A rare case of Rubber Band Syndrome in elderly: JHSGO

Tokyo, Japan: Rubber band syndrome (RBS) is a rare condition in which a rubber band around a limb becomes embedded under the skin, causing tissue damage. Most reported cases are in children, and its occurrence in adults is considered extremely rare. In this report, Erica Amemiya et al present the case of a patient with RBS in whom a rubber band around the wrist became embedded under the skin.

The patient was a 71-year-old man, who experienced swelling, tingling, numbness, and difficulty performing finger movements using his left hand. Two weeks after the onset of symptoms, the patient visited a local hospital, where he was diagnosed with cellulitis and received antimicrobial therapy. However, there was no improvement in his symptoms, and he was referred to their hospital 1 month after initial onset of symptoms

The initial examination showed swelling, induration, and hypesthesia of the whole left hand. The range of motion for the affected wrist was flexion of 0(compared with healthy wrist flexion of 65) and dorsal flexion of 60(compared with healthy wrist dorsal flexion of 80), indicating notable restriction in flexion. The hand was contracted in an intrinsic minus position. There was no redness or warmth. There was a circumferential scar on the proximal wrist crease and a skin ulcer on the side of the palmar joint. Blood tests indicated a white blood cell count of 8,290/mL with 69% neutrophils, C-reactive protein level of 0.05 mg/dL, and blood glucose level of 102 mg/dL. There were no findings indicative of infection or diabetes. Plain radiography confirmed a slight indentation on the radial bone. Magnetic resonance imaging (MRI) confirmed edematous changes in the whole hand, entrapment of the median nerve in the wrist joint, and a cord-like object compressing the wrist. This led to the suspicion of constriction of the wrist joint by a cord-like object; therefore, an emergency surgery was performed.

A zigzag incision was made on the palmar joint side, and 2 rubber bands were found embedded circumferentially under the skin, matching the scar on the proximal wrist crease. After the rubber bands were removed and the transverse carpal ligament was separated, a widespread adhesion of the flexor tendons in the carpal tunnel was discovered. The median nerve had been considerably constricted by the rubber bands and flexor tendolysis and median nerve neurolysis were performed. The patient started rehabilitation with range of motion exercises for the fingers from the first postoperative day, followed by exercises for the wrist from the second postoperative week onward.

The skin ulcer epithelialized 3 weeks after surgery. Extensor tendolysis was scheduled for the third week after surgery; however, the patient expressed a strong preference for conservative therapy. Therefore, hand therapy was conducted, and to resolve the remaining intrinsic minus position of the hand, knuckle bender orthosis was applied, with which an intrinsic plus position was secured. At 1 year after surgery, the pain and swelling had subsided completely; however, a slight numbness remained in the pulp of the thumb and the index, middle, and ring fingers. The range of motion for the affected/ healthy wrist was as follows: flexion of 47/65, dorsal flexion of 66/80, pronation of 80/80 and supination of 90/90.

Although the patient still exhibited some movement restriction on the affected side compared with the healthy side, his condition had improved. Grip strength and pinch strength improved to 9.8 kg and 3.4 kg, respectively, at 1 year after surgery compared with 4.9 kg and 2 kg immediately after surgery. In comparison, the grip strength of the healthy side was 20.7 kg and the pinch strength was 3.5 kg.

The authors recommended that - when elderly patients with cognitive impairment present with chief complaints of swelling and contracture in the limbs due to an unknown cause, accompanied by a circumferential scar on the affected limb, RBS should be considered. In order to establish a diagnosis, the characteristic circumferential scar, ultrasonography, and MRI are useful. This syndrome involves the risk of deep tissue necrosis; thus, an early extraction is necessary.

Further reading:

A Case of an Elderly Patient With Rubber Band Syndrome

Erica Amemiya, MD, Kazuhiro Maeda, MD, PhD, Takayuki Nemoto, MD,

Iris Wiederkehr, MD, Takeshi Miyawaki, MD, PhD, Mitsuru Saito, MD, PhD

Journal of Hand Surgery Global Online

https://doi.org/10.1016/j.jhsg.2021.07.005