FIGURE 130.42 Removal of a fish hook HAIR TOURNIQUET REMOVAL Indications To remove constricting bands of hair or thread Complications Damage to nerves or vascular structures Damage to tendons Damage to corpus cavernosum, corpus spongiosum, clitoris, or urethra Equipment Topical, local, or regional anesthesia materials Scalpel blade with handle no 11 blade Antiseptic solution Fine-tip forceps Blunt probe Fine-tip scissors Magnifying glasses or loupes can be very helpful Procedure Constriction by hair or thread of a digit or penis and occasionally the clitoris occurs most often in the first few months of life but can be seen in older children on occasion On physical examination, a sharp circumferential demarcation is usually apparent Hair tourniquets on digits have been confused with a felon or paronychia Hair tourniquets on a penis have been confused with paraphimosis or balanitis The application of topical lidocaine or other anesthetic cream/gel to the site 30 to 45 minutes before the procedure may provide some pain relief Isolating the band If the hair or thread is not deeply embedded, a blunt metal probe may be used to isolate the constricting band ( Fig 130.43 ) The band is best isolated by placing the probe under the hair or thread on the dorsal aspect of the finger or toe Digital or penile block may be necessary if topical anesthetic does not provide sufficient pain relief Once the band is isolated, it may be cut with a fine-tip scissors or by placing a scalpel blade against the probe being careful to protect the underlying skin Improvement of the swelling and release of the constriction must be noted before discharging the patient Commercial hair remover Application of hair remover can dissolve a hair and provide relief This method will not work with synthetic fibers Hair remover should not be used if there is marked inflammation or swelling This method is also not recommended for removing a constricting band from the penis Improvement of the swelling and release of the constriction must be noted before discharging the patient Surgical removal If the hair or fiber cannot be isolated and removed by the aforementioned methods, then direct incision of the band is indicated a Digit A digital block should be performed and the area should be cleansed and draped in a sterile fashion To avoid the neurovascular bundle, an incision should be made at the o’clock or the o’clock positions on the lateral aspects of the digit The incision should be made longitudinally along the digit, perpendicular to the band The incision should be extended to the bone to ensure removal After improvement in the constriction is noted, a dressing may be applied b An incision on the dorsal aspect is an alternative, since the tourniquet may be less deeply embedded on the dorsal surface This approach will probably result in a longitudinal incision into the extensor tendon With splinting and general wound care, this incision should heal without complications c Neurovascular status and tendon function should be documented after the procedure Tetanus prophylaxis should be given as indicated, and reevaluation is suggested in 24 hours when the swelling should have mostly resolved d Penis Urologic consultation is advised before undertaking this procedure, unless ischemic damage might worsen because of a delay A penile nerve block should be performed, and the area should be cleansed and draped in a sterile fashion The incision should be made at the o’clock or o’clock position This location represents the junction of the corpus cavernosum and corpus spongiosum The goal is to release the constricting band without penetrating the lumen of the corpus Reperfusion normally occurs within several minutes after relief of the constricting band; however, some swelling may persist for several days A loose dressing should be applied e Clitoris Although an uncommon occurrence, the procedure for such a situation has been described Topical lidocaine or other anesthetic cream should be applied If difficult to release the constricting band utilizing one of the noninvasive methods noted above, immediate urologic or gynecologic consultation is indicated FIGURE 130.43 Removal of a hair tourniquet ARTHROCENTESIS—GENERAL CONSIDERATIONS Indications Removal of a joint effusion causing severe pain and distension that limits function To obtain joint fluid for the diagnosis of arthritis Complications Bleeding Infection, joint space or bone Contraindications (Relative) Bleeding diathesis Patients with bleeding diatheses (i.e., hemophilia) as the cause of the joint effusion usually require only immobilization and replacement of coagulation factors Presence of a fracture around the joint space Aspiration may increase the chance of infection when a fracture is present Equipment Marking pen, antiseptic solution, gauze, bacteriostatic saline solution, adhesive bandage Local anesthetic 1% lidocaine, topical anesthetic such as 4% lidocaine cream 25- or 27-gauge needle, 3-mL syringe, 18- or 20-gauge needle, and 5- to 10mL syringe, specimen collection tubes with patient labels Knee Joint Procedure The knee is the joint that most commonly requires aspiration in children, primarily to evaluate for possible bacterial infection or Lyme disease Radiographs should be obtained before aspirating the joint, and ultrasound may also be useful to document the presence of an effusion if not obvious on radiographs Place the child supine on the examination table, and completely extend the knee if possible Pain may prevent full extension If so, a towel roll placed under the slightly flexed joint may be helpful for comfort and in stabilizing the position Restrain the child as necessary Have an assistant hold both the thigh and calf of the involved leg Consider pharmacologic sedation as necessary Consider applying topical 4% lidocaine or other anesthetic cream 30 to 45 minutes prior to the procedure The lateral approach to the knee is preferred because it avoids passage through the vastus medialis muscle Pick a puncture point at the midpatellar level in the anteroposterior view and at the posterior margin of the patella in the lateral view ( Fig 130.44 )