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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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CASE REPORT
Year : 2005  |  Volume : 10  |  Issue : 1  |  Page : 55-56
 

Hair tourniquet syndrome


Department of Pediatric Surgery, St. Stephens Hospital, Tis Hazari, Delhi - 110054, India

Correspondence Address:
A K Bangroo
Department of Pediatric Surgery, St. Stephens Hospital, Tis Hazari, Delhi - 110054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.16080

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   Abstract 

A frequently unrecognized and potentially devastating form of penile strangulation is that caused by human hair. Hair tourniquet syndrome frequently occurs during the time period when post partum mothers are experiencing increased hair loss. The majority of cases are thought to be accidental, however possibility of child abuse should be considered in every case.


Keywords: Telogen effluvium, hair tourniquet syndrome, urethrocutaneous fistula, gangrene


How to cite this article:
Bangroo A K, Chauhan S. Hair tourniquet syndrome . J Indian Assoc Pediatr Surg 2005;10:55-6

How to cite this URL:
Bangroo A K, Chauhan S. Hair tourniquet syndrome . J Indian Assoc Pediatr Surg [serial online] 2005 [cited 2017 Apr 23];10:55-6. Available from: http://www.jiaps.com/text.asp?2005/10/1/55/16080


The hair-thread tourniquet syndrome occurs when hair, and occasionally thread or fibre, wraps tightly around a young child's appendage and obstructs the circulation. Although most cases are felt to be accidental child abuse must be considered in selected cases.[1] The condition, although potentially preventable, can be quite serious if not promptly recognised and treated.

Reflecting the type of appendage involved, hair-thread tourniquet syndrome cases can be grouped into 3 distinct subsets: cases involving the toes, cases involving the fingers, and cases involving the genitals.[2]

Penile tourniquet injury probably is not a rare entity and has been reported following the application of numerous foreign objects, including rings, rubber bands, bottles, pipes and threads.[3],[4] A frequently unrecognized and potentially devastating form of penile strangulation is that caused by human hair.


   Case report Top


A ten-year old Muslim boy was brought to the hospital with history of black discoloration of the shaft of penis and glans (Figure 1), and passage of urine through an abnormal opening on the ventral side of penis.

Two months prior, patient had developed penile swelling, involving shaft and glans, for which he received treatment from a general practitioner in his village. Edema was not relieved, but itching and purulent discharge set in. He continued to be treated by the same practitioner till he developed loss of sensation and bluish discoloration of the penile shaft, which later on turned blackish.

Physical examination of the penis revealed dried, shriveled up, blackish glans and distal penile shaft. There was a marked mid penile constriction. Urethrocutaneous fistula was present on the ventral aspect of penis, proximal to the constriction.

Patient was examined, under anesthesia, inside the operating room. A coil of hair was found encircling the shaft of penis, which was deeply embedded in the necrotic tissue. The coil of hair was carefully removed and the gangrenous shaft amputated.


   Discussion Top


Telogen effluvium is a form of alopecia characterized by diffuse hair shedding, often with an acute onset.[5] Typically a person sheds no more than 50 to 100 hairs per day. However, excessive hair loss on the order or >100 hairs per day can occur because of the reactive process such as that found in the post partum period.[5],[6] Hair tourniquet syndrome frequently occurs during the time period when post partum mothers are experiencing increased hair loss.[7]

Human hair is extremely thin and, therefore, easily overlooked, especially when there is a foreign body reaction and local swelling. Hair has a tensile strength of greater than 29,000 pounds per square inch. It also stretches when wet, and contracts and tightens as it dries. These characteristics make it an excellent agent for intentional constriction.[8],[9]

Penile strangulation secondary to human hair was reported first by Morgenstern in 1888.[10] Since then, a number of cases have been reported. These patients always are children, with an age range of 21 days to 8 years.[11] Circumcision is an important predisposing factor, since it appears that the condition is much more common in circumcised boys.[12] How these injuries occur is a matter of some speculation. The majority of cases are thought to be accidental.[13] Strangulation of penis, by an ancient folklore, was used to ward of evil spirits. In more recent times it has been reported to have been used to prevent enuresis or nocturnal emission.[14] Thomas et al ;[13] have raised a possibility of child abuse and the importance of its consideration in every case.

The wrapping of a hair or thread around an appendage may produce a tourniquet effect, the degree of damage is highly variable, and usually correlates with the duration of the ongoing process. A constricting hair may decrease lymphatic drainage from the appendage. The lymph edema so produced impedes venous drainage, causing more edema and eventually prevents arterial flow to the tissue. If left unrelieved obstruction will lead to necrosis and tissue loss.

Important anatomical properties of the penile shaft were reviewed, by Bashir and EL-Barbary,[15] and correlated them to the progressive nature of injury. They categorized penile strangulation as: Grade 0: Constriction of skin without urethral injury, Grade 1: Partial division of corpus spongiosum with an urethrocutaneous fistula, Grade 2: Complete division of the corpus spongiosum and constriction of the corpus cavernosum and Grade 3: gangrene, necrosis and, complete amputation of the glans.

Based on an understanding of complication due to hair coil around an appendage, it is necessary to have high index of suspicion. The presence of a strangulating hair may go unnoticed, and the diagnosis may be missed, if the clinician is not alert to its possibility. Young boys especially circumcised presenting with penile or glanular swelling, purulent discharge or urine leaking from coronal sulcus, or a gangrenous glans.

Diagnosis is always based on clinical examination which at times is difficult due to edema or the hair being masked by the skin fold. Prompt removal of the hair by unwinding or cutting prevents complications like urethral fistula or gangrene. When severity is unclear, it is safer to err on the side of formal inspection in the operating room. If there is any doubt about the presence of a retained hair, and incision should be made at the depressed area on one side of the latero-inferior aspects of the penis. This will avoid injury to the urethra, the main nerves and to the blood supply.



 
   References Top

1.Wang M, Schott J, Tunnessen WW Jr. Picture of the month. Hair-thread tourniquet syndrome. Arch Pediatr Adolesc Med 2001;155:515-6.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome. Pediatrics 1988;82:925-8.  Back to cited text no. 2  [PUBMED]  
3.Stoller MI, Lue TF, McAninch JW. Constrictive penile band injury, anatomical and reconstructive considerations. J Urol 1987;137:740-2.  Back to cited text no. 3    
4.Tiwari VS, Razdan JL, Yadav VN. Strangulation of the penis by a metallic nut. Int Surg 1977;62:558-60.  Back to cited text no. 4  [PUBMED]  
5.Lynfield YL, Effect of pregnancy on the human hair cycle. J Invest Dermatol 1960;35:323-7.  Back to cited text no. 5    
6.Headington JT. Telogen effluvium. New concepts and review. Arch Dermatol 1993;129:356-63.  Back to cited text no. 6  [PUBMED]  
7.Stahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics 2003;111:685-7.  Back to cited text no. 7    
8.Alpert JJ, Filler R, Glaser HH. Strangulation of an appendage by hair wrapping. N Eng J Med 1965;273:866-7.  Back to cited text no. 8  [PUBMED]  
9.Summers JL, Guira AC. Hair Strangulation of the external genitalia. Report of two cases Ohio State Med J 1973;69:672-3.  Back to cited text no. 9  [PUBMED]  
10.Morgenstern J. Retention of urine and edema of penis from constriction by hairs. Pediatrics 1888;5:248.  Back to cited text no. 10    
11.Sheinfeld J, Cos LR, Erturk E, Cockett AT. Penile tourniquet injury due to coil of hair. J Urol 1985;133:1042-3.  Back to cited text no. 11  [PUBMED]  
12.Kirtane JM, Samuel KV. Hair coil strangulation of the penis. J Pediatr Surg 1994;29:1317-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Thomas AJ Jr, Timmons JW, Perlmutter AD. Progressive penile amputation. Tourniquet injury secondary to hair, Urology 1977;9:42-4.  Back to cited text no. 13  [PUBMED]  
14.Nazir Z, Rasheed K, Moazzam F. Penile constrictive band injury. J Pak Med Assoc 1993;43:135-7.  Back to cited text no. 14    
15.Bashir AY, El - Barbary M. Hair coil strangulation of penis. J Roy Coll Surg Edin 1980;25:47-9.  Back to cited text no. 15    


Figures

[Figure - 1]


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