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Injury Extra 43 (2012) 21–24
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Injury Extra
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Case report
Unusual complication of pneumatic tourniquet-chemical burn
Loveneesh G. Krishna *, Davinder Singh, Alok Gupta, Sunil Sehrawat, Abbas Shehreyar
Orthopaedics Department, Central Institute of Orthopaedics, Vardhman Mahavir Medical College, & Safdarjang Hospital, New Delhi, India
16,28,18
in the injury to the nerves than distal ischaemia. The
A R T I C L E I N F O
application of tourniquet causes tissue ischemia both beneath the
Article history: cuff and distal to the occluded area affecting the underlying
Accepted 11 November 2011
muscles. This causes functional and microscopic changes in the
muscles proportional to the duration and pressure applied, such
25,29
that reversal is significantly prolonged after 3 h of ischaemia.
Direct vascular injury is an uncommon complication of tourniquet
27
1. Introduction use with an incidence of 0.03–0.14% in knee arthroplasty.
Excessive tourniquet time or poorly placed tourniquets may result
5,23
The pneumatic tourniquet is widely used in extremity surgeries in cutaneous abrasions, blisters and even pressure necrosis.
to provide a bloodless field and to facilitate dissection. However, it Friction burns arise if the tourniquet is unpadded, or telescopes
3
is important to appreciate their potential complications, which away from its padding during surgery.
may be minimized by understanding the principles of tourniquet Skin complications due to the use of pneumatic tourniquet are
22
use. The complications associated with use of pneumatic tourni- very rare (1:13,000).
32
quet can be systemic and local as follows : Aim of the case report is to present a case of chemical burn, a
rare complication, associated with the use of pneumatic tourniquet
1.1. Systemic complications (Figs. 1–6).
2. Case report
Cardiovascular system: transient rise in central venous pressure
31
and systolic blood pressure.
23 year old male patient presented with a history of compound
Metabolic: arterial ph, PaO2, PaCO2, lactic acid, and potassium
grade II fractures both bones, right leg, in region of distal one third of
levels change significantly after release, the degree is largely
12,24,30 1 year duration. He was initially managed at periphery with tubular
dictated by the duration of ischaemia time.
external fixator which was applied for 4 months. The fracture failed
Temperature: core body temperature increases during the
9 to unite. The fixator was removed and open reduction and internal
tourniquet inflation, and decrease following tourniquet release.
fixation with plating was done at periphery. The fracture still failed
Drug kinetics: application of extremity tourniquet decreases the
to unite and the plate was removed after 3 months and replaced by
concentration and penetration of intravenous perioperative
Ilizarov External Fixator which was removed after 4 months of
medication. In general though, at least 5 min interval is optimal
2,11 application at periphery. The fracture still failed to unite. Then the
to achieve the appropriate tissue concentration.
patient presented to our institution after 11 months from the date of
Reperfusion syndrome: the re-establishment of blood flow
injury. On examination frank abnormal mobility was present at the
following a period of ischaemia is essential to restore energy
fracture site and radiologically there was sclerosis of the fracture
and remove toxic metabolites, however reperfusion can induce a
13 ends, absence of callus formation and obliteration of the medullary
paradoxical extension of ischemic damage and it can cause a
canal. Open reduction and external fixation with freshening of the
group of complications known as reperfusion syndrome.
bone ends followed by application of Ilizarov External Fixator with
proximal tibial corticotomy and bone grafting was planned and
1.2. Local complications
carried out at our institution.
The patient was laid supine on the OT table and spinal
The compression of the nerve causes microvascular congestion
anaesthesia was given. Cautery was applied on the normal side leg.
and oedema, causing inadequate tissue perfusion and axonal
1,4,10,19 A cylindrical pneumatic tourniquet was applied in the region of
degeneration. Mechanical pressure seems more important
mid-thigh on the affected leg and cotton padding was given under
the tourniquet. The limb was elevated for 5 min to exsanguinate
the blood from the lower limb. During the elevation of the limb
* Corresponding author at: G-10, Sector-56, Noida, Haryana 201301, India.
painting was done with a solution containing 63% isopropanol and
Tel.: +91 9310204289; 91 9810097804.
E-mail addresses: [email protected] (L.G. Krishna), 0.025% benzelkonium chloride and then with a solution containing
[email protected] (A. Gupta). 75% propanol and 0.2% ethyl dimethyl ammonium ethylsulphate.
1572-3461 ß 2011 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2011.11.023
22 L.G. Krishna et al. / Injury Extra 43 (2012) 21–24
Fig. 1. Tourniquet burn in the posterolateral aspect of thigh – on day 3 after Fig. 4. Tourniquet burn in the posterolateral aspect of thigh – 8 weeks after
surgery (1). surgery (1).
site and Ilizarov External Fixator was applied. Proximal tibial
metaphyseal corticotomy was done. After one & half hours of the
surgery the tourniquet was released and reflated after 10 min of
15,33
deflation as per guidelines and further surgery was continued.
Wound was closed in layers and sterile dressing was applied. The
procedure took about 3 h. Tourniquet was deflated and distal
vascularity was checked. Normal distal pulsations were felt.
On the next day after surgery, the tourniquet site showed
extensive bruising and blister formation over posterolateral aspect
of the right thigh in the region where tourniquet was applied. The
bruise measured about 12 cm  30 cm with a clear line of
demarcation with the skin. The blisters were punctured and
Gentian Violet paint was applied at the blister site. No occlusive
dressings were applied.
Over the next 3 days, the bruising started showing signs of
hardness over the entire bruised area and a clear line of
demarcation from the normal surrounding skin. In the following
Fig. 2. Tourniquet burn in the posterolateral aspect of thigh – on day 3 after days 3–6 after surgery the entire bruised area over the
surgery (2).
posterolateral thigh transformed into a frank eschar measuring
the same dimensions as that of the bruise with the normal
The tourniquet was inflated with a pressure of 270 mmHg and limb surrounding skin. Plastic surgery opinion was taken and no
was draped. The fracture site was opened with a curved surgical intervention was planned. Wound healing took 6 weeks.
anterolateral incision, fracture margins were freshened, medullary On the last follow up, at 3 months, there was loss of hair over the
canal opened and temporary fixation with K wires was done. Bone overlying skin and the hardness of the underlying tissue decreased.
graft from ipsilateral iliac crest was harboured onto the fracture
Fig. 5. Tourniquet burn in the posterolateral aspect of thigh – 8 weeks after
Fig. 3. Tourniquet burn in the posterolateral aspect of thigh – on day 9 after surgery. surgery (2).
L.G. Krishna et al. / Injury Extra 43 (2012) 21–24 23
insufficient evidence from randomised trials to support the use
of one antiseptic over another.
Alcohol is the most microbiologically active agent in producing
the largest and most rapid inactivation of vegetative bacteria (it is
less active against spores); the use of alcohol solutions (preferably
70% by v/v) in combination with agents that provide residual
activity is recommended for pre-operative skin preparation, due to
17
their greater efficacy at killing bacteria. Both chlorhexidine
gluconate and iodophors have broad spectra of antimicrobial
activity. In some comparisons of the two antiseptics when used as
preoperative hand scrubs, chlorhexidine gluconate achieved
greater reductions in skin microflora than did Povidone iodine
14
and also had greater residual activity after a single application.
4. Conclusion
We considered friction burn in this case but it was disregarded
Fig. 6. Tourniquet burn in the posterolateral aspect of thigh – 8 weeks after in the favour of chemical burns because of following reasons:
surgery (3).
1. Chemical burns are known to occur with alcohol based
7
3. Discussion preparations as were used in this case. (63% isopropanol and
75% propanol).
Skin complications like cutaneous abrasions, blisters and 2. Cotton padding was found to be soiled with disinfectants after
6,7
pressure necrosis have been described due to excessive tourniquet the surgery.
time or poorly placed tourniquets. Chemical burns can occur by 3. There was no slipping of tourniquet and there was no contact of
5
70% or more alcohol held in contact with skin under pressure for the tourniquet with bare skin as occurs with friction burns. 32,7
60–90 min.
In this patient’s case, the tourniquet was applied in the same Skin burns associated with pneumatic tourniquets are very rare
22
manner as in other surgeries by trained technicians under the (1:13,000). In our experience also, tourniquet complications such
supervision of the anaesthetist and the surgeon. However, no as chemical burn are very rare, in fact this was the first case we
precautions were taken to prevent seepage of chemical disinfec- came across. But the danger and precautions should be known to
tant under the tourniquet during the painting of the limb. The limb all the theatre staffs. Every precaution should be taken to prevent
was elevated to exsanguinate the limb before the tourniquet was seepage of alcohol based skin disinfectants beneath the tourniquet.
inflated, and during this time the limb was painted. The chemicals This complication can further be reduced by the use of a self-
21
seeped in the loose, uninflated tourniquet and due to the effect of adhesive optape at the distal end of the tourniquet to seal it off
the gravity, on to the posterior aspect of the thigh under the whilst preparing the limb. This fluid repellant tape prevents any
tourniquet. After the tourniquet was inflated, the chemicals got liquid from passing underneath the tourniquet and being absorbed
trapped between the tourniquet and the skin. Another practice that by cotton padding. Furthermore a combination of alcohol–
is being followed is ‘‘pouring’’ the disinfectants over the skin. The chlorhexidine is recommended for preoperative skin preparation
disinfectants went down with the gravity under the uninflated as chlorhexidine is not found to be associated with chemical
26
tourniquet. The surface disinfectants used for skin preparations burns.
were, a solution containing 63% isopropanol and 0.025% benzelk-
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