Swollen Red Toe: Child Abuse-or Mimic?

A 5-month-old boy was brought to his primary care physician after his mother had talked to the on-call nurse the evening before. The mother was concerned that the child’s toe appeared swollen and slightly red. The redness, which she noticed while bathing the child, had worsened overnight. The symptoms had been present for approximately 16 hours by the time the child arrived at the clinic.

There was no past significant medical history. More specifically, there was no history of foot abnormalities or infections. The child reportedly only wore socks or booties and had not worn new footwear.

There were 3 children in the family, which was well known to the clinic. There had never been any concerns of abuse or neglect in the family. The mother had commented at the last health maintenance examination that this child was her “easiest” child to care for.

Does this look like abuse to you, or a condition that mimics abuse?

Many will immediately recognize this as a hair tourniquet. But what, if any, is the connection to child abuse?

A hair tourniquet is thought to be caused by repetitive movement of the extremity in a confined area, such as a glove or feet in pajamas. Others have theorized that the condition is more common when postpartum mothers are at the peak of their postpartum excessive hair loss (telogen effluvium).¹ Aside from accidental sources, other associations are auto-aggression, punishment for enuresis, ainhum (Dactylolysis spontanea), and child abuse.² The tourniquet causes tissue ischemia and necrosis.

There are case reports of tourniquets involving the toes, fingers, penis, clitoris, and the uvula. The first documented case is thought to be in 1882, when a disgruntled nanny wrapped a hair around the penis of a 4-week-old child. More than 100 cases have since been reported, but no single article stands out as having a definitive answer to the abuse verses accident question. A high index of suspicion and a thorough review is required in all cases.

Hair tourniquets of the fingers and toes are not unusual. Hair and cotton or nylon fibers are the offending materials in most tourniquet injuries, but a rubber band was reportedly used in one case of abuse. The toes are involved in 43% of patients according to one review article and hair was the offender in 79% of those cases. The median age is 4 months (range 1 to 15 months).³ The third and fourth toes are most commonly affected. Finger tourniquets occur more frequently in children 4 days to 19 months of old (median 3 weeks).³ Genital tourniquets occur in an older age range and always raise the possibility of abuse.³

The diagnosis was made in this case after the linear crease on the toe was explored with a blunt instrument and a hair was found. The hair was cut using a #11 surgical blade and was removed. The ligature should always be examined for evidence of knots because the presence of a knot would obviously heighten one’s consideration of abuse.

An oral antibiotic was prescribed along with a topical antibiotic cream. The child was seen for 2 more years, with no long-term sequel. He was subsequently lost to follow-up.

References:

References 

1. Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003;111:685-687.

2. Klusmann A, Lenard H-G. Tourniquet syndrome-accident or abuse Eur J Pediatr. 2004;163:495-498.

3. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome Pediatrics. 1988;82; 925-928.