ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Hair tourniquet and other narrow constricting bands: Clinical manifestations, diagnosis, and treatment

Hair tourniquet and other narrow constricting bands: Clinical manifestations, diagnosis, and treatment
Author:
Eric Hoppa, MD
Section Editor:
Anne M Stack, MD
Deputy Editor:
James F Wiley, II, MD, MPH
Literature review current through: Jan 2024.
This topic last updated: Nov 01, 2022.

INTRODUCTION — This topic discusses the clinical manifestations, diagnosis, and management of hair tourniquets and also strangulation of digits or external genitalia by thread or other narrow constricting bands.

TERMINOLOGY — Hair tourniquet or hair-thread tourniquet syndrome describes swelling or ischemia of an appendage (eg, toe, finger, or genitalia) caused by a tightly wound hair or thread in a young infant, although it may rarely occur in older patients [1]. (See 'Etiology' below and 'Epidemiology' below.)

For this topic, the discussion of hair tourniquets has been expanded to include intentionally applied tourniquets that may consist of materials other than hair or thread.

PATHOPHYSIOLOGY — Narrow constriction of the digit or external genitalia decreases lymphatic and venous drainage, which results in pain, swelling, and edema. If not recognized in a timely fashion, ischemia occurs. With progressive swelling, the constricting agent may become embedded in the soft tissue or cut through the skin and underlying tissues. If not promptly removed, permanent tissue necrosis can develop.

ETIOLOGY — The source of the tourniquet varies by the site of constriction:

Hair tourniquet – In young infants, hair or thread entrapment of digits (picture 1) or genitalia arises from the presence of a loose hair or fiber that wraps around the appendage because of movement of the digit or genitalia in a confined area (eg, feet-in pajamas, socks, mittens, or diaper). Discomfort from the hair or thread leads to additional movement, which encourages further entrapment of the appendage over the course of hours or days.

In infants, the hair is frequently the mother's because of increased maternal hair loss during the postpartum period (telogen effluvium). When hair falls unnoticed into the bath water during routine care, it may become attached to the patient's toe, finger, or genitalia (penis, labia, or clitoris) [2]. Hair stretches when wet and can be wound loosely around an appendage but will become constrictive as it dries. Hair may also fall into the diaper during changing.

In addition, pubic hair tourniquets of the clitoris, labia majora, or labia minora may occur in postpubertal adolescents [3-10], and self-applied hair tourniquets of the genitalia have been reported in prepubertal girls [3,11].

Thread tourniquets – Threads may arise from mittens, socks, or feet-in pajamas when fibers become loosened and retained in the clothing during washing, especially if the clothing is not turned inside out [12].

Elastic band tourniquets of the penis – Strangulation injuries of the penis may occur after application of a rubber band or other elastic wrap by the patient (picture 2) (older child, adolescent, or adult) or by a caregiver as a means to control nocturnal enuresis [1].

EPIDEMIOLOGY — Hair tourniquets and entrapment of the digit or genitalia are rare conditions. Based upon reviews of reported cases and one small single-center observational series, the tourniquets are most commonly found on the toes, but can also involve the fingers or the external genitalia [1,10,13,14]. Hair tourniquet syndrome is more common during winter months in settings with colder climates [14]. Strangulation injuries of the digits are usually considered to be unintentional.

Although most commonly unintentional in young infants, tourniquets of the penis should raise the question of self-application by the patient in older children, adolescents, and adults or child abuse in toddlers who are toilet training. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination'.)

Although evidence is limited, the location of the injury appears to be associated with the patient's age and the type of tourniquet:

Toes – Toe strangulation most commonly happens in infants younger than 6 months and typically is caused by hair tourniquets (picture 1) [1,13]. Postpartum telogen effluvium (postpartum hair loss, seen in 90 percent of mothers) may be a contributing factor. (See 'Etiology' above.)

Fingers – Finger strangulation tends to be caused by fiber or thread tourniquets and also occurs primarily during infancy [1,13]. Finger tourniquets have been described in patients as young as the first few days of life with the thread likely arising from mittens worn to prevent scratching of the face and eyes.

External genitalia – Hair tourniquets occur less commonly on the external genitalia than the digits but have been well described [1,10,13,15]. Outside of infancy, tourniquets of the penis are more commonly intentionally applied by the patient or caregiver (picture 2) [1,16]. Intentional wrapping of head hair around the labia or clitoris by the patient has also been reported in prepubertal girls [3,11]. Inadvertent strangulation of the labia or clitoris has occurred in postpubertal females. (See 'Etiology' above.)

CLINICAL MANIFESTATIONS

History — The infant with a hair or thread tourniquet usually presents with irritability. Parents/primary caregivers may also report a swelling and discoloration at the site of strangulation. The tourniquet frequently has not been discovered when the infant presents. Older patients frequently report pain and swelling at the site of constriction.

Among prepubertal girls and older males with genital tourniquets, some patients will admit that they applied the constricting band. However, this history is not always forthcoming. Furthermore, if the genital tourniquet was applied as punishment or a means to prevent nocturnal enuresis in a toddler or young child by the caregiver, a history may be absent. (See 'Etiology' above and 'Epidemiology' above.)

Physical examination — Infants who present with fussiness or irritability should be carefully examined for evidence of a hair or thread tourniquet as well as other etiologies of prolonged or excessive crying (table 1).

The digits and genitalia should be carefully inspected for a circumferential band proximal to the swelling. On the fingers or toes, the physician can more easily see the hair on the dorsal surface where it usually penetrates less deeply. Magnification can help to differentiate nonspecific swelling from a hair or fiber tourniquet [17].

Physical examination findings of entrapment include swelling and discoloration of the digits (picture 1) or genitalia (picture 2):

Superficial tourniquets – In patients with superficial tourniquets, the constricting band is readily visible with magnification and the type of material (hair, thread, or other substance) is often discerned (picture 1). Swelling may be significant, but discoloration or large amounts of skin breakdown associated with ischemia is not present.

Deep tourniquets – Deeply embedded tourniquets present with significant edema and often have tissue ischemia with distal color change (purple, blue, or black). Swelling or reepithelialization can obscure or hide the strand, making the diagnosis more difficult. Due to deep penetration into the soft tissue, the constricting hair, thread, or other tourniquet usually cannot be seen without probing the wound or manipulating the digit which may be too painful to accomplish without sedation. However, a deep, encircling, and narrow indentation of the appendage is highly suggestive of a tourniquet (picture 3). Rarely, patients may have ischemia and necrosis from long neglected hair tourniquets [18].

When intentional application of a penile tourniquet by the caregiver is suspected, the physician should evaluate for other signs of child physical abuse (table 2 and table 3) and, whenever possible, involve a multidisciplinary child abuse team to further assess the patient. (See "Physical child abuse: Recognition", section on 'Red flag history' and "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

DIAGNOSIS — The diagnosis of a superficial hair tourniquet or other entrapment is made by visualization of a constricting hair, thread, or other material proximal to swelling in the affected appendage (digit, penis, labia, or clitoris) (picture 1). On the fingers or toes, the physician can more easily see the hair on the dorsal surface where it usually penetrates less deeply. If the tourniquet is visible, magnification often serves to differentiate hair from other types of tourniquets.

Embedded tourniquets usually hide the constricting band but have a characteristic appearance of a narrow, encircling constriction of the digit or external genitalia (picture 3). Rarely, in adolescent or adult uncircumcised males, the constricting band may be located under the foreskin and require its full retraction to be visualized [19].

In cases with longstanding hair tourniquet with painful swelling of the external genitalia, the constricting band may not be clearly visible. In those rare instances, expert consultation may be warranted to assist in management and differentiation from other lesions such as an abscess, cellulitis or cyst [10,18].

DIFFERENTIAL DIAGNOSIS — The identification of an encircling hair or constricting band below the swollen appendage is the primary means of differentiating hair or other constricting band tourniquet from other types of secondary swelling such as trauma, insect bites or stings, allergic reaction, contact dermatitis, abscess, balanitis, or paraphimosis.

MANAGEMENT — The management of a hair or string tourniquet depends upon the extent of tissue damage and the depth of the fiber or hair (algorithm 1).

Indications for specialty consultation — Most superficial tourniquets can be managed by primary care and emergency physicians. Some physicians may prefer to consult a gynecologist or, in young female infants, a pediatric surgeon for superficial hair tourniquets involving the vulva.

Deeply embedded tourniquets with ischemia or necrosis require excision and warrant consultation with a surgical specialist according to the site:

Digits – General, plastic, or orthopedic surgeon according to availability and local practice

Penis – Urologist

Vulva – Gynecologist or, in young children, pediatric surgeon

Some experienced physicians may feel comfortable excising embedded digital tourniquets without surgical consultation.

Superficial tourniquet — In patients with superficial tourniquets, the hair, string, or constricting band is readily visible with magnification (picture 1). Swelling may be significant but discoloration or large amounts of skin breakdown associated with ischemia is not present.

Hair tourniquet — The technique for removal varies by the site of the tourniquet:

Digit (toe or finger) or penis – Based upon small observational studies, we suggest that patients with superficial hair tourniquets of the digit or penis initially have a chemical depilatory agent (eg, Nair, Magic Shave, or Veet), if available, applied to dissolve the hair. If this method is unsuccessful or a chemical depilatory is not available, the physician should proceed to mechanical removal (algorithm 1) [13,20,21]:

Dissolve the hair with a chemical depilatory agent – The technique for use of a depilatory agent to remove a hair tourniquet is as follows:

-Apply chemical depilatory lotion, spray, or cream (eg, Nair, Magic Shave, or Veet) for 3 to 6 minutes according to specific product package instructions. Do not leave on longer than 10 minutes.

-Gently wipe off the depilatory with clean gauze and rinse with lukewarm water. The treatment can be reapplied in 10 to 15 minutes if the first treatment is unsuccessful.

-Using magnification, carefully inspect the digit and remove any residual hair strands with fine forceps or a hemostat.

Chemical depilatory agents contain thioglycolates which disrupt disulfide bonds in the hair with dissolution of the hair into a gelatinous form that can be wiped or scraped away. Minor irritation may accompany application of these agents but is minimal when the chemical is removed in a timely fashion. These agents should not be applied to regions adjacent to mucosal surfaces (eg, the vulva). (See "Removal of unwanted hair", section on 'Depilation'.)

In a retrospective review of a single center's 10-year experience with hair tourniquet removal, 64 percent of hair tourniquets that did not involve the female genitalia or have tissue ischemia were successfully removed with either one or two depilatory treatments [13]. All patients who failed depilatory removal had successful mechanical removal of the tourniquet. A subsequent published literature review demonstrated similar findings [22].

Mechanical removal – If chemical depilatory agents fail to remove the hair tourniquet or are not available, proceed to one of the following techniques for mechanical removal:

-Under magnification, locate and grasp the loose end of the fiber with fine forceps or a hemostat and unwind it from the digit.

-If a loose end cannot be found, insert a blunt probe or curette under the hair to isolate it, and then cut the hair tourniquet with scissors or a scalpel. Remove any adherent hair strands with fine forceps or a hemostat.

After tourniquet removal from a digit, test distal neurovascular and motor function.

Female external genitalia – Because chemical depilatory agents should not be applied near mucosa, superficial hair tourniquets of the labia or clitoris must undergo mechanical removal with fine forceps or a hemostat or excision with fine scissors or a scalpel as described above. Depending upon level of comfort with the procedure, some physicians may prefer to consult a gynecologist or, in young female infants, a pediatric surgeon.

After successful chemical or mechanical removal, improved perfusion and pain relief is usually obvious within minutes of release although swelling may persist for several days.

Thread or other constricting band — Superficially constricting strings or other band located on the digit or external genitalia require direct excision under magnification; the physician inserts a blunt probe or curette under the string or constricting band to isolate it, and then cuts it with scissors or a scalpel [20,21]. Any remnants adhering to the appendage are then removed by fine forceps or a hemostat. Improved perfusion and pain relief is usually seen within minutes of release although swelling may persist for several days.

Deeply embedded tourniquet — Deeply embedded tourniquets present with significant edema and often have tissue ischemia with distal color change (purple, blue, or black). Due to deep penetration into the soft tissue, the constricting hair, thread, or other tourniquet usually cannot be seen without probing the wound or manipulating the digit which may be too painful to accomplish without sedation. However, a deep encircling and narrow indentation of the appendage is highly suggestive of a tourniquet (picture 3).

Direct incision of the constricting band is necessary to ensure proper treatment of a deeply embedded tourniquet; surgical consultation is warranted. The specific specialist necessary depends upon the location of the tourniquet (ie, urologist for penile tourniquets; gynecologist or, in young females, a pediatric surgeon for tourniquets of the vulva; or general surgeon, plastic surgeon, or orthopedic surgeon for digital tourniquets).

The patient must have proper pain control and sedation for the procedure. Options include:

Regional anesthesia – For patients able to tolerate the procedure without general anesthesia, regional anesthesia (eg digital block (picture 4) or dorsal penile block (figure 1) can augment and decrease the necessary depth of sedation. (See "Digital nerve block", section on 'Digital block procedures' and "Management of zipper entrapment injuries", section on 'Dorsal penile block'.)

Procedural sedation – Procedural sedation is appropriate for children and may also be helpful in adults with marked pain or anxiety. (See "Procedural sedation in children: Selection of medications" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

General anesthesia – Examination under anesthesia and lysis of the ligature in the operating room enables the best control of pain and visualization of the injury. This approach is especially appropriate for deeply embedded tourniquets of the penis (maybe complicated by urethral disruption) or vulva (especially if the clitoris is involved).

Incision of penile or vulvar ligatures require detailed knowledge of the anatomy and are best performed by a surgical subspecialist (urologist or gynecologist).

Some experienced physicians may feel comfortable excising embedded digital tourniquets without surgical consultation. Otherwise, consultation of a general surgeon, plastic surgeon, or orthopedic surgeon, depending upon local availability and practice, is warranted.

Key principles for successful incision of digital tourniquets by experienced physicians include:

When incising the tourniquet, avoid the neurovascular bundles by choosing the 3 o'clock or 9 o'clock position (figure 2). The incision should be made longitudinally in the proximal to distal direction with the scalpel blade perpendicular to the surface of the skin. To ensure that the hair is cut completely, the incision should be to the depth of bone.

Alternatively, an incision can be made in the dorsal surface of the digit, completely avoiding the neurovascular bundles [21]. Injury to the extensor tendon is the major disadvantage for this approach. However, a longitudinal incision parallel to the length of the tendon is expected to heal well without long-term sequelae.

After incision, identify and remove any residual hair, thread, or constricting band from the digit and assess neurovascular and motor (tendon) function. Reperfusion and improvement of pain is usually evident within a few minutes of tourniquet excision. Depending upon the degree of soft tissue injury, however, normal perfusion may not return for several days.

AFTERCARE AND FOLLOW-UP — After removal of the tourniquet, the caregiver or patient should be instructed to keep the affected region elevated if possible to promote more rapid decrease of swelling. Prophylactic antibiotics are not necessary.

The patient should be reevaluated 24 hours later to assure resolution of swelling (superficial tourniquets) or continued improvement (deep tourniquets). If swelling is not changed or worse, surgical consultation is warranted to evaluate for continued strangulation caused by a residual tourniquet.

COMPLICATIONS — Superficial tourniquets typically are easily managed and do not cause significant complications.

Complications of embedded digital tourniquets with ischemia include soft tissue loss, bony injury, and amputation [23]. Damage to neurovascular structures can be caused by ischemia, the cutting action of the hair tourniquet, or incision of the constricting band. Infection is unusual but can also occur.

Embedded penile tourniquets may result in ischemic injury to the corpus cavernosum, corpus spongiosum, and/or urethra [24,25]. Amputation of the penis has been described [18].

Similarly, amputation of the clitoris and labia have been described in adolescent girls [3,10].

PREVENTION — Although not proven to reduce the frequency of hair or thread tourniquets, the following anticipatory guidance has been proposed as practical advice to prevent hair and thread tourniquets in infants [26]:

Reduce the infant's exposure to loose hairs and threads through the following actions:

Inform mothers of expected postpartum hair loss and instruct them to brush their hair frequently, dispose of loose hair in a timely fashion, and keep their hair tied back.

Advise mothers to wash their clothes and the baby's clothes separately.

Wash infant's clothes inside out.

Check the hands, feet, and genitalia at each diaper change and after bathing for the presence of erythema, swelling, or loose hairs.

SUMMARY AND RECOMMENDATIONS

Etiology – Hair tourniquet or hair-thread tourniquet syndrome describes swelling or ischemia of the digit or external genitalia caused by a tightly wound hair or thread in a young infant although it may also occur in older patients and be caused by self-application of other materials which form a constricting band. Intentional application by a caregiver to discourage urination at night in young boys has also been described. (See 'Terminology' above and 'Etiology' above.)

History – The infant with a hair or thread tourniquet usually presents with irritability. Parents/primary caregivers may also report a swelling and discoloration at the site of strangulation. However, the tourniquet frequently has not been discovered when the infant presents. Older patients typically report pain and swelling at the site of constriction but often do not admit to intentional application of the tourniquet. (See 'History' above.)

Physical examination and diagnosis – Infants who present with fussiness or irritability should be carefully examined for evidence of a hair or thread tourniquet as well as other etiologies of prolonged or excessive crying (table 1).

The diagnosis of hair tourniquet is usually made on physical examination (see 'Physical examination' above and 'Diagnosis' above):

Superficial tourniquets – Superficial tourniquets are typically visible with magnification and the type of material (hair, thread, or other substance) can often be identified (picture 1). On the fingers or toes, the physician can more easily see the hair on the dorsal surface where it usually penetrates less deeply. Swelling may be significant but discoloration or large amounts of skin breakdown associated with ischemia is not present.

Deeply embedded tourniquets – Deeply embedded tourniquets present with significant edema and often have tissue ischemia with distal color change (purple, blue, or black). Due to deep penetration into the soft tissue, the constricting hair or other material usually cannot be seen, but the physician can appreciate a characteristic narrow, encircling constriction of the digit or external genitalia (picture 3).

Management – The management of a hair or thread tourniquet depends upon whether it is superficial or deeply embedded and whether strangulation is caused by hair or other material (algorithm 1):

We suggest that patients with superficial hair tourniquets of the digit or penis initially have a chemical depilatory agent (eg, Nair, Magic Shave, or Veet), if available, applied to dissolve the hair (Grade 2C). If this method is unsuccessful or a chemical depilatory is not available, the physician should proceed to mechanical removal. Because chemical depilatory agents should not be applied near mucosa, superficial hair tourniquets of the labia or clitoris must always undergo mechanical removal. (See 'Superficial tourniquet' above.)

Superficially constricting strings or other band located on the digit or external genitalia require direct excision under magnification. (See 'Thread or other constricting band' above.)

Deeply embedded tourniquets with ischemia or necrosis require excision and warrant consultation with a surgical specialist. The patient must have proper pain control or sedation for removal. In some patients, especially children with deep tourniquets of the genitalia, general anesthesia may be most appropriate. Alternatively, regional anesthesia (digital or dorsal penile block) and procedural sedation may suffice. (See 'Indications for specialty consultation' above and 'Deeply embedded tourniquet' above.)

Reperfusion and pain relief is usually evident within a few minutes of tourniquet release. (See 'Superficial tourniquet' above and 'Deeply embedded tourniquet' above.)

Aftercare and follow-up – After removal of the tourniquet, the caregiver or patient should be instructed to keep the affected region elevated if possible to promote more rapid decrease of swelling. Prophylactic antibiotics are not necessary. (See 'Aftercare and follow-up' above.)

The patient should be reevaluated 24 hours later to assure resolution of swelling (superficial tourniquets) or continued improvement (deep tourniquets). If swelling is not changed or worse, surgical consultation is warranted to evaluate for continued strangulation caused by a residual tourniquet. (See 'Aftercare and follow-up' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Joan Bothner, MD, who contributed to earlier versions of this topic review.

  1. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome . Pediatrics 1988; 82:925.
  2. Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics 2003; 111:685.
  3. Kuo JH, Smith LM, Berkowitz CD. A hair tourniquet resulting in strangulation and amputation of the clitoris. Obstet Gynecol 2002; 99:939.
  4. Stock C, Wang LC, Spigland NA. Untangling a web: an unusual case of labial necrosis in an adolescent female. J Pediatr Adolesc Gynecol 2012; 25:e21.
  5. Bacon JL, Burgis JT. Hair thread tourniquet syndrome in adolescents: a presentation and review of the literature. J Pediatr Adolesc Gynecol 2005; 18:155.
  6. Pomeranz M, Schachter B, Capua T, Beyth Y. Hair-thread tourniquet syndrome of labia minor. J Pediatr Adolesc Gynecol 2009; 22:e111.
  7. Dua A, Jamshidi R, Lal DR. Labial hair tourniquet: unusual complication of an unrepaired genital laceration. Pediatr Emerg Care 2013; 29:829.
  8. Parlak M, Karakaya AE. Hair-thread tourniquet syndrome of the hypertrophic clitoris in a 6-year-old girl. Pediatr Emerg Care 2015; 31:363.
  9. Panagidis A, Sinopidis X, Alexopoulos V, Georgiou G. Hair Tourniquet Syndrome of Labia Minora. APSP J Case Rep 2015; 6:22.
  10. Golshevsky J, Chuen J, Tung PH. Hair-thread tourniquet syndrome. J Paediatr Child Health 2005; 41:154.
  11. Sylwestrzak MS, Fischer BF, Fischer H. Recurrent clitoral tourniquet syndrome. Pediatrics 2000; 105:866.
  12. Uygur E, Çarkçi E, Ünkar E. Can washing socks without flipping inside out cause hair tourniquet syndrome? A claim with two case reports. J Pediatr Orthop B 2017; 26:193.
  13. Bean JF, Hebal F, Hunter CJ. A single center retrospective review of hair tourniquet syndrome and a proposed treatment algorithm. J Pediatr Surg 2015; 50:1583.
  14. Martonovich N, Khatib M, Assaf M. Hair tourniquet syndrome: A retrospective study. Pediatr Dermatol 2023; 40:125.
  15. Adjei NN, Lynn AY, Grimshaw A, et al. Systematic Literature Review of Pediatric Male and Female Genital Hair Thread Tourniquet Syndrome. Pediatr Emerg Care 2022; 38:e799.
  16. Pahwa HS, Kumar A, Srivastava R, et al. Partial penile amputation due to penile tourniquet syndrome in a child troubled with primary nocturnal enuresis--a rare emergency. Urology 2013; 81:653.
  17. Pantuck AJ, Kraus SL, Barone JG. Hair strangulation injury of the penis. Pediatr Emerg Care 1997; 13:423.
  18. Hussain HM. A hair tourniquet resulting in strangulation and amputation of penis: case report and literature review. J Paediatr Child Health 2008; 44:606.
  19. Haddad FS. Penile strangulation by human hair. Report of three cases and review of the literature. Urol Int 1982; 37:375.
  20. O'Gorman A, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care 2011; 27:203.
  21. Loiselle J, Cronan KM. Hair tourniquet removal. In: Textbook of Pediatric Emergency Procedures, 2nd ed, Henretig FM, King C (Eds), Lippincott Williams & Wilkins, Philadelphia 2008.
  22. Kudzinskas A, Reed A, Mahdi M, Tyler M. Evaluation of Depilatory Agents in the Treatment of Hair-Thread Tourniquet Syndrome. J Emerg Med 2021; 61:507.
  23. Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg 2006; 57:447.
  24. Badawy H, Soliman A, Ouf A, et al. Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases. J Pediatr Surg 2010; 45:1514.
  25. Gazali ZA, Singal AK. Hair Thread Tourniquet Syndrome of Penis Causing Urethral Fistula. Indian Pediatr 2015; 52:538.
  26. Templet TA, Rholdon RD. Assessment, Treatment, and Prevention Strategies for Hair-Thread Tourniquet Syndrome in Infants. Nurs Womens Health 2016; 20:421.
Topic 6318 Version 19.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟