Rosen & Barkin's 5-Minute Emergency Medicine Consult (624 page)

• 733.19 Pathologic fracture of other specified site
  
• 807.00 Closed fracture of rib(s), unspecified
  
• 807.09 Closed fracture of multiple ribs, unspecified
  

BASICS

• Primary constricting band
  : A band tightened around an appendage causes swelling and pain (e.g., a hair knotted around a toddler’s toe).
  
• Secondary constricting band
  : Injury or disease process that causes swelling and edema as a result of tightness against the band (e.g., impacted ring with an underlying fracture of the finger)
  
• Untreated, the constricting band may become
  embedded
  and interrupt skin integrity.
  
• Tourniquet syndrome occurs when anything causes a constriction and there is distal tissue effect.
  

In the preverbal child, a constricting band may be a manifestation of child abuse or neglect. It should also be considered as a cause of inconsolable crying.

The cognitively impaired nursing home resident or Alzheimer patient may be unable to give an indication of injury or pain.

Tourniquet syndrome may result from allergic, dermatologic, iatrogenic, endocrinologic, infectious, malignant, metabolic, physiologic, or traumatic conditions, or it may be related to pregnancy.

DIAGNOSIS

• A constricting band with swollen tissue and skin of an appendage, most commonly involving a finger
  
• Other locations include wrist, ankle, toe, umbilicus, earlobe, nipple, septum or nares of nose, penis, scrotum, vagina, labia, uvula, or tongue.
  
• Pain on manipulation of the appendage or constricting band
  

Usually straightforward but in nonverbal populations it can be a cause of unidentified pain. An inconsolable crying infant may be having pain due to a hair tourniquet.

• Evaluate area of concern.
  
• If evaluating an inconsolable infant or agitated nonverbal adult, assess fingers, toes, and genitalia.
  

• Primary constricting band: Diagnosis made by history and physical exam with special attention to neurovascular status.
  
• Secondary constricting band: Diagnosis of underlying pathology may depend on results of imaging and lab test results.
  

• Usually not indicated for acute treatment
  
• Measurement of electrolytes, BUN, and creatinine; thyroid function tests; and Tzanck smear of vesicular lesions may be useful in identifying the underlying diagnosis.
  

Plain films for evaluation of underlying fracture or residual foreign body
after
band removal

Any
condition causing marked swelling and edema predisposing to the tourniquet syndrome

TREATMENT

Remove rings and other potential constricting bands before development of tourniquet syndrome:

• Particularly in regions of extremity trauma
  

Pain management or procedural sedation as needed

• Removal of the constricting band either by advancing the band distally or by division
  
• These adjuvant methods may be used alone or in combination:
  
  • Elevation of the affected extremity may decrease vascular congestion.
    
  • Cooling
    the extremity with ice or cold water may reduce edema and erythema.
    
  • Lubrication
    with soap or mineral oil may allow slippage over an inflamed or edematous area.
    
  • Digital block
    with 1–2% lidocaine
    without epinephrine
    decreases the discomfort of removal and manipulation of an underlying injury.
    
  • A digital block may; however, increase local swelling. Consider regional blocks.
    
  • Gauze
    or a
    needle holder
    may be used to manipulate the band.
    
• The distal swollen finger, especially the proximal interphalangeal joint, is an important obstacle in constricting band removal.
  
• Distal to proximal edema reduction by sequential compression:
  
  • Self-adherent tape
    is wrapped from distal to proximal to form a smooth and decompressed area over which the band is advanced.
    
  • A
    Penrose surgical drain
    or a finger cut from a small glove is stretched to fit over the distal swelling before attempted removal.
    
  • With lubrication, the proximal end of the drain is pulled under the ring to form a cuff around the ring; the cuff with distal traction applied advances the band over the decompressed area.
    
  • Suture material
    (no. 0 silk, dental floss, or umbilical tape) is wrapped under tension in a tight layer advancing over the edema in a distal-to-proximal direction; the proximal tail of the suture material or floss is tucked under the ring; with lubrication, the tail under tension is pulled distally and unwound, forcing the ring over the layered suture material and decompressed area.
    
• Constricting band removal by division:
  
  • Scissors
    may be used to 1st lift and then cut the offending fibrous band constricting a toddler’s toe or penis.
    
  • A
    no. 11 scalpel
    blade with cutting edge up may be sufficient to cut constricting bands formed by hair, fibers, or plastic ties.
    
  • A topical commercially available depilatory agent may be used to divide a tourniquet formed by a suspected hair obscured by local edema.
    
  • A
    handheld wire cutter/stripper
    may divide small-girth metallic rings with minimal discomfort to the underlying injury; this type of removal may; however, impart a crush defect to the ring, making repair difficult.
    
  • A
    long-handled bolt cutter,
    available in most operating rooms or hospital engineering departments, may be used to divide large-girth or broad-sized rings:
    
    • Long handles provide the significant mechanical advantage needed to cut large rings.
      
    • The reinforced cutting blades may not easily fit through a constricting band with adjacent swollen tissue and skin.
      
    • A
      standard hand-powered, medically approved ring cutter
      (Steinmann pin cutter with a MacDonald elevator) may be used to divide small-girth metallic constricting bands made of soft metals (gold/silver)
      
    • This method has the advantage of a cleaner cut for subsequent repair of the ring.
      
    • The disadvantage is that the handheld ring cutter is labor-intensive and may aggravate the pain of an underlying injury.
      
    • A
      motorized high-RPM cutting device
      may be used to rapidly divide constricting bands irrespective of girth and size of the ring; it may be DC- or AC-powered or pneumatically driven in the operating suite.
      
• Cutting procedure:
  
  • The initial cut is made on the band on the volar aspect of the extremity.
    
  • A tenaculum may be used to spread the band in softer metals.
    
  • For a 2nd cut, the band should be rotated 180° on the extremity, allowing the 2nd cut on the band over the volar aspect of the extremity.
    
• Motorized cutting:
  
  • Remove
    flammable solvents
    from the work area.
    
  • Protective eyewear
    should be worn by everyone present, including the patient.
    
  • Place a thin
    aluminum splint
    (shaped to the curvature of the ring) between the patient’s skin and the ring as a shield to protect underlying tissue.
    
  • Cool splint and cutting surface with ice water irrigations before and during the cutting procedure.
    
  • Limit cutting with motorized device to 5 sec with max. intervals of 60–90 sec between ice water irrigations to avoid producing local excessive heat.
    
• Depilatory cream:
  
  • Can be used if suspected constriction is caused by hair in place of “unwinding or excising” the hair.
    
  • Swelling of tissues heaped up around the hair may obscure the hair tourniquet leaving only a visible crease with the underlying hair buried below.
    
  • Depilatory cream applied to the crease may release the hair tourniquet within 10 min.
    
• Postdivision care:
  
  • Underlying injuries should be irrigated thoroughly to remove metallic dust and avoid foreign-body reaction and granuloma formation.
    
  • Tetanus prophylaxis should be provided if indicated.
    

• Tetanus prophylaxis: Tetanus toxoid 0.5 mL IM
  
• No medications are typically required unless evidence of or at risk for infection
  

• Cefazolin: 1 g IV/IM (peds: 20–40 mg/kg IV/IM single dose in ED) and
  
• Cephalexin: 500 mg PO (peds: 25–50 mg/kg/d) QID for 7 days.
  
• Amoxicillin/clavulanate: 875/125 mg PO (peds: 25 mg/kg/d) BID for 7 days
  
• Erythromycin: 333 mg PO TID (peds: 40 mg/kg/d q6h for 7 days)
  

• If patient is penicillin allergic:
  
• EES: 800 mg PO, then 400 mg PO q6h for 7 days
  or
  
• Clindamycin: 300 mg PO q6h for 7 days
  

FOLLOW-UP