An infant is brought in with increased irritability x 2 days. The parents note that she hasn’t had any remarkable symptoms – no fever, cough, congestion, vomiting, diarrhea. She is tolerating feeds, but more fussy than usual. Your initial exam is normal. The mother later directs you to take a closer look at the infant’s feet, stating she noticed what looks like a bug bite on the tip of a toe.

 Toe2

What is the most likely diagnosis?

What are your treatment / intervention options?

The image above is consistent with a Hair – Thread Tourniquet. This is a potentially dangerous clinical finding that needs to be addressed immediately. Hairs or threads can sometimes become tightly wrapped around digits or genitals, leading to distal ischemia and amputation. Often times the hairs or threads are very difficult to visualize, therefore you must perform very detailed physical exams and maintain this diagnosis on your list of differentials when presented with a fussy / irritable child.

 

Options for removal of superficial threads:

-Grasp loose end of thread/hair with toothless forceps or hemostat and unwrap (if possible)
-Insert blunt probe under hair and cut across
-Chemical depilatory (Nair) to dissolve hair – requires topical application for 30-60 minutes

Surrounding edema and deeply embedded hairs will require more invasive techniques to relieve constriction:

– Dorsal incision to completely avoid neurovascular bundle on digits
– Choosing 3 o’clock or 6 o’clock position with a longitudinal incision with blade perpendicular to skin (see below)

Technique

 

References:

Roberts: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th Ed.

http://www.uptodate.com/contents/hair-entrapment-removal-techniques