Tourniquet Paralysis. CLINICAL MATERIAL OF necessity, a very large sample of procedures

Transcription

1 TOURNIQUET PARALYSIS MIDbLETON AND VARIAN Tourniquet Prlysis K. W. D. MIDDLE TON^ AND J. P. VARIAN~ Royl Alexndr Hospitl for Children, Sydney The prnciplcs of the use of the limb tourniquet hve been unchnged for over IOO yers, but the detils of the techniques involved hve grdully ltered. This pper describes the modern prctice of the use of the limb tourniquet in Austrli, estimtes the incidence of coinplictions nd indictes the firessure which my be produced by the Esmrcl bndge. CLINICAL MATERIAL OF necessity, very lrge smple of procedures needs to be gthered to give significnt mount of informtion, s complictions from the use of tourniquets re rre. Becuse of their rrity nd the concern of the surgeon on these occsions, it ws thought tht questionnire informtion ws likely to be quite ccurte. One hundred nd fiftyone members of the Austrlin Orthopdic Assocition hve supplied dt. TYPE AND SITE OF TOURNIQUET USED Both the Esmrch bndge (Figure I) nd the pneumtic cuff tourniquet re in use (Tble I ). There is decided preference for the pneumtic cuff on the rm, but significnt number of surgeons still employ n Esmrch bndge, nd this occurs to greter extent in reltion to the lower limb, where over 50% of tourniquets used re of this type. It ws thought impossible to quntify the pplictions to the vrious sites, so tht the lterntives to the question bout site were usul, occsionl nd never (Tble I). Only I I % of surgeons pply n rm tourniquet below the elbow. There is greter diversity in respect of the lower limb. Although ll surgeons except one use the re bove the Red t the Combined Meeting of the Austrlin nd New Zelnd Orthopedic Associtions, Queenstown, New Zelnd, September, Honorry Orthopedic Surgeon. Orthopedic Registrr. Reprints: Mr R. W. D. Middleton, North Shore Medicl Centre, 6680 Pcific Highwy, St Leonrds, N.S.W I 24 knee s their usul site of ppliction, considerble number use the clf nd nkle s need rises. Forty out of the 151 responding surgeons use no other sites thn bove the elbow nd bove the knee. Informtion concerning the durtion of occlusion ws not sought except when compliction occurred. Arm Pneumtic Esmrch Either Lower limb Pneumtic Esmrch Either.. TABLE I Tourniquet Pveferencc Tourniquet type 1. Sitc of Afifiliction Number ~ of surgeons Usul Occsionl Never Above elbow 149 I I Below elbow z Thigh 150 I Clf s Ankle 38 3 Number of Applictions.Retrospective nd prospective counting of the number of tourniquets used is tsk of such mgnitude s to be prcticlly impossible. An ttempt ws therefore mde to guge the order of the number of tourniquets used per week. Assuming 45week working yer nd knowing the number of yers the surgeon hd ctively prctised surgery, we obtined n estimted AUST. N.Z. J. SURG., VOL. 44 NO. 2, MAY, 1974

2 TOURNIQUET PARALYSIS figure of 630,000 cses in the reported series. This is equivlent to pproximtely 200 tourniquets per surgeon per nnum, figure which flls well within credible rnge. Further, it ws estimted tht there were 240,000 pplictions on the rm nd 390,000 on the lower limb. The following deductions re bsed on these ssumptions. COMPLICATIONS Most complictions reported consisted of peripherl nerve dmge (Tble 2). The incidence ws one in 8,000 with somewht I. Totl Rdil TABLE 2 Plsy Type 52 Arm Plsies Medin z7 mr 1 2. Rdil nerve only Medin nerve only... z 4. Other Lown Limb Plsies I. Scitic 2 z. Lterl poplitel :: Other four which could not be clssified becuse of lck of description. The rm plsies (Tble 2) occurred both with Esmrch bndges nd pneumtic cuffs. All ptients mde full recovery fter vrying periods, except one who developed complete rdil nerve lesion which persisted. This followed the use of n Esmrch bndge for 40 minutes. The pproximte verge time for recovery ws four to five months, lthough some plsies were trnsient nd others required up to 12 months to dispper. In the lower limb there were 30 reported nerve injuries, but the clssifiction ws not s precise s in the rm (Tble 2). Thirteen cses were difficult to clssify, lrgely becuse of lck of ccurte informtion. There ws one cse of femorl nd scitic plsy fter forgotten tourniquet the only one reported in the series. This tourniquet ws found t higher figure of one in 5,000 for the rm thn tht for the leg, which ws one in 13,000. It hs not been possible to decide whether the rm is niore susceptible to presis or whether recognition is esier in the upper limb. Tohl rm plsics TABLE 3 Plsies nd Tourniquet Type Type of tourniquet.. Pneumtic, 8 Time of ppliction.. Recovery Time of recoviii Rdil nerve plsies All recovered Few dys to one yer Type of tourniquet Pneumtic, XI Esmrch, 8 Time of ppliction 15 minutes to xf hours Recovery Time of recovery Lown limb plsies Esmrch, xg 20 minutes to 2f hours.... One permnent plsy ; ll recovery Few dys to 6 months Type of tourniquet All Esmrch Site of uuliction Above knee. 27 Clf.3. Time of ppliction 30 minutes to 4f hours Recovery Prtil, I Full, zg Time of recovery.. Few dys to g months others full The rm plsies fell minly into two distinct groups (Tble 3), the lrgest being involvement of medin, ulnr nd rdil nerves below the tourniquet. There ws slightly smller group of isolted rdil nerve lesions. Other cses included two medin nerve lesions nd FIGURE I four nd hlf hours. It ws removed when discovered, nd the ptient mde full recovery. None of the tourniquets were kept on for more thn n hour nd hlf except the forgotten one. All reported complictions followed n Esmrch bndge, except the single cse of incomplete recovery which occurred mny yers go when tubing tourniquet hd been used (Tble 3). Other Complictions. Vrious surgeons hve ttributed other mishps to the ppliction of tourniquet. These hve included deth from crdic rrest fter bilterl leg exsnguintion, nd full thickness burns from hot tourniquet. There ws one cse of femorl rtery spsm, with full recovery, nd AUST. N.Z. J. SURG., VOL. MNo. 2, MAY, 1974

3 TOUKKIQUET PARALYSIS 'l number of cses 100% CHILDREN ( 35 cses 1 % number of cses 100% 1 ADULTS ( 10 cses 1. 40% 20% 20% 10% 10% 8, Tourniquet FIGURE z Tourniquet two cses of postopertive cludiction, one of which ws treted by bypss grfting. There ws one cse of Volkmnn's ischzmic contrcture. Eight surgeons rised the question of deep venous thrombosis. but there ws lck of ny specific evidence of its reltionship to tourniquet usge. Becuse of the pprent greter incidence of complictions with the Esmrch bndge nd the lck of knowledge of the s produced under it, study ws undertken to determine those s. METHOD All tourniquets were pplied in the midthigh rcgion. At this level there re very few tendons. There is single bone surrounded by muscle in three fsci1 comprtments, with ft nd skin coverge. Wheres the fsci nd the skin strongly resist from within, they cnnot resist from without, so tht the thigh cn be considered to obey the lws of fluid mechnics. I'rcssure is therefore distributed eqully in ll directions from externl compression, nd smll superficil sensor ccurtely reflects deeper s. Pressure is the function of force per unit re With n Esmrch tourniquet, the force in the systcm is tht used to stretch the bndge, but it I26 bll in 80 r mmhg * * 0.." U I I I. I I Ausr. N.Z. J. SURG., VOL. 44 No. 2, MAY, 1974

4 *. I OUKNIQUET PARALYSIS 10 tlic guge by Polythene tubing with n onter dimeter of 4.5 mm nd bore of 3 mm. The guge ws stndrd Bourden tube guge with 6" guge fce (Figure I). It ws clihrted to 2,000 full deflection. Accurcy ws I% OF full scle. The Polythene bg, tube nd guge were filled with wter to ensure tht the sensor did not empty significntly under. To llow esier filling of the system, the Bourden Fll in I 50 m this filed becuse of inbility to ttch the guge without tering the rubber. The circumference of the midthigh region ws mesured before ppliction of the tourniquet. I'res. sure recordings were tken immeditely fter ppliction, fter 30 minutes, nd t the end of the procedure before removl of the tourniquet. In five cses reding ws tken fter ech wind of the tourniquet during ppliction. In children the men obtined under six turns ws 710 (Figure z), vrying from 510 to 1,015. The men in dults ws 585. In ll cses there ws fll in over the first 30 minutes, fter which it remined stedy. The fll vried between 20 nd 80 mni Hg per hour. This fll bore little reltion to the height of the initil nd no reltion to the circumference of the thigh (Figure 4). On the five occsions when mesurement ws mde fter ech turn the increse in w\ found to be by rithmeticl progression (Figure 5) 1,ooc Tourniquet 50t Thigh circumference cm. FIGURE 4 tulie ws reversed nd needle vlve ws included in the system. The redings were checked ginst those of the pneumtic tourniquet. Forty children nd ten dults dmitted to hospitl for lower limb surgery were studied. An Esmrch hndge ws pplied from the toes to the midthigh re to exsnguinte the limb, nd ws then mintined t the sme level for six turns to form tourniquet, with the Polythene bg included under the first turn. The guge ws lwys kept out of sight of the pplier. The bndge ws then univound from the toes upwrds to uncover the opertion site. The tourniquet ws pplied by the sme person using the sme technique nd, s fr s he could tell, comprble force. An ttempt ws mde to mesure the stretch force in the tourniquet during the ppliction, but I I I I I I Number of turns FIGURE 5 11 ISC u SSIO N The produced by the Esnirch tourniquet is vrible, but is certinly greter thn is generlly pprecited. The difference between the s found in dults nd children is reflection of the differences in limb circumference. These findings re in ccord with those of Griffiths nd Hmilton (1970). There is definite drop, not due to tourniquet loosening, in the first 30 minutes. It is suggested tht this is probbly due to the movement of extrcellulr fluid from under AUSI. N Z. J. STJIG., Vm. 44 NO. 2, MAY, 1974

5 TOURNIQIJET PARALYSIS the tourniquet nd tht this my be responsible for some tourniquet filures. Vriously, tourniquet complictions hve heen stted to be frequent, nd to be uncominon (Bruner, 1951 ; Eckhoff, 1931 ; Hmilton, 1967), but most reports hve either been of spordic cses, or hve consisted of editoril comment, presumbly bsed on the personl ruperience of the editor. The lrgest reported ieries of complictions is tht of Eckhoff (rqr), who reported 14 cses, ll in the upper limh. Moldver (1954) dded nother seven, gin ll involving the upper limb. There hve been no previously reported series of complictions in the lower limb. The only rstinite of the incidence of morbidity hs been Wtt s (1972) report of two cses of nerve plsy in T,500 opertions. Tn this series, despite the vrition in the tjpe of tourniquet used nd the site of its ppliction, the incidence of complictions from its we hs been extrordinrily smll. Tn 630,000 pplictions the morbidity rte of one in 8,000 for peripherl nerve lesions indictes the sfety of present techniques. This is further emphsized by the finding of only two permnent nerve lesions. The Esmrch bndge hs previously been hlmed for most (Bruner, 1951 ; Eckhoff, 1931 : Klenernin, 1962 ; WtsonJones, 1957), if not ll, tourniquet coniplictions. Tht it crries somewht higher risk of morbidity thn the pneumtic cuff is implied by the present series, hut no exct definition of this hs heen possible, nor hs it been possible to drw ny conclusions regrding the cuse of tourniquet prlysis. From the informtion obtined there is no pprent common fctor. In the reported cses there ws considerble vribility in the period of tourniquet ppliction nd presumbly in the s generted. It seems cler, however, tht n uncontrolled Esmrch bndge cn produce high s beneth it, nd yet the incidence of nerve plsy is extrordinrily low. The evidence suggests tht excessive contributes to the peripherl nerve lesions, hut the mechnisms involved re uncler. Undetermined fctors my explin the pprent rndom distribution of this type of nenropthy. SUMMARY Complictions follow the use of both Esmrch nd pneumtic tourniquets s they re presently used, but this incidence is very low, nd the lesions produced do not cuse permnent disbility. REFERENCES BRUNER, J. M. (I~sI), J. Bone Jt Surg., 33A: 221 ECKHOFF, N. L. (1931), L~ncet, 2: 343. FLATT, A. E. (1972), Arch. Surg. 104: rgo GRIFFITHS, J. C., nd HAMILTON, P. H. (1970), J. my. COX Surg. Edinb., 15: 114. HAMILTON, W. K. (1967), J. Anzer. nzed. Ass., 199: 37. KLENERMAN, L. (1g62), I. Bone Jt Surg., 44B : 937. MOLDAVER, J. (r954), Arch. Surg., 68: 136. WATSONJONES, SIR, R. (I957), Frctures & Joint Injuries, fourth edition, vol. I, E. S. Livingstone Ltd, Edinburgh nd London: 121. CORRIGENDUM IN the rticle The Use of Autopolymerizing Acrylic: Cement in Osteosynthesis : An Experimentl Approch, by Quzi M. Iqbl nd M. Knnn Kutty (December, I973), 43 : , there ppers in pr. I, p. 307, the sttement: Erly systemic effects... except in those nimls in which the totl volume of blood lost hd not heen replced (Hrrington ed &, 1972). The word nimls shoulii red cses. We regret this error. T 28