- Email: [email protected]
Upper extremity tourniquet tolerance
The Journal of HAND SURGERY
Terrono et a/.
Three of the patients
had the transfer
after there had
been previous surgery in the area. In each case the palmar fascia had healed and provided adequate tissue to add length to the palmaris longus tendon. There were no operative complications such as infection, improper wound healing, or scar tenderness.
hood of improving thumb function. Rather than weaving the transfer into the abductor pollicis brevis, it may be woven into the extensor mechanism to allow simultaneous metacarpophalangeal joint extension.
REFERENCES Discussion
The goal of this tendon transfer is to restore some abduction. Cooney, Linscheid, and An4 demonstrated that the palmaris longus has an adequate excursion (3 cm) to enhance palmar abduction if the ulnar nerve is intact and provides power from the adductor policis and flexor policis brevis muscles. As dictated by the presence of an arteriovenous shunt in the forearms of most of our patients, the procedure can be successfully performed while the patient is under local anesthesia without the aid of a tourniquet. The palmaris longus is fully expendable, and our experience indicates that its transfer has a high likeli-
1. Camitz H. iiber die behandlung der opposition&&mung. Acta Chir Stand 1929;65:77-81. 2. Littler JW, Li CS. Primary restoration of thumb opposition with median nerve decompression. Plast Reconstr Surg 1967;39:74-5. 3. Braun RM. Palmaris longus tendon transfer for augmentation of thenar musculature in low median nerve palsy. J HAND SURC 1978;3:488-91. 4. Cooney WP, Linscheid RL, An K. Opposition of the thumb: an anatomic and biochemical study of tendon transfers. J HAND SURG 1984;9A:777-86. 5. Burkhalter WE. Median nerve palsy. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1988:1499-534.
.
Upper extremity tourniquet
tolerance
Twenty unsedated volunteers were tested to compare the relative tolerance of an arm tourniquet on one side and of a forearm tourniquet on the other. The forearm tourniquet was tolerated an average
of 13 minutes
immediately
(45%)
longer and was consistently
rated as less painful during and
after the test. No subject tolerated the arm tourniquet
longer than the forearm
tourniquet. Two peaks of discomfort were found, one just before deflation beneath the tourniquet and one in the hand 2 minutes later. Ulnar nerve distribution changes experienced;
however, complete numbness
paresthesias
were the earliest
occurred first in the median nerve distri-
bution. Complete paralysis occurred 7 minutes later (24%) with the forearm tourniquet. rate did not correlate with tourniquet pain, but blood pressure did. No measurable induced edema occurred on either side. (J HAND SURG 1993;18A:206-10.)
Douglas
T. Hutchinson,
Baltimore,
MD,
Salt Lake City, Utah, and Michael
Nov. 18, 1991; accepted
Hos-
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Douglas T. Hutchinson, MD, Division of Orthopaedics, University of Utah, 50 North Medical Dr., Salt Lake City, UT 84132. 3/l/40688
206
A. McClinton,
MD,
Md.
From the Raymond M. Curtis Hand Center, Union Memorial pital, Baltimore, Md. Received for publication May 15, 1992.
Pulse
tourniquet-
THE JOURNALOFHANDSURGERY
T
he use of a pneumatic tourniquet to provide a bloodless field has become routine for most surgical procedures on the hand. As Bunnell’ stated, the tourniquet allows the surgeon to “see every little nerve and vessel or other structure, and to dissect with accuracy and minimal trauma.” Tourniquet discomfort has usually been controlled with a regional (axillary or supraclavicular) block or with general anesthesia. Increasingly, however, surgery on the hand is being performed with only local anesthesia in an effort to decrease the
Vol. 18A, No. 2 March 1993
cost to the patient, increase the efficiency of outpatient surgical facilities, and allow patients to maintain active motion of the fingers during the procedure. We, as well as others,‘. 3 have begun using a tourniquet distal to the elbow as much as possible to decrease discomfort and to delay the onset of tourniquet paralysis. This study was done in an effort to compare the standard upper arm tourniquet with the forearm tourniquet in terms of discomfort, paresis and paralysis, and posttourniquet swelling.
Materials and methods Twenty healthy paid volunteers, all medical personnel familiar with the operating room, participated in the study. Each subject’s sex, age, height, and weight were recorded. The volume of each hand was measured by a standard water-displacement method (an average of three trials).4 Next the subjects were placed in the supine position on the operating room table with both arms comfortably abducted on arm boards. Blood pressure. monitored by a below-the-knee cuff, and heart rate. monitored by a pulse oximeter on the opposite great toe, were allowed to equilibrate for 5 minutes. One arm was randomly chosen (by a coin flip) for an arm tourniquet high in the axilla, and the other had a forearm tourniquet placed over the forearm muscle with the most proximal aspect approximately 5 cm distal to the medial epicondyle. Two thicknesses of smoothly applied cast padding were placed under each tourniquet. Tourniquet cuffs (46 x 9.5 cm) were used for both limbs, and accuracy of the applied pressure was verified before inflation. Both extremities were then exsanguinated simultaneously with two Martin bandages and the tourniquets were elevated to a pressure of 300 mm Hg. Subjective discomfort levels were recorded with a visual analog scale (VAS) for both extremities at 5minute intervals, starting with the initial inflation of the tourniquet and continuing until completion of the test. Likewise, blood pressure and pulse rate were recorded every 5 minutes. Subjective feelings of tingling and objective loss of light touch sensation in various peripheral nerve distributions were recorded. The time to complete paralysis of the intrinsic as well as extrinsic muscles to the hand were also noted. The tests were continued on each limb until the discomfort could no longer be tolerated (VAS rating of 10). That particular tourniquet was then deflated and measurements were continued on that side for an additional 15 minutes. The posttourniquet hand volumes were then measured and recorded. When the tourniquet on the opposite side also became intolerable, it was deflated and again 15 minutes of measurements was followed by volume determination.
Upper extremity tourniquet tolerance
Table I. Results; arm tourniquet
207
versus
forearm tourniquet
Tourniquet tolerance Arm Forearm Complete numbness AlItI Forearm Complete paralysis Arm Forearm
Average (min)
Range (min)
29 42
13-65 20-80
25 29
20-30 20-40
29 36
25-35 35-40
Results (Table I) Patient data. The twenty volunteers included 13 women and 7 men. They ranged in age from 23 to 53 years (mean, 33 years), in weight from 50 kg to 90 kg (mean, 68 kg), and in height from 150 cm to 188 cm (mean, 173 cm). Tourniquet discomfort. The forearm tourniquet was tolerated for a significantly longer time than the arm tourniquet (p < 0.0001 with use of the two-tailed, paired Student t test). This additional tourniquet time averaged 13 minutes (range, 0 to 30 minutes) or 45% longer. No subject tolerated the arm tourniquet longer than the forearm tourniquet. In addition, the average discomfort as measured by the VAS during the test was consistently and significantly greater on the side with the upper arm tourniquet by an average of 2.3 VAS points (p < 0.0001). The tendency was for men to tolerate both tourniquets longer, but this was not statistically significant. No correlations were found between tourniquet tolerance and age, height, or weight of the subject. The few heavier subjects we studied did not tolerate the tourniquets any longer than their thin counterparts, despite their theoretical advantage in having more padding between the cuff and the nerves and muscles. Two peaks of tourniquet discomfort were noted during the test. As can be seen in Fig. 1 and as expected, one occurred just before deflation of the tourniquet. Another peak, which was sometimes higher. occurred approximately 2 minutes later and was described as an intense tingling in the hand and arm as blood flow was restored. This second peak tended to be higher for the arm tourniquet as well and was directly related to how long this tourniquet was tolerated. In other words, those who tolerated the tourniquet for only 15 to 20 minutes did not experience as significant a rebound discomfort as did those who tolerated it longer than 30 minutes.
The Journal of
208
HAND
Hutchinson and McClinton
TOURNIQUET TOLERANCE CURVE
0
5 10 15202530354045505560 Time (minutes) CA Complete Aneslhesta CP Complete Paralysis
UP Ulnar Parastheslas UR Ulnar Paralysis
SURGERY
Blood pressure and pulse rate. No correlation was found between pulse rate and tourniquet discomfort or time with the tourniquet on. In contrast, blood pressure did show significant changes from the beginning of the test to the point of tourniquet deflation. For the arm tourniquet, this change was an average systolic rise of 19 mm Hg (p < 0.0002) and a diastolic rise of 11 mm Hg (p < 0.0015). For the forearm tourniquet, the systolic blood pressure rose an average of 13 mm Hg (p < 0.004) and the diastolic pressure rose 9 mm Hg (p < 0.0007). Those who tolerated the tourniquets the longest time had the largest blood pressure changes. Posttourniquet edema. Hand volumes determined before the test and 15 minutes after the tourniquets were released showed no significant changes for either side. These measurements were carried out for the first 11 subjects only, since the lack of any change was evident by that point and no further testing was deemed necessary.
Fig. 1. Representative subject’s tourniquet tolerance curve showing relative onset of tourniquet discomfort and neurologic changes between arm tourniquet on right side and forearm tourniquet on left side (tourniquets elevated simultaneously).
Discussion
When the forearm tourniquet was tolerated the usual 13 minutes or so longer than the arm tourniquet (but both were tolerated longer than 30 minutes), the rebound effect was often equal in intensity. The site of this rebound discomfort was also different, as it was always in the hand and distal portion of the limb, unlike the first peak discomfort, which was directly beneath the tourniquet itself. The discomfort rating usually returned to 0 within 15 minutes after cuff detlation. Effects on nerve function (Fig. 1). Eighty-five percent of the subjects complained of ulnar nerve paresthesias on the side with the arm tourniquet as their first uncomfortable sensation. This always occurred in the first 5 minutes. In 87% of the patients, however, the first area to lose complete light touch sensation was the median nerve distribution. Total anesthesia of the fingers (both median and ulnar distributions) occurred at an average of 25 minutes for the upper arm tourniquet and 4 minutes later for the forearm tourniquet. Motor function was lost slightly later than was sensation. Intrinsic muscles of the hand became paralyzed at an average of 27 minutes for the side with the arm tourniquet and 35 minutes for the side with the forearm tourniquet. Complete paralysis, including extrinsic flexors and extensors, followed soon after in an average of 29 minutes for the arm tourniquet and 36 minutes for the forearm tourniquet. This was a significant difference (p < 0.003) but included only four subjects since most did not tolerate the tourniquet long enough to attain complete paralysis.
Since the invention of the pneumatic tourniquet in 1904’ and the subsequent scientific studies regarding the tourniquet pressure required and the maximal tourniquet time allowed, G” the incidence of significant tourniquet complications has been minimal.” With the increased use of outpatient operating room facilities and the increase in procedures done with the use of straight local anesthesia in recent years, a patient’s ability or inability to tolerate the tourniquet for the duration of the procedure becomes extremely important. Consequently, we believe that tourniquet pain should be considered a complication of tourniquet use and is the most common complication seen in clinical practice. Several authors have reported the use of tourniquets below the elbow in an effort to reduce this tourniquet pain and thus increase the operative time available.‘, 3 This is despite previous articles stating that “tourniquets should never be placed distal to the elbow”‘* because of increased complications and break-through bleeding.6. I3 The increased complications noted by these authors are theoretical only and reflect a concern about nerve safety with less surrounding muscle available for protection. The break-through bleeding problems discussed seem also to be only theoretical and not based on experience. Persistent patency of the interosseous vessels despite adequate cuff pressures is described as the cause of this problem. In our clinical experience, the complication rate has not been higher with the forearm tourniquet. We have not had one instance of neurologic injury or compartment syndrome in more than 1000 cases. In fact, if one considers tourniquet pain as a complication, the overall complication rate would certainly be less with the fore-
Vol. 18A. No. 2 March 1993
Both the average gain of 13 additional minutes in operating time and the decrease in discomfort from the tourniquet during the operation are significant advantages of the forearm tourniquet. In addition, the advantage of having patient participation with active motion for 7 minutes longer is extremely helpful in tenolysis, multiple trigger finger releases, and joint contracture procedures. Although one of us (M. A. M.) does believe that break-through bleeding occurs slightly more often with the forearm tourniquet, this has not been sufficient to discourage its use. Again speaking theoretically, as we have not yet proved this, we believe that if break-through bleeding due to persistent interosseous vessels does occur, it does so less often than the venous ooze due to humeral medullary cavity bypass of venous blood associated with arm tourniquets.“, 14.” We used 300 mm Hg as our cuff pressure because it is generally considered to be the highest acceptable pressure for the upper extremity. We were concerned that break-through bleeding might occur with lower pressures. in view of the subject’s blood pressure elevation and inevitable muscular contractions due to the discomfort of the tourniquet. We do not often use this pressure clinically, because we rarely ask a patient to endure a tourniquet as long as these volunteers. Our normal cuff pressure is approximately 100 mm above systolic for the forearm tourniquet and slightly higher for the arm tourniquet (usual range, 225 to 280 mm Hg). The literature varies somewhat with respect to what is thought to be a reasonable time for someone to tolerate a tourniquet. Beasley16 thought that “if blood is expressed from the arm before application of the tourniquet, most patients will experience no ischemic pain for 30-45 minutes.” Pain-free ischemia for as long as 75 minutes is claimed by Dushoff,” who again cited proper Martin bandaging of the arm before tourniquet inflation as a key element. Kessler’8 reported use of the arm tourniquet and local anesthesia for close to 40 minutes, but he used preoperative sedation. Proponents of the use of wrist tourniquets state that anywhere from 60 to 135 minutes can be tolerated by the patient.’ This technique requires sterile tourniquets and an arm tourniquet in place as a backup. Procedures at wrist level cannot be performed because of the distal position of the cuff. Bennett and Mohler” performed studies similar to ours on healthy volunteers. One group of 10 subjects tolerated the arm tourniquet without sedation for an average of 29 minutes (exactly the average found in our 20 subjects). They then went on to study two smaller groups-one with arm tourniquets and one with forearm tourniquets-but they added preoperative searm tourniquet.
Upper extremity tourniquet tolerance
209
dation. Tolerance was increased to 1 hour, but no differences were noted between tourniquet sites. Hagenouw et al.” performed similar studies on the lower extremity with use of a high thigh cuff. Again, a similar average tolerance of 31 minutes was found for these unsedated volunteers. They also found a double peak of VAS discomfort and a statistically significant blood pressure increase, again similar to our findings. Posttourniquet edema has been another complication of tourniquets about which much has been written but little has been studied. Described as part of the complex of symptoms of “postischemic hand syndrome”” or “posttourniquet syndrome,“” most authors believe that it is not inherent with tourniquet use but more a result of prolonged tourniquet time or excessive tourniquet pressure. ‘. 6. ‘o-“. ” On the other hand. Ward” recommended that the Dupuytren fasciectomy be performed without a tourniquet to reduce postoperative edema. Sanders” and Sapega et al.’ believe that the amount of ischemic muscle below the tourniquet corresponds to the amount of edema found afterward. As stated by Sanders, “There is no record in the literature of the minimum time a tourniquet needs to be applied to produce detectable edema.“” Our study suggests that with tourniquet times of less than 60 minutes, no appreciable tourniquet-induced edema occurs with the use of either arm or forearm tourniquets.
REFERENCES 1. Bunnell S. Surgery of the hand. 5th ed. Philadelphia: JB Lippincott, 1956. 2. Guirguis EM, Bell MSG. The wrist tourniquet: an alternative technique in hand surgery. J HAND SURG 1990;15A:516-9. 3. Chow SP, Pun WK, Luk KDK, So YC, Ip FK, Chan KC. Modified forearm intravenous regional analgesia for hand surgery. J HAND SURG 1989;14A:913-4. 4. Brand PW. Clinical mechanics of the hand. St. Louis: CV Mosby, 1985. 5. Cushing H. Pneumatic tourniquets with special reference to use in craniotomies. Med News 1904;84:577-80. 6. Tajima T. Considerations on the use of the tourniquet in surgery of the hand. J HAND SURG 1983;8:799-802. 7. Sapega AA, Heppenstall RB, Chance B, Park YS, Sokolow D. Optimizing tourniquet application and release times in extremity surgery. J Bone Joint Surg 1985;67A:303-14. 8. Wilgis EFS. Observations on the effects of tourniquet ischemia. J Bone Joint Surg 1991;53A:l343-6. 9. Flatt AE. Tourniquet time in hand surgery. Arch Surg 1972;104:190-2. 10. Bruner JM. Safety factors in the use of pneumatic tourniquet for hemostasis in surgery of the hand. J Bone Joint Surg 1951;33A:221-4.
The Journal of HAND SURGERY
Hutchinson and McClinton
11. Palmer AK. Complications from tourniquet use. Hand Clin 1986;2:301-5. 12. Sanders R. The tourniquet, instrument or weapon? Hand 1973;5:119-23. 13. Kalisman M, Miller JB. Use and abuse of the surgical tourniquet. Infect Surg 1983: 197-204. 14. Paletta FX, Willman V, Ship AG. Prolonged tourniquet ischemia of extremities. J Bone Joint Surg 1960;42A:945-50. 15. Furlow LT. Cause and prevention of tourniquet ooze. Surg Gynecol Obstet 1971;132:1069-72. 16. Beasley R. Hand injuries. Philadelphia: WB Saunders, 1981:61. 17. Dushoff IM. Hand surgery under wrist block and local
18. 19. 20.
21.
22.
infiltration anesthesia using an upper arm tourniquet [letter to the editor]. Plast Reconstr Surg 1973;51:685. Kessler FB. The brachial tourniquet and local analgesia in surgery of the upper limb. J Trauma 1966;6:43-7. Bennett JE, Mohler L. Arm tourniquet tolerance in unanesthetized adults. Surg Forum 1964;15:463-5. Hagenouw R, Bridenbaugh PO, Van Egmond J, Stuebing R. Tourniquet pain: a volunteer study. Anesth Analg 1986;65: 1175-80. Dreyfuss UY, Smith RJ. Sensory changes with prolonged double-cuff tourniquet time in hand surgery. J HAND SURC 1988;13A:730-40. Ward CM. Oedema of the hand after fasciectomy with or without tourniquet. Hand 1986;8:179-85.
The effect of hypothermia on changes in isometric contractile function in skeletal muscle after tourniquet The effect of hypothermia
ischemia
on changes in contractile function of skeletal muscle observed after
an episode of tourniquet ischemia has been investigated. hours of unilateral
hypothermic
Male Wistar rats were subjected to 2
(n = 33) or normothermic
(n = 39) pneumatic
ischemia of a hind limb. Isometric contractile function was measured bilaterally
tourniquet
from the gas-
trocnemius muscles after 1, 7, 14, 28, or 42 days of recovery. Compared to muscle subjected to normothermic ischemia, muscle that underwent hypothermic ischemia demonstrated more twitch tension at 1 day postischemia,
higher maximum
tetanic tension at all time periods, including 6
weeks after ischemia, and greater muscle weight at 6 weeks. Rat gastrocnemius muscle function is much better 1 day to 6 weeks after 2 hours of hypothermic ischemia than after 2 hours of normothermic
ischemia. The results thus document the benefit of hypothermia during tourniquet
ischemia in preventing or minimizing the changes in isometric contractile function observed after normothermic
ischemia. (J HAND SURC 1993;18A:210-7.)
Joel S. Fish, BSc, MD, MSc, Nancy H. McKee, MD, FRCS(C), William M. Kuzon, Jr., MD, PhD, FRCS(C), and Michael J. Plyley, PhD, Toronto, Ontario, Canada
From the Microvascular Research Laboratory, Department gery, University of Toronto, Toronto, Ontario, Canada.
of Sur-
This study was supported by The Physician’s Services Incorporated Foundation 88-33 and the Medical Research Council of Canada (No. 10536). Received for publication 9, 1992.
Nov. 8, 1990; accepted in revised form Oct.
311144197
210
THEJOURNALOFHANDSURGERY
FACS,
Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund. foundation, educational institution, or other nonprofit organization with which one or more of the authors are associated Reprint requests: Nancy H. McKee, MD, Microvascular Research Laboratory, Department of Surgery, Room 6270, Medical Sciences Building, University of Toronto, Toronto, Ontario, Canada M5S 1A8.
Terrono et a/.
Three of the patients
had the transfer
after there had
been previous surgery in the area. In each case the palmar fascia had healed and provided adequate tissue to add length to the palmaris longus tendon. There were no operative complications such as infection, improper wound healing, or scar tenderness.
hood of improving thumb function. Rather than weaving the transfer into the abductor pollicis brevis, it may be woven into the extensor mechanism to allow simultaneous metacarpophalangeal joint extension.
REFERENCES Discussion
The goal of this tendon transfer is to restore some abduction. Cooney, Linscheid, and An4 demonstrated that the palmaris longus has an adequate excursion (3 cm) to enhance palmar abduction if the ulnar nerve is intact and provides power from the adductor policis and flexor policis brevis muscles. As dictated by the presence of an arteriovenous shunt in the forearms of most of our patients, the procedure can be successfully performed while the patient is under local anesthesia without the aid of a tourniquet. The palmaris longus is fully expendable, and our experience indicates that its transfer has a high likeli-
1. Camitz H. iiber die behandlung der opposition&&mung. Acta Chir Stand 1929;65:77-81. 2. Littler JW, Li CS. Primary restoration of thumb opposition with median nerve decompression. Plast Reconstr Surg 1967;39:74-5. 3. Braun RM. Palmaris longus tendon transfer for augmentation of thenar musculature in low median nerve palsy. J HAND SURC 1978;3:488-91. 4. Cooney WP, Linscheid RL, An K. Opposition of the thumb: an anatomic and biochemical study of tendon transfers. J HAND SURG 1984;9A:777-86. 5. Burkhalter WE. Median nerve palsy. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1988:1499-534.
.
Upper extremity tourniquet
tolerance
Twenty unsedated volunteers were tested to compare the relative tolerance of an arm tourniquet on one side and of a forearm tourniquet on the other. The forearm tourniquet was tolerated an average
of 13 minutes
immediately
(45%)
longer and was consistently
rated as less painful during and
after the test. No subject tolerated the arm tourniquet
longer than the forearm
tourniquet. Two peaks of discomfort were found, one just before deflation beneath the tourniquet and one in the hand 2 minutes later. Ulnar nerve distribution changes experienced;
however, complete numbness
paresthesias
were the earliest
occurred first in the median nerve distri-
bution. Complete paralysis occurred 7 minutes later (24%) with the forearm tourniquet. rate did not correlate with tourniquet pain, but blood pressure did. No measurable induced edema occurred on either side. (J HAND SURG 1993;18A:206-10.)
Douglas
T. Hutchinson,
Baltimore,
MD,
Salt Lake City, Utah, and Michael
Nov. 18, 1991; accepted
Hos-
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Douglas T. Hutchinson, MD, Division of Orthopaedics, University of Utah, 50 North Medical Dr., Salt Lake City, UT 84132. 3/l/40688
206
A. McClinton,
MD,
Md.
From the Raymond M. Curtis Hand Center, Union Memorial pital, Baltimore, Md. Received for publication May 15, 1992.
Pulse
tourniquet-
THE JOURNALOFHANDSURGERY
T
he use of a pneumatic tourniquet to provide a bloodless field has become routine for most surgical procedures on the hand. As Bunnell’ stated, the tourniquet allows the surgeon to “see every little nerve and vessel or other structure, and to dissect with accuracy and minimal trauma.” Tourniquet discomfort has usually been controlled with a regional (axillary or supraclavicular) block or with general anesthesia. Increasingly, however, surgery on the hand is being performed with only local anesthesia in an effort to decrease the
Vol. 18A, No. 2 March 1993
cost to the patient, increase the efficiency of outpatient surgical facilities, and allow patients to maintain active motion of the fingers during the procedure. We, as well as others,‘. 3 have begun using a tourniquet distal to the elbow as much as possible to decrease discomfort and to delay the onset of tourniquet paralysis. This study was done in an effort to compare the standard upper arm tourniquet with the forearm tourniquet in terms of discomfort, paresis and paralysis, and posttourniquet swelling.
Materials and methods Twenty healthy paid volunteers, all medical personnel familiar with the operating room, participated in the study. Each subject’s sex, age, height, and weight were recorded. The volume of each hand was measured by a standard water-displacement method (an average of three trials).4 Next the subjects were placed in the supine position on the operating room table with both arms comfortably abducted on arm boards. Blood pressure. monitored by a below-the-knee cuff, and heart rate. monitored by a pulse oximeter on the opposite great toe, were allowed to equilibrate for 5 minutes. One arm was randomly chosen (by a coin flip) for an arm tourniquet high in the axilla, and the other had a forearm tourniquet placed over the forearm muscle with the most proximal aspect approximately 5 cm distal to the medial epicondyle. Two thicknesses of smoothly applied cast padding were placed under each tourniquet. Tourniquet cuffs (46 x 9.5 cm) were used for both limbs, and accuracy of the applied pressure was verified before inflation. Both extremities were then exsanguinated simultaneously with two Martin bandages and the tourniquets were elevated to a pressure of 300 mm Hg. Subjective discomfort levels were recorded with a visual analog scale (VAS) for both extremities at 5minute intervals, starting with the initial inflation of the tourniquet and continuing until completion of the test. Likewise, blood pressure and pulse rate were recorded every 5 minutes. Subjective feelings of tingling and objective loss of light touch sensation in various peripheral nerve distributions were recorded. The time to complete paralysis of the intrinsic as well as extrinsic muscles to the hand were also noted. The tests were continued on each limb until the discomfort could no longer be tolerated (VAS rating of 10). That particular tourniquet was then deflated and measurements were continued on that side for an additional 15 minutes. The posttourniquet hand volumes were then measured and recorded. When the tourniquet on the opposite side also became intolerable, it was deflated and again 15 minutes of measurements was followed by volume determination.
Upper extremity tourniquet tolerance
Table I. Results; arm tourniquet
207
versus
forearm tourniquet
Tourniquet tolerance Arm Forearm Complete numbness AlItI Forearm Complete paralysis Arm Forearm
Average (min)
Range (min)
29 42
13-65 20-80
25 29
20-30 20-40
29 36
25-35 35-40
Results (Table I) Patient data. The twenty volunteers included 13 women and 7 men. They ranged in age from 23 to 53 years (mean, 33 years), in weight from 50 kg to 90 kg (mean, 68 kg), and in height from 150 cm to 188 cm (mean, 173 cm). Tourniquet discomfort. The forearm tourniquet was tolerated for a significantly longer time than the arm tourniquet (p < 0.0001 with use of the two-tailed, paired Student t test). This additional tourniquet time averaged 13 minutes (range, 0 to 30 minutes) or 45% longer. No subject tolerated the arm tourniquet longer than the forearm tourniquet. In addition, the average discomfort as measured by the VAS during the test was consistently and significantly greater on the side with the upper arm tourniquet by an average of 2.3 VAS points (p < 0.0001). The tendency was for men to tolerate both tourniquets longer, but this was not statistically significant. No correlations were found between tourniquet tolerance and age, height, or weight of the subject. The few heavier subjects we studied did not tolerate the tourniquets any longer than their thin counterparts, despite their theoretical advantage in having more padding between the cuff and the nerves and muscles. Two peaks of tourniquet discomfort were noted during the test. As can be seen in Fig. 1 and as expected, one occurred just before deflation of the tourniquet. Another peak, which was sometimes higher. occurred approximately 2 minutes later and was described as an intense tingling in the hand and arm as blood flow was restored. This second peak tended to be higher for the arm tourniquet as well and was directly related to how long this tourniquet was tolerated. In other words, those who tolerated the tourniquet for only 15 to 20 minutes did not experience as significant a rebound discomfort as did those who tolerated it longer than 30 minutes.
The Journal of
208
HAND
Hutchinson and McClinton
TOURNIQUET TOLERANCE CURVE
0
5 10 15202530354045505560 Time (minutes) CA Complete Aneslhesta CP Complete Paralysis
UP Ulnar Parastheslas UR Ulnar Paralysis
SURGERY
Blood pressure and pulse rate. No correlation was found between pulse rate and tourniquet discomfort or time with the tourniquet on. In contrast, blood pressure did show significant changes from the beginning of the test to the point of tourniquet deflation. For the arm tourniquet, this change was an average systolic rise of 19 mm Hg (p < 0.0002) and a diastolic rise of 11 mm Hg (p < 0.0015). For the forearm tourniquet, the systolic blood pressure rose an average of 13 mm Hg (p < 0.004) and the diastolic pressure rose 9 mm Hg (p < 0.0007). Those who tolerated the tourniquets the longest time had the largest blood pressure changes. Posttourniquet edema. Hand volumes determined before the test and 15 minutes after the tourniquets were released showed no significant changes for either side. These measurements were carried out for the first 11 subjects only, since the lack of any change was evident by that point and no further testing was deemed necessary.
Fig. 1. Representative subject’s tourniquet tolerance curve showing relative onset of tourniquet discomfort and neurologic changes between arm tourniquet on right side and forearm tourniquet on left side (tourniquets elevated simultaneously).
Discussion
When the forearm tourniquet was tolerated the usual 13 minutes or so longer than the arm tourniquet (but both were tolerated longer than 30 minutes), the rebound effect was often equal in intensity. The site of this rebound discomfort was also different, as it was always in the hand and distal portion of the limb, unlike the first peak discomfort, which was directly beneath the tourniquet itself. The discomfort rating usually returned to 0 within 15 minutes after cuff detlation. Effects on nerve function (Fig. 1). Eighty-five percent of the subjects complained of ulnar nerve paresthesias on the side with the arm tourniquet as their first uncomfortable sensation. This always occurred in the first 5 minutes. In 87% of the patients, however, the first area to lose complete light touch sensation was the median nerve distribution. Total anesthesia of the fingers (both median and ulnar distributions) occurred at an average of 25 minutes for the upper arm tourniquet and 4 minutes later for the forearm tourniquet. Motor function was lost slightly later than was sensation. Intrinsic muscles of the hand became paralyzed at an average of 27 minutes for the side with the arm tourniquet and 35 minutes for the side with the forearm tourniquet. Complete paralysis, including extrinsic flexors and extensors, followed soon after in an average of 29 minutes for the arm tourniquet and 36 minutes for the forearm tourniquet. This was a significant difference (p < 0.003) but included only four subjects since most did not tolerate the tourniquet long enough to attain complete paralysis.
Since the invention of the pneumatic tourniquet in 1904’ and the subsequent scientific studies regarding the tourniquet pressure required and the maximal tourniquet time allowed, G” the incidence of significant tourniquet complications has been minimal.” With the increased use of outpatient operating room facilities and the increase in procedures done with the use of straight local anesthesia in recent years, a patient’s ability or inability to tolerate the tourniquet for the duration of the procedure becomes extremely important. Consequently, we believe that tourniquet pain should be considered a complication of tourniquet use and is the most common complication seen in clinical practice. Several authors have reported the use of tourniquets below the elbow in an effort to reduce this tourniquet pain and thus increase the operative time available.‘, 3 This is despite previous articles stating that “tourniquets should never be placed distal to the elbow”‘* because of increased complications and break-through bleeding.6. I3 The increased complications noted by these authors are theoretical only and reflect a concern about nerve safety with less surrounding muscle available for protection. The break-through bleeding problems discussed seem also to be only theoretical and not based on experience. Persistent patency of the interosseous vessels despite adequate cuff pressures is described as the cause of this problem. In our clinical experience, the complication rate has not been higher with the forearm tourniquet. We have not had one instance of neurologic injury or compartment syndrome in more than 1000 cases. In fact, if one considers tourniquet pain as a complication, the overall complication rate would certainly be less with the fore-
Vol. 18A. No. 2 March 1993
Both the average gain of 13 additional minutes in operating time and the decrease in discomfort from the tourniquet during the operation are significant advantages of the forearm tourniquet. In addition, the advantage of having patient participation with active motion for 7 minutes longer is extremely helpful in tenolysis, multiple trigger finger releases, and joint contracture procedures. Although one of us (M. A. M.) does believe that break-through bleeding occurs slightly more often with the forearm tourniquet, this has not been sufficient to discourage its use. Again speaking theoretically, as we have not yet proved this, we believe that if break-through bleeding due to persistent interosseous vessels does occur, it does so less often than the venous ooze due to humeral medullary cavity bypass of venous blood associated with arm tourniquets.“, 14.” We used 300 mm Hg as our cuff pressure because it is generally considered to be the highest acceptable pressure for the upper extremity. We were concerned that break-through bleeding might occur with lower pressures. in view of the subject’s blood pressure elevation and inevitable muscular contractions due to the discomfort of the tourniquet. We do not often use this pressure clinically, because we rarely ask a patient to endure a tourniquet as long as these volunteers. Our normal cuff pressure is approximately 100 mm above systolic for the forearm tourniquet and slightly higher for the arm tourniquet (usual range, 225 to 280 mm Hg). The literature varies somewhat with respect to what is thought to be a reasonable time for someone to tolerate a tourniquet. Beasley16 thought that “if blood is expressed from the arm before application of the tourniquet, most patients will experience no ischemic pain for 30-45 minutes.” Pain-free ischemia for as long as 75 minutes is claimed by Dushoff,” who again cited proper Martin bandaging of the arm before tourniquet inflation as a key element. Kessler’8 reported use of the arm tourniquet and local anesthesia for close to 40 minutes, but he used preoperative sedation. Proponents of the use of wrist tourniquets state that anywhere from 60 to 135 minutes can be tolerated by the patient.’ This technique requires sterile tourniquets and an arm tourniquet in place as a backup. Procedures at wrist level cannot be performed because of the distal position of the cuff. Bennett and Mohler” performed studies similar to ours on healthy volunteers. One group of 10 subjects tolerated the arm tourniquet without sedation for an average of 29 minutes (exactly the average found in our 20 subjects). They then went on to study two smaller groups-one with arm tourniquets and one with forearm tourniquets-but they added preoperative searm tourniquet.
Upper extremity tourniquet tolerance
209
dation. Tolerance was increased to 1 hour, but no differences were noted between tourniquet sites. Hagenouw et al.” performed similar studies on the lower extremity with use of a high thigh cuff. Again, a similar average tolerance of 31 minutes was found for these unsedated volunteers. They also found a double peak of VAS discomfort and a statistically significant blood pressure increase, again similar to our findings. Posttourniquet edema has been another complication of tourniquets about which much has been written but little has been studied. Described as part of the complex of symptoms of “postischemic hand syndrome”” or “posttourniquet syndrome,“” most authors believe that it is not inherent with tourniquet use but more a result of prolonged tourniquet time or excessive tourniquet pressure. ‘. 6. ‘o-“. ” On the other hand. Ward” recommended that the Dupuytren fasciectomy be performed without a tourniquet to reduce postoperative edema. Sanders” and Sapega et al.’ believe that the amount of ischemic muscle below the tourniquet corresponds to the amount of edema found afterward. As stated by Sanders, “There is no record in the literature of the minimum time a tourniquet needs to be applied to produce detectable edema.“” Our study suggests that with tourniquet times of less than 60 minutes, no appreciable tourniquet-induced edema occurs with the use of either arm or forearm tourniquets.
REFERENCES 1. Bunnell S. Surgery of the hand. 5th ed. Philadelphia: JB Lippincott, 1956. 2. Guirguis EM, Bell MSG. The wrist tourniquet: an alternative technique in hand surgery. J HAND SURG 1990;15A:516-9. 3. Chow SP, Pun WK, Luk KDK, So YC, Ip FK, Chan KC. Modified forearm intravenous regional analgesia for hand surgery. J HAND SURG 1989;14A:913-4. 4. Brand PW. Clinical mechanics of the hand. St. Louis: CV Mosby, 1985. 5. Cushing H. Pneumatic tourniquets with special reference to use in craniotomies. Med News 1904;84:577-80. 6. Tajima T. Considerations on the use of the tourniquet in surgery of the hand. J HAND SURG 1983;8:799-802. 7. Sapega AA, Heppenstall RB, Chance B, Park YS, Sokolow D. Optimizing tourniquet application and release times in extremity surgery. J Bone Joint Surg 1985;67A:303-14. 8. Wilgis EFS. Observations on the effects of tourniquet ischemia. J Bone Joint Surg 1991;53A:l343-6. 9. Flatt AE. Tourniquet time in hand surgery. Arch Surg 1972;104:190-2. 10. Bruner JM. Safety factors in the use of pneumatic tourniquet for hemostasis in surgery of the hand. J Bone Joint Surg 1951;33A:221-4.
The Journal of HAND SURGERY
Hutchinson and McClinton
11. Palmer AK. Complications from tourniquet use. Hand Clin 1986;2:301-5. 12. Sanders R. The tourniquet, instrument or weapon? Hand 1973;5:119-23. 13. Kalisman M, Miller JB. Use and abuse of the surgical tourniquet. Infect Surg 1983: 197-204. 14. Paletta FX, Willman V, Ship AG. Prolonged tourniquet ischemia of extremities. J Bone Joint Surg 1960;42A:945-50. 15. Furlow LT. Cause and prevention of tourniquet ooze. Surg Gynecol Obstet 1971;132:1069-72. 16. Beasley R. Hand injuries. Philadelphia: WB Saunders, 1981:61. 17. Dushoff IM. Hand surgery under wrist block and local
18. 19. 20.
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infiltration anesthesia using an upper arm tourniquet [letter to the editor]. Plast Reconstr Surg 1973;51:685. Kessler FB. The brachial tourniquet and local analgesia in surgery of the upper limb. J Trauma 1966;6:43-7. Bennett JE, Mohler L. Arm tourniquet tolerance in unanesthetized adults. Surg Forum 1964;15:463-5. Hagenouw R, Bridenbaugh PO, Van Egmond J, Stuebing R. Tourniquet pain: a volunteer study. Anesth Analg 1986;65: 1175-80. Dreyfuss UY, Smith RJ. Sensory changes with prolonged double-cuff tourniquet time in hand surgery. J HAND SURC 1988;13A:730-40. Ward CM. Oedema of the hand after fasciectomy with or without tourniquet. Hand 1986;8:179-85.
The effect of hypothermia on changes in isometric contractile function in skeletal muscle after tourniquet The effect of hypothermia
ischemia
on changes in contractile function of skeletal muscle observed after
an episode of tourniquet ischemia has been investigated. hours of unilateral
hypothermic
Male Wistar rats were subjected to 2
(n = 33) or normothermic
(n = 39) pneumatic
ischemia of a hind limb. Isometric contractile function was measured bilaterally
tourniquet
from the gas-
trocnemius muscles after 1, 7, 14, 28, or 42 days of recovery. Compared to muscle subjected to normothermic ischemia, muscle that underwent hypothermic ischemia demonstrated more twitch tension at 1 day postischemia,
higher maximum
tetanic tension at all time periods, including 6
weeks after ischemia, and greater muscle weight at 6 weeks. Rat gastrocnemius muscle function is much better 1 day to 6 weeks after 2 hours of hypothermic ischemia than after 2 hours of normothermic
ischemia. The results thus document the benefit of hypothermia during tourniquet
ischemia in preventing or minimizing the changes in isometric contractile function observed after normothermic
ischemia. (J HAND SURC 1993;18A:210-7.)
Joel S. Fish, BSc, MD, MSc, Nancy H. McKee, MD, FRCS(C), William M. Kuzon, Jr., MD, PhD, FRCS(C), and Michael J. Plyley, PhD, Toronto, Ontario, Canada
From the Microvascular Research Laboratory, Department gery, University of Toronto, Toronto, Ontario, Canada.
of Sur-
This study was supported by The Physician’s Services Incorporated Foundation 88-33 and the Medical Research Council of Canada (No. 10536). Received for publication 9, 1992.
Nov. 8, 1990; accepted in revised form Oct.
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THEJOURNALOFHANDSURGERY
FACS,
Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund. foundation, educational institution, or other nonprofit organization with which one or more of the authors are associated Reprint requests: Nancy H. McKee, MD, Microvascular Research Laboratory, Department of Surgery, Room 6270, Medical Sciences Building, University of Toronto, Toronto, Ontario, Canada M5S 1A8.