A rare case of rubber band syndrome of wrist with distal radius and ulna fracture

Abstract

Rubber band syndrome (Dhaga Syndrome) is a very rare condition seen mostly among children in whom elastic bands worn around the wrist or forearm for religious or decorative purpose and its presence is overlooked by the parents. These forgotten bands slowly cuts through the skin and soft tissue underneath causing constriction and damage to the underlying structures. Circumferential constricting scar with discharging sinus is the cardinal feature. We report a case of rubber band syndrome in a 2 year old boy in which the constriction was severe enough to cause fracture of the distal radius and ulna.

1. Introduction

Elastic rubber bands or Dhagas (sacred threads) are tied to wrist especially of younger children as part of their communal or religious rituals or for decorative purposes. The threads are often worn for prolonged duration and the presence of it is often forgotten or neglected, which in due course of time burrows deep through skin and soft tissues. This is often presented with distal edema, loss of function and even neurovascular structure damage,.1, 2, 3, 4 These symptoms are often difficult to be related to this rare but typical manifestation. Herein we report a unique case of rubber band syndrome which presented all the cardinal features of the condition. In addition, this case of elastic band syndrome involved fractures of distal radius and ulna which has not yet been reported. Timely diagnosis and treatment of rubber band syndrome would avoid catastrophic events that lead to extensive structural damage and prolonged use of antibiotics.

1.1. Case report

A two-year-old boy was presented to us with multiple discharging sinus at the wrist and inability to move the fingers and thumb of the right hand for one month. He had no history of trauma as per the parents. A linear circumferential constriction mark with multiple discharging sinuses was noted at the wrist (Fig. 1A and B). Sensation to the distal portions of the linear mark was absent and finger movements were grossly restricted. The child had low grade fever but had no gangrenous changes in the hand. Radiological examination showed fracture of distal radius and ulna with marked periosteal reaction (Fig. 2A and B). Surgical exploration (combined volar and dorsal approach) revealed a rubber band lying in a plane deep to the muscles and tightly encircling the radius and ulna (Fig. 3A and B). The tendons and neurovascular structures were found to be in continuity. The band was removed. No attempt was made to repair any structure. The child was immobilized in dorsal splint. The sinus healed in three weeks (Fig. 4A and B). The wound culture was sterile. The fractures healed well and recovery of soft tissue (tendons, neurovascular) were noted 7 months post op (Fig. 5A and B).

Fig. 1.

1A and 1B shows the circumferential constricting scar around the wrist with multiple pus discharging sinuses.

Fig. 2.

2A and 2B shows the anteroposterior and lateral view of the distal radius and ulna showing fractures of the distal radius and ulna.

Fig. 3.

3A shows the rubber band lying deep beneath all the soft tissues in the wrist. 3B shows an intact median nerve.

Fig. 4.

4A and 4B shows a well healed scar with good function of the hand at 7 months follow-up.

Fig. 5.

5A and 5B shows the anteroposterior and lateral view of right wrist with healed distal radius and ulna fracture at 7 months follow-up.

2. Discussion

Rubber band syndrome (acquired constriction band syndrome, Dhaga Syndrome) is a unique infective syndrome due to forgotten band tied around the wrist. Linear constricting scar with pus discharging sinus around the wrist are cardinal features of this syndrome. It is uniquely seen in children and most of the times, parents forget the band tied to the child's wrist for some religious purpose, fashion or accidently while playing. The band cuts through underlying soft tissue with rapid increase in the circumference of the wrist. Finally, the skin epithelizes over the band and the constriction band becomes invisible. Slow tissue penetration with rapid healing of overlying tissue allows the band to penetrate deeper. Ultimately it cuts tendons and the neurovascular structures, and finally bone. Random such cases have been reported majority of which are among children, involving upper limbs causing wounds, infection, and compartment syndrome,.^5,6

In the present case, the band reached the bone resulting in fracture of radius and ulna, cutting through all underlying soft tissue including tendons and neurovascular structures. The fracture of the underlying bones was never reported earlier with constriction band syndrome. The removal of the band led to complete recovery of hand function within 3 months of the surgery. Prognosis of the acquired constriction band syndrome is better than congenital constriction band syndrome,.^1,3

Clinicians must be alert to suspect rubber band syndrome in case of a linear constricting scar around the wrist in the presence of a discharging sinus without history of trauma or infection. The prognosis of the surgical removal of rubber band is good without need for major reconstruction of the tendon, nerves and bone.

Funding

There is no funding source.

Ethical approval

Ethical approval obtained.

Informed consent

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Disclosure

None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.

Declaration of competing interest

The authors declare that they have no conflict of interest.