pneumatic tourniquet paralysis - Semantic Scholar

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in a bloodless field, using a pneumatic tourniquet. The sensory defect resolved in two months and the paresis in five and a half months. We consider that direct ...
PNEUMATIC

TOURNIQUET CASE

KARl

AHO,

KIMMO

SAINIO,

From

PARALYSIS

REPORT MARTTI

the Central

KIANTA,

Hospital

ESKO

of Kotka

We describe a 31-year-old man in whom a paresis and sensory amputation of the index finger. The operation was performed in tourniquet. The sensory defect resolved in two months and the paresis that direct pressure produced by the tourniquet caused the nerve lesion. inflated to a pressure of 500 millimetres of mercury instead of the because of a faulty gauge. In order to avoid this rare complication, gauge each time before use.

Paralysis of an upper limb after the use of a tourniquet for establishing a bloodless field was first described 100 years ago by Montes and Putnam (Speigel and Lewin 1945). When rubber tubing or an elastic bandage were used the complication was more common, but even now, when pneumatic tourniquets are in common use, this complication is estimated to occur once in 5000 to 8000 operations performed in a bloodless field (Love 1978; Yates, Hurst and Brown 198 1). However, only a few case reports have been published. We now describe one such case. CASE

REPORT

man presented on January 1 , 1982, after a he had been holding in his left hand exploded. of an extensive laceration the index finger had

A 3 1-year-old

firework Because

to be amputated.

The

operation

was

performed

under

general anaesthesia and a bloodless field was used. His arm was emptied of blood using an Esmarch’s bandage, after which a pneumatic cuff was applied to the upper arm and the pressure adjusted to 250 millimetres of mercury. The tourniquet time was I hour 15 minutes. After

the operation,

sensory

the

patient

noticed

weakness

and

defect

a

in his arm. On January 1 1 , examination revealed that the left wrist and fingers were totally paralysed, and flexion of the elbow was weaker than normal; the remaining muscles functioned normally. There was wasting of the upper arm and forearm amounting to two centimetres. K. Aho, MD, ChiefNeurologist, M. Kianta, MD, Specialist E. Varpanen, MD, Assistant Central Hospital of Kotka,

Neurophysiologist Children’s 29, Finland.

Requests

to Dr K. Aho.

©

for reprints

1983 British 0301 -620X/83/4l00

VOL.

65-B,

should

be sent

Editorial Society $2.00

No. 4, AUGUST

1983

of Bone

and

Joint

Hospital,

Surgery

biceps

defect of the left arm developed after a bloodless field, using a pneumatic in five and a half months. We consider It is probable that the tourniquet was intended 250 millimetres of mercury it is advisable to check the tourniquet

and

radial

reflexes

were

nearly

absent,

the

triceps reflex normal. The patient stated that his sensory response to pin prick in the forearm and hand was more “superficial” than normal. By January

returned At the

but end

18 some

no other of February,

active

active the

flexion

of the

movements

were

fingers

began

wrist

had

detected.

to move

and

sensation to return. The patient returned to work on March 1 . On March 23, the wasting and reflexes were found to be unchanged ; the muscles of the wrist and fingers were a little weaker than normal, as were the flexors of the elbow. Sensation to pin prick was normal. Examination on September 10 revealed only 0.5 to 0.8 centimetres ofwasting in the upper arm and forearm. The

biceps

ished. muscles

and

radial

reflexes

were

still

clearly

dimin-

Extension of the thumb was weak, but other were normal and no sensory defects were found.

Electromyography.

An

electromyogram

on February

19

showed a severe lesion in the muscles of the forearm and hand. There was abundant pathological spontaneous activity and a clear loss of motor units. No muscle was, however, totally denervated. In the triceps muscle (supplied by the radial nerve) and in the biceps (supplied by the musculocutaneous nerve) the lesion was mild. The deltoid muscle was intact. The motor nerve conduction velocities of the median and ulnar nerves in the upper arm were somewhat less than in the forearm. The muscle action potentials elicited by stimulation of both nerves had a lower amplitude when stimulated in the proximal upper arm than when stimulated in the distal upper arm. Two months later, the lesion was clearly milder : the loss

Department of Neurology in Surgery, Department of Surgery Surgeon, Department of Surgery 48210 Kotka 21, Finland.

K. Sainio, MD, Consultant Clinical Laboratory of Clinical Neurophysiology, sity of Helsinki, SF-00290 Helsinki

The

VARPANEN

Univer-

of motor units and the pathological spontaneous activity had lessened, and muscle action potentials were equal when stimulated in the proximal or distal upper arm. By Septemb’r 1 1, 1982, the lesion had healed and the only abnormal finding was altered polyphasic and long-lasting motor

unit

potentials. 441

442

K. AHO,

K. SAINIO,

M. KIANTA,

Gilliatt (1972) noted that in baboons a tourniquet caused both a displacement of the nodes of Ranvier and an invagination of myelin. In cases of paralysis described in the literature the tourniquet time varies from 28 minutes to 2 hours 40 minutes. The significance of the duration of exsanguination in the causation of the neural lesion remains unclear. Ischaemia of more than two hours is not usually recommended, because in experimental studies even muscle tissue begins to suffer from acidosis and other metabolic changes after that time (Solonen and Hjelt

DISCUSSION We

found

the

literature

of 55 cases

reports

of tourniquet paralysis in 1931 ; Speigel and Lewin 1945; and Varian 1973 ; Rudge 1974;

(Eckhoff 1951 ; Middleton

Bruner Trojaborg

1977;

Bolton

and

McFarlane

1978).

However,

most were caused by rubber tubing or an elastic bandage; only 15 were caused by a pneumatic tourniquet (Bruner 1951; Moldaver 1954; Middleton and Varian 1973; Rudge 1974 ; Mukherjee 1977 ; Bolton and McFarlane 1978); and only two cases of tourniquet paralysis have been described in detail (Rudge 1974 ; Bolton and McFarlane 1978). The

radial

nerve

is the

most

ulnar and median nerves also (Sunderland 1968). Damage to nerve, as in our patient, is rare been reported previously (Bolton Sensory defects are usually minor than

motor

defects

(Eckhoff

vulnerable,

but

1968; Wilgis

as was

found

1971).

The pressure recommended for a pneumatic cuff applied to in the upper arm is 250 millimetres of mercury in adults and 200 millimetres in children (Flatt 1972). In

the

are often damaged the musculocutaneous and only one case has and McFarlane 1978). and heal more rapidly

1931),

E. VARPANEN

our

case,

this

recommendation

was

followed,

but

when

damage was detected our tourniquets were checked ; of the two which may have been used for the operation one had a gauge which showed a pressure only half the actual pressure. (In retrospect, it was impossible to determine

in our

patient. Disturbance of sweating, and causalgia, as a sequel to damaged autonomic nerve fibres has been described (Bolton and McFarlane 1978), but were not present in our patient. Nerve lesions heal spontaneously in three to six months (Sunderland 1968) and are only exceptionally permanent (Speigel and Lewin 1945). In our patient, the sensory loss resolved in two months and the paresis in five and a half months ; by eight months from the onset of symptoms abnormal findings were insignificant. Direct pressure caused by the pneumatic cuff is usually regarded as the cause of the nerve lesion as shown by clinical studies (Eckhoff 1931 ; Moldaver 1954; Bolton and McFarlane 1978 ; Love 1978) and experimental findings (Allen 1938; Paletta, Willman and Ship 1960; Fowler, Danta and Gilliatt 1972); only a few authors regard ischaemia as the most important cause of the lesion (Denny-Brown and Brenner 1944). Speigel and Lewin (1945) surgically explored three cases of tourniquet paralysis. They noted that at the site of compression the diameter of the nerve was reduced to one-half or one-quarter of the normal. In addition, scarring and neuromata were found. Ochoa, Fowler and

which

tourniquet

described suspected (Bruner

had

been

in the literature, to have shown, 1951 ; Flatt 1972;

We

believe,

been

used

therefore,

used.)

In four

the gauges less than

that

of the

15 cases

had shown, or were the actual pressure

Bolton and McFarlane a faulty gauge had

1978). probably

in our case.

A corresponding more rarely ; it has

lesion in the lower extremity occurs been described only in connection

with the use of an elastic bandage and not with a pneumatic tourniquet (Love 1978). However, after meniscectomy using a pneumatic tourniquet, 18 out of 25 patients had transient electromyographic changes (Weingarden, Louis and Waylonis 1979). Tourniquet paralysis nearly always resolves spontaneously. However, the patient is unable to work for a considerable length of time, and his recovery from operation is clearly impeded. Moreover, the causalgic syndrome, with its distressing features, may appear during convalescence (Bolton and McFarlane 1978). In order to avoid tourniquet paralysis, the gauge should be checked each time before use (Flatt 1972). A safety valve which prevents excessive pressure can also be installed in the device (Wheeler and Lipscomb 1964).

REFERENCES Allen

FM.

Bolton Bruner

The

CF, JM. 221-4.

Safety

Denny-Brown Eckhoff

Flatt Fowler Love

NL.

D,

and RM.

factors

in the

Brenner

Tourniquet

local

asphyxia.

Human use

C. Paralysis paralysis

BRT.

Moldaver Mukheajee

The RWD,

tourniquet. Varian

J. Tourniquet DJ. J, Fowler

Aust JP.

Tourniquet TJ,

Gilliatt

RW.

1938:41

induced

by direct

for the extended

J Surg

J md Anatomical

Neurology for

pressure

use of the

1978:28:787-93.

hemostasis and

pneumatic

190-2. after

in surgery

of the

by tourniquet.

Arch

tourniquet.

Lancet

a pneumatic

tourniquet

hand.

Neurol

J Bone Psvchiat

Joint (Chicago)

Surg

[Am] 1944

1951 :33-A:

: 51 : 1-26.

1931 : ii : 343-5. : observations

on

the

hindlimb

of the

baboon.

1978:48:66-70.

paralysis.

syndrome.

192-200.

tourniquet

surgery. Arch Surg 1972; 104: Recovery of nerve conduction 1972 :35 :638-47.

AZ

:

paralysis.

pneumatic

of nerve

Tourniquet paralysis.

J Surg

tourniquet

of the

: a plea

paralysis

Am

pneumatic

AE. Tourniquet time in hand TJ, Danta G, Gilliatt RW. J Neurol Neurosurg Psychiatry

Middleton

Ochoa

tourniquet

McFarlane

Arch Med

J Bone Surg Assoc

changes

Joint

1954 :68:

Surg

[Br]

1973 ;55-B

:432.

136-44.

1977 ;69 : 130-2. in peripheral

nerves

compressed

by a pneumatic

THE

tourniquet.

JOURNAL

J Anat

OF BONE

1972

AND

; I 13 : 433-55.

JOINT

SURGERY

PNEUMATIC Paletta

FX, 42-A

Rudge Solonen

Willman : 945-50.

P. Tourniquet

V, Ship paralysis

IJ, Lewin

Sunderland

W.

and

Prolonged

Wheeler

DK, EN. 5K,

65-B,

Lipscomb

PR.

Observations

conduction

block

in striated

muscle

Hurst

LN,

Brown

No. 4. AUGUST

block

A safety WF.

1983

JAMA

and axonal

London

Electromyographic

device

for a pneumatic

of tourniquet pathogenesis

: an experimental

: an electro-physiological ischaemia:

study

study. a clinical

: E & S Livingstone

degeneration

GW.

effects The

with

of extremities

during

443

PARALYSIS

J Bone

on dogs. Joint

and

histological

study.

J Neurol

Surg

J Bone [Br]

study

Joint

Surg

1960;

: 7 16-20.

l974;56-B

in man.

[Am]

Acta

Orthop

Scand

1945;129:432-5.

Edinburgh

Wayloms

on the

ischemia

changes

injuries.

conduction

tourniquet

prolonged

paralysis.

nerve

Weingarden SI, Louis DL, 1979:241 : 1248-50.

VOL.

with

P. Tourniquet

S. Nerves

Trojaborg

Yates

Prolonged

KA, Hjelt L. Morphological l968;39: 13-9.

Speigel

Wilgis

AG.

TOURNIQUET

changes tourniquet.

ischemia. of pneumatic

1968.

: an electrophysiological

J Bone

in postmeniscectomy J Bone Joint

tourniquet

Joint

Surg

Surg

[Am]

paralysis

patients [Am]

1964:46-A

1971 :53-A in man.

: role

Neurosurg of the

Psychiatry

pneumatic

1977 :40 : 50-7. tourniquet.

JAMA

: 870.

: 1343-6.

J Neurol

Neurosurg

Psychiatry

1981 ;44:

759-67.