/3 of cases will have multiple digits involved.
• The offending agent for both toe and penile strangulation is predominantly human hairs. Finger cases usually involve synthetic fibers.
• Finger cases usually occur in the first few months of life. Toe strangulation is more common in older infants. Penile cases have an average age of 2 years. Clitoral and labial cases are found in older children.

Prevalence
Prevalence is not known. Many cases are likely not reported by caregivers.

Etiology and Pathophysiology

• Circumferential strangulation of an appendage initially leads to distal blockage of the lymphatic and venous drainage. This fluid congestion leads to tissue edema that causes further vascular blockage and arterial occlusion.
• Prolonged interruption of arterial flow will lead to tissue damage and death. This process can take hours to days, depending on multiple factors; if not interrupted, can result in amputation
• Hair tourniquet syndrome likely occurs as an infant’s fingers/toes come in contact with a hair or similar fiber in the enclosed covering of mittens/socks or a similar situation. As the infant moves digits back and forth, the hair is progressively wound around the digit.
• Wet hair especially may constrict as it dries, leading to additional strangulation.

General Prevention

• Parents should consider laundering their child’s clothing inside out to prevent accumulation of human hairs/fibrous materials that contribute to strangulation. This is especially true for socks, mittens, and similar clothing items with blind ends.
• Parents who notice an increased amount of hair loss after giving birth (i.e., telogen effluvium) should be mindful to remove loose hairs.
• It has also been suggested that being circumcised can increase a child’s risk for penile strangulation because an uncircumcised glans is more difficult to entrap. Also postulated is that the increased size of adult appendages accounts for the rare number of cases of hair tourniquets in older children and adults with cognitive impairment.

Commonly Associated Conditions

• Although hair tourniquet syndrome is rarely reported in older children/adults, any individual with compromised mentation/communication abilities may be at risk.
• If a child presents multiple times with this complaint, medical providers should consider nonaccidental child abuse (e.g., fabricated illness by a caregiver) as a cause.