P107 Thumb auto-amputation following tourniquet syndrome

Case Report A 12 month old boy presented to the Paediatric Emergency Department (PED) with ischaemic necrosis of the distal phalanx of the left thumb as a result of Tourniquet Syndrome. Six days prior to presentation an adhesive bandage had been applied to the digit to discourage thumb sucking. His mother described crying and irritability, and when the dressing was removed forty-eight hours after application, the infant’s mother noted the digit to be shrivelled and mottled. The following day the area began to blister and he was brought to his General Practitioner for review, where hospital attendance was advised. Examination of the left thumb revealed dry necrosis of the nailbed and distal phalanx extending 1 cm proximal to the nailfold, with an obvious tourniquet mark present at the interphalangeal joint. The infant was admitted under the joint care of the Plastic Surgery and General Paediatric Teams. The injury was initially managed conservatively. The distal phalanx subsequently auto-amputated and formal surgical debridement and terminalisation at the level of the interphalangeal joint was undertaken. At follow-up twelve months later the injury had healed well with a satisfactory functional outcome. The severity of the injury coupled with the delay in presentation raised suspicion of neglect or non-accidental injury, and the case was referred to the Medical Social Work Department. The history given by both parents was consistent with the presenting injury. No other concerning injuries or previous hospital presentations were noted and appropriate child-parent interaction was noted throughout. A child protection case conference found that the injury was unintentional and that the infant was not at ongoing risk of significant harm through neglect. A family support plan was put in place on discharge to the community. Discussion Tourniquet Syndrome is a surgical emergency as circumferential constriction impedes lymphatic drainage with resultant venous outflow obstruction and oedema. Raised interstitial pressures then restrict arterial supply, causing ischaemia and associated pain. If it is not possible to remove the tourniquet in the PED, general anaesthetic and removal in theatre may be required. In cases of significant vascular compromise necrosis and auto amputation may occur as illustrated. Due to it’s insidious nature, a high index of suspicion for this condition is required for timely detection. Added vigilance is required in the case of preverbal children and those with speech or learning difficulties who may not be able to express discomfort easily.