Rubber band syndrome: An under recognised condition in pediatric patients

Dear Editor,

Rubber band syndrome (RBS) is a rare but potentially devastating condition that occurs when tight ligatures are tied around the wrist for prolonged periods, leading to progressive tissue compression and necrosis.¹ Due to its rarity, it is frequently misdiagnosed as more common dermatological conditions like cutaneous tuberculosis (endemic in India)¹. Early recognition is crucial to prevent permanent damage and avoid unnecessary antibiotic use. A 1-year-old girl was brought to the dermatology clinic with a 3-months history of circumferential swelling in her left wrist associated with purulent discharge. Four months earlier, a thread was tied around the child’s wrist for religious reasons. This thread was removed two months later due to perceived tightness. Mother however, could not recall tying of a rubber band to her wrist. Despite repeated antibiotics, the swelling gradually progressed to involve the entire hand.

Examination revealed an apparently healthy child with no lymphadenopathy. Cutaneous examination [Figure 1a and b] revealed a linear circumferential constriction scar on the left wrist, with four discharging sinuses on the volar, dorsal, and radial aspects, with sprouting granulation tissue and crusting. It was associated with swelling on the dorsum of the hand and fusiform swelling of fingers with erythema. Active finger movements were intact but left wrist movement was restricted. Distal pulses were impalpable due to swelling and sinus formation; however, capillary refill in the thumb and fingers was normal. No trophic changes were present in the digits, and she appropriately responded to painful stimuli.

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Figure 1a and 1b:

: Linear circumferential lesion with discharging sinuses on the lateral and volar aspect of the wrist with distal swelling.

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Routine haematological investigations were within normal limits. Ultrasound of the left wrist revealed a near-complete circumferential foreign body located in the subcutaneous plane, superficial to the carpal tunnel and extensor tendons. Doppler studies demonstrated triphasic flow in both radial and ulnar arteries, and all three major nerves appeared intact. Magnetic resonance imaging [Figure 2a and b] revealed a T2 hypointense band around the wrist joint with osteolysis of the radius and normal neurovascular bundles.

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Figure 2:

a; (coronal) and b (axial): Pre-operative short tau inversion recovery MRI shows (2a) a T2 hypointense band (yellow arrows) around wrist joint with pressure osteolysis of the radial shaft and (2b) Band encasing both flexor and extensor tendons, suggestive of rubber band syndrome (yellow arrows indicate the band)

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The patient was scheduled for surgical exploration under general anaesthesia, which revealed an embedded rubber band overlying the flexor tendons [Figure 3a]. Following surgery, the patient received antibiotics, analgesics, and daily dressings. The wound healed without complications with complete restoration of wrist joint function [Figure 3b].

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Figure 3:

(a) Intra-operative image of the deeply embedded rubber band, (b) Well-healed scar one month post surgery.

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RBS or acquired constriction band syndrome or Dhaga syndrome, is a rare condition most frequently reported from India.² It involves gradual compression of soft tissues with sacred threads (Dhaga/Kalava) or elastic bands, typically tied around the wrist for cultural reasons, though cases involving ankle, forearm, and fingers have also been reported. Hogeboom et al.³ initially described it in 1965. Children under six are primarily affected as rubber bands get trapped in creases of their chubby hands, gradually penetrating through soft tissue and going unnoticed due to rapid re-epithelialisation.^2,4 Additionally, elderly individuals or those with cognitive impairments may not be able to identify or express the presence of ligature, leading to unnoticed damage to tendons and neurovascular structures.⁵

RBS can present in acute and chronic forms. The acute form is due to tight, non-elastic bands causing compartment syndrome, necessitating urgent interventions like fasciotomy or carpal tunnel release.^6,7 The chronic variant is due to elastic bands which gradually penetrate deeper structures like fascia, tendons, nerves, and bone, and become hidden due to epithelisation, causing oedema, dysfunction, and neurovascular issues.^1,6,8

Clinically, it presents as a linear circumferential scar with granulation tissue and non-healing discharging sinuses, which are pathognomonic.⁸ However due to its rarity, it is often mistaken for other conditions like cutaneous tuberculosis, deep fungal infections, and tubercular osteomyelitis.^1,8 Although diagnosis is primarily clinical, imaging studies aid in confirming the presence of a foreign body. Ultrasound (USG) is useful for identifying the rubber band and guiding its removal, while MRI is the gold standard for assessing soft tissue involvement and planning surgery.⁹

Management involves surgical exploration and removal of the rubber band, accompanied by debridement and sinusectomy if necessary. With prompt intervention, the prognosis is excellent with full recovery and favourable functional outcomes. Delayed treatment can lead to severe complications, including irreversible neurovascular damage and loss of function.

In conclusion, RBS is a rare but important cause of chronic, non-healing lesions in children, particularly in cultures where threads/bands are tied for religious or decorative reasons. High index of suspicion, supported by imaging, is vital for early diagnosis. This case highlights the need to include RBS in the differential diagnosis of persistent wrist and hand lesions, especially in children unresponsive to conventional therapies.