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).
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