Hair-Thread Tourniquet Syndrome in a Cognitively Impaired Nursing Home Resident

Advances in Skin & Wound Care, Sep 2004 by Miller, Ram R, Baker, William E, Brandeis, Gary H

Hair-thread tourniquet syndrome is a general term that refers to a constriction injury resulting from a strand of hair or a thread wrapped tightly around an appendage. Although extensively described in infants, it is believed that no cases have been reported among adults.1'2 This article describes a case of hairthread tourniquet syndrome in a cognitively impaired nursing home resident.

Case History

An 84-year-old woman with a history of severe Alzheimer's disease (Mini Mental State Examination [MMSE] score = 5) has : been a nursing home resident for 3 years. She is dependent in all activities of daily living (ADLs) and responds only to her first name. When asked direct questions, she gives single-word answers such as "OK." She is incontinent of both urine and feces. The nursing home staff dresses and changes her multiple times daily. One morning after taking off the resident's socks for routine care, the certified nursing assistant (CNA) noticed a deep circumferential laceration of the left fourth toe, with tenderness to palpation. No history was obtainable from the patient due to her advanced dementia. However, nursing staff at the facility did not report that she had been exhibiting any signs of pain or discomfort or that she had any changes in behavior. The resident was transferred to the emergency department (ED) for evaluation.

On presentation to the ED, the patient denied complaints; she specifically denied any complaints pertaining to the affected toe. On examination, the patient was calm and cooperative. Her vital signs, including temperature, were normal. With the exception of the affected toe, the physical examination was within normal limits. Her left fourth toe was swollen and erythematous, with a well-demarcated circumferential line over the mid-portion of the proximal phalanx. Closer inspection of this area revealed a fine circumferential laceration of the toe (Figures 1 and 2). Erythema distal to the laceration blanched and capillary refill was brisk, although the toe was tender. No gross bony deformity was observed, and sensory and motor functions were intact. The remainder of the extremity appeared normal.

The wound was cleansed and gently explored with a forceps. At this point, a light-colored thread was discovered in the wound (Figure 3).The end was located and the thread was gently unwound from the wound without the aid of anesthesia. A radiograph was obtained; no fracture or radiopaque foreign body was revealed.

The wound was irrigated with normal saline solution and dressed. The patient was treated with tetanus toxoid and oral ccphalexin because of concern for the presence of woundassociated cellulitis. The resident was discharged back to the nursing home with wound care instructions and a course of oral cephalexin. A scab formed over the wound after 2 days, and the wound healed completely within 2 weeks. The patient did not suffer any permanent sequelae.

Discussion

This is believed to be the first reported case of hair-thread tourniquet syndrome in an adult.The term /?m'r-Mm?d fourm^urf syndrome is used to refer to a constriction injury that results from a strand of hair or a thread wrapped tightly around an appendage. This phenomenon has been extensively reported in infants.1,2 The earliest such case, reported in 1832, involved a 4week-old boy with a hair wrapped around his penis.^ A review of 66 cases from the literature reported that 43% involved toes, 24% involved fingers, and 22% involved external genitalia.'* Of the cases involving toes, the age of the patients ranged from 20 days to 15 months. Knitted socks or mittens, particularly those made of synthetic fibers, are believed to be the most likely sources of the constricting threads. These items often have a wide weave and are made of fibers that do not easily stretch, which may increase the risk of appendages becoming entrapped.5-7 Constriction banding injuries have been reported in older children, generally in the context of abuse or selfdestructive behavior.8,9

In this case study, the patient's cognitive impairment, her dependence in all ADLs, and her decreased ability to communicate may have resulted in a pattern of risk for this phenomenon similar to that of very young children. Approximately 7% to 8% of adults in the United States have severe cognitive impairment.'^ Given this statistic, it is unclear why a greater number of hair-thread tourniquet syndrome injuries have not been reported. The postulated mechanism by which these injuries occur in children requires entrapment of an appendage in a loose thread or weave. Perhaps the larger-sized digits of adults confer some protection from such injuries, in that a larger band is required to cause constriction.

In this patient's case, the cotton-polyester blend of socks she wore was the probable source of the constricting thread. The lack of expressed pain, discomfort, or change in behavior (which is often the presenting sign of pain in cognitively impaired elders) made the diagnosis of this condition difficult. Severe injury, including loss of the toe, might have resulted had the CNA not noted the wound.