Rabindran1, Hemant Parakh2
1Dr. Rabindran, Junior Consultant Neonatologist, 2Dr. Hemant Parakh, Consultant Neonatologist. Both are affiliated with Sunrise Super specialty Children’s Hospital, Hyderabad, India
Address for Correspondence: Dr Rabindran, E mail: rabindranindia@yahoo.co.in
Abstract
Hand injury secondary to mittens application have been reported since 1960s. A neonate was brought with history of bilateral hand swelling with dusky discoloration predominantly involving the right hand. Two mittens were worn in both hands and tightened at the wrist by elastic bands. Discoloration of the right hand with constriction mark at the wrist was noted. Hair thread tourniquet syndrome was suspected which is caused by hair or synthetic strands tightly wrapped around appendages.The underlying pathophysiology is impedance of lymphatic flow, venous outflow and/or arterial inflow obstruction. Treatment is prompt removal of the constricting substance with supportive care.
Key words: Hair thread tourniquet syndrome, Mittens, Hand injury in neonate
Manuscript received: 12th Jan 2015, Reviewed: 30th Jan 2015
Author Corrected: 9th Feb 2015, Accepted for Publication: 21th Feb 2015
Introduction
Hand injuries secondary to mittens application have been reported since 1960s [1]. Most of the cases reported are injuries limited to the fingers only & are variants of Hair-Thread Tourniquet Syndrome [2][3]. We report an unusual injury involving the entire hand in a neonate caused by mittens application. Fortunately the injury recovered within 2 weeks without subsequent tissue loss.
Case report
One 8 day old male neonate was brought with history of bilateral hand swelling with dusky discoloration predominantly involving the right hand. He was delivered by lower segment cesarean birth with uneventful antenatal history. On day 8 of life, the mother noticed that the neonate was crying ceaselessly and irritable. There were 2 mittens worn in both hands and tightened at the wrist by elastic bands to keep them in place. The exact timing of the mittens application was unknown. On examination there was swelling associated with discoloration of the right hand with constriction mark present at the wrist. There was darkening of the palmar aspect & dorsum of the hand. Finger tips were dusky in colour. There were multiple blebs noticed more in the dorsal aspect. There was paucity of movements of the fingers with prolonged capillary refill time. On the left hand also there was a constriction mark with mild swelling associated with discoloration. Blebs were opened and antibiotic dressing was done. He was started on broad spectrum IV antibiotics and oral analgesics. Colour Doppler study of both upper limb arteries was done which showed normal colour flow signals and blood flow velocities. Periodic dressings of the hand was done. With above management, the swelling decreased gradually and the perfusion improved dramatically. The finger and hand movements were preserved altogether and the discoloration subsided at the end of second week.
Figure- 1 Baby on Admission
Figure-2 Left Hand Showing Constriction Band
Figure-3 Mittens with Elastic Band
Figure-4 Dorsal Aspect Showing Discoloration with Blebs and Constriction Band
Figure-5 Palmar Aspect Showing Discoloration with Blebs and Constriction Band
Figure-6 During Recovery Stage
Figure-7 At Discharge- Dorsal Aspect Showing Recovery
Figure-8 At Discharge- Ventral Aspect Showing Good Perfusion Of Digits
Discussion
Hair thread tourniquet syndrome is caused by hair or synthetic strands tightly wrapped around appendages causing constriction and damage. It can involve toes, fingers or genitalia [2,3]. Most of the cases reported are injuries limited to the fingers only. The underlying pathophysiology is impedance of lymphatic flow, venous outflow obstruction and arterial inflow obstruction in case of prolonged constriction. Treatment is prompt identification of the constricting substance and removal. Antibiotics and analgesics should be started. In case the distal part is unsalvageable, amputation should be considered [4]. There have been multiple case reports of mittens injuries [5-16][Table-1]. Majority of them occur in preterm babies as they have thinner subcutaneous fat and lesser tension can cause vascular compromise [5,11]. Reviewing the literature, the outcome of mittens injuries is variable with half of them requiring amputation of the distal unsalvageable part [15].
TABLE-1 CASE REPORTS OF MITTEN INJURIES
Parental education about mittens injury is a must and they should regularly examine the extremities to allow early diagnosis and prompt management. Practice of using additional constriction band around the wrist must be avoided. Finally Prevention is the best management.
Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes
References
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How to cite this article?
Rabindran, Parakh H, Ramesh JK, Reddy P. Association of Postnatal growth with birth weight, gestational age, sex and intrauterine growth in very low birth weight Infants. Int J Med Res Rev 2015;3(2):207-215. doi:10.17511/ijmrr.2015.i2.039.