Digital Ischemia After Application of Self-Adherent Elastic Wrap Dressing: a Case Series Christopher A

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Digital Ischemia After Application ofChristopher Self-Adherent A. Makarewich, MD, Penelope Lang, MD, Elastic Douglas T. Hutchinson, Wrap MD

Dressing: A Case Series abstract Self-adherent elastic wrap dressings are a convenient option to manage pediatric hand and finger injuries. However, when improperly applied, they have the potential to cause devastating complications. We detail in this report 5 cases of dressing-induced ischemic injury to the hand in pediatric patients with a review of the literature. All patients were treated by the senior author between 2007 and 2015 and were retrospectively reviewed for initial injury, frequency of dressing changes, presence of pain, ’ time to evaluation by the orthopedic hand team, treatment, and outcome. Patients families were contacted for clinical updates and to obtain current Primary Children’s Hospital, Salt Lake City, Utah; and Department of Orthopaedics, University of Utah, Salt Lake photographs. Age at injury ranged from 11 months to 3 years with 2 girls City, Utah and 3 boys. Only 1 of 5 patients complained of pain or discomfort during Dr Makarewich performed the retrospective review, the onset of their ischemic injury. Treatment of the ischemic injury included communicated with families to obtain updates, and local wound care without surgery in 3 cases (including sympathetic block drafted the initial manuscript; Dr Lang contributed in 1) and surgical intervention with partial or complete digital amputation to data collection and reviewed and revised the manuscript; Dr Hutchinson conceptualized and in 2 cases. At final follow-up, 2 of the 5 patients reported currently being designed the study and reviewed and revised bothered by the appearance of the injured hand; however, none had the manuscript; and all authors approved the persistent pain or difficulty using the hand. Through these examples, final manuscript as submitted and agree to be accountable for all aspects of the work. health care professionals can be educated on the potentially disastrous ’ complications of improper dressing application in the pediatric population DOI: https://doi.org/10.1542/peds.2016-3067 and can be encouraged to share this information with patients families. Accepted for publication Mar 24, 2017 Address correspondence to Christopher A. Makarewich, MD, Department of Orthopaedics, University of Utah, 590 Wakara Way Rm A0100, Self-adherent elastic wrap (3M Tourniquet injuries to fingers have Salt Lake City, UT 84108. E-mail: christopher. 4 [email protected] Nexcare; Coban, St Paul, MN; Co-Flex; been described to occur by hair, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, Andover Healthcare, Salisbury, MA) procedural tourniquets accidently– 5,6 7 1098-4275). is an excellent dressing option for left in place, ‍ buddy taping, and2,8 19a hand and finger injuries treated in variety of bandaging materials. ‍ ‍ ‍ Copyright © 2018 by the American Academy of Pediatrics the emergency department (ED) and These all share a common mechanism primary care settings. Unfortunately, of circumferential wrapping around FINANCIAL DISCLOSURE: The authors have a digit leading to blockage of arterial indicated they have no financial relationships without careful attention to their relevant to this article to disclose. application, these bandages can inflow and/or venous outflow with FUNDING: No external funding. cause devastating damage through a subsequent ischemia, tissue necrosis, POTENTIAL CONFLICT OF INTEREST: The authors tourniquet effect. Pediatric patients are and potential amputation. have indicated they have no potential conflicts of particularly susceptible to this because This article describes 5 patients with interest to disclose. they often do not have the language injuries ranging from skin blistering or cognitive1 ability to communicate and discoloration to amputation To cite: Makarewich CA, Lang P, Hutchinson DT. their pain and are unable2 to remove secondary to tight circumferential Digital Ischemia After Application of Self-Adherent the dressing themselves. With the high application of a self-adherent elastic Elastic Wrap Dressing: A Case Series. Pediatrics. 2018;141(1):e20163067 rate of hand injuries in young children,3 wrap dressing. It is important that most of which involve the fingertip, this both health care professionals and concern becomes even more prominent. caretakers of pediatric patients Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 141, number 1, January 2018:e20163067 Case Report TABLE 1 Case Descriptions Case Agea/Sex Injury Initial Treatmentb Initial Orthopedic Final Treatment and Outcome (Length of Follow-up) Hand Clinic Follow-upc 1 9 mo, girl Fingerstick tip left Dressing applied in the 15 d; swelling from Local wound care, normal function, transverse nail deformity middle finger ED, removed the next DIPJ distal, healed (3 y follow-up) day by parents blister and eschar 2 11 mo, girl Superficial Parents performed 11 d; fingertip Local wound care, auto amputation distal fingertip soft laceration right daily dressing necrotic tissue had tissue, normal function (6 mo follow-up) index finger changes fallen off to expose viable tissue below 3 3 y, boy Superficial Seen in ED, parents 5 d; blistering at Ischemia resolved after sympathetic block with no laceration right instructed to thumb MCPJ complications (7 y follow-up) thumb perform daily dressing changes 4 22 mo, boy Superficial Seen in pediatric clinic, 7 wk; necrotic tissue Amputation middle finger DIPJ 6 wk after injury laceration tip left parents instructed from DIPJ distal (2 y follow-up) middle finger to perform daily dressing changes 5 2 y, boy Laceration right Seen in ED for primary 10 d; dry necrosis Amputation base of proximal phalanx middle and index index and middle closure, parents middle and index fingers 15 d after initial injury (8 y follow-up) fingers performed dressing fingers from MCPJ changes every few distal days MCPJ, metacarpophalangeal joint. a Age at initial presentation. b All cases initially treated with a circumferential self-adherent elastic wrap dressing. c Days after injury; physical examination finding.

recognize this potential complication girls and 3 boys (Table 1). All cases 15 days went on to completely and learn how to properly apply involved the application of self- resolve, although a transverse nail these dressings. adherent elastic wrap dressings. In deformity remained. Patient 2 Methods 4 of the 5 cases, parents performed (Fig 2) was placed into an extension dressing changes at home. In only 1 splint and treated with daily case was the dressing causing injury dressing changes with bacitracin. applied by a medical professional. She went on to autoamputate a After obtaining institutional review In all cases, the parents were small amount of nonviable tissue board approval, we reviewed the unaware that the wrap could be distal to the distal interphalangeal medical records of 5 patients who placed too tightly around the finger joint (DIPJ), but healed with an suffered finger injuries from self- and none recalled receiving specific otherwise normal appearance adherent elastic wrap dressings and ’ instruction on dressing application. without dysfunction. In patient were subsequently seen by 1 surgeon at Patients received a formal pediatric 3, an axillary nerve block was 1 academic children s hospital between orthopedic hand evaluation 2 to performed on initial presentation the years 2007 and 2015 (Table 1). All 11 days after injury and were to the ED in an attempt to decrease records were reviewed for the history managed in-clinic from 15 to 125 sympathetic tone and increase of the initial injury and treatment, days after injury. Only 1 of 5 patients blood flow to the digit. His frequency of dressing changes at home, complained of pain or discomfort perfusion improved overnight, and presence of pain at time of compressive during the onset of their ischemic during follow-up the ischemia had dressing injury, time to evaluation by injury. resolved with mild blistering that the pediatric orthopedic hand team, went on to minimal scarring and treatment of ischemic injury, and Three patients were treated with ’ normal function (Fig 3). patient outcome. For further follow-up, local wound care without surgical the patients families were contacted intervention (Table 1). One patient Surgical intervention in the form to update their progress and obtain had a sympathetic block in addition. of an amputation in the operating current photographs. Patient 1 (Fig 1) was treated with room was required in 2 cases after Results and Cases local wound care. At her last clinic waiting for full demarcation of follow-up 2 and a half months after nonviable tissue (Table 1). Patient injury, she had healed with intact 4 underwent amputation at the long Patient age at time of injury ranged sensation and no contracture. The finger DIPJ (Fig 4), and patient 5 from 11 months to 3 years with 2 swelling and erythema noted at underwent amputation through Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 Makarewich et al Discussion and Review of the Literature

Self-adherent elastic wrap is a convenient and effective dressing option for hand and finger injuries ’ and one that we use daily in our institution s hand surgery practice. Beyond hand surgery, the use of these dressings is ubiquitous, FIGURE 1 crossing the lines of many clinical Clinical images of patient 1. A, Dorsal and B, radial views 15 days after injury. practice settings including general pediatrics, urgent care, family practice, emergency care, and postoperative care. However, the same elastic properties that make it desirable for wound management have the potential to cause devastating and long-lasting complications when improperly applied. To date, examples of injuries secondary to self-adherent elastic wrap dressings have not been addressed in the literature. However, the tourniquet effect and resulting digital ischemia have been described–

with the use of several other9 dressing19 types such 13as tubular gauze, ‍ ‍ 7 Band-Aids, and buddy taping. All of these reported cases involved circumferential bandage application around digits inarguably causing proximal occlusion of arterial inflow and/or venous outflow with subsequent tissue ischemia. One factor that may increase the risk of ischemia with digital bandages is the accidental rolling of dressing edges

after application, which causes2,17, 19 focal FIGURE 2 compression around digits. ‍ This Clinical images of patient 2. A and B, Two days after injury in the ED and C and D, 1 month after injury. possibility has led some to advocate for extending finger dressings 2 proximally to include the hand. Other variables implicated– in–

causing injury include8 materials10,14 16 the base of the proximal phalanx 4.1 years). Two of the 5 patients, with greater– elasticity ‍ ‍ ‍ ‍ of the index and long fingers both amputations (patients 4 and 5), and applying9,10, 14 16, dressings18 in multiple (Fig 5). All surgical wounds reported currently being bothered layers. ‍ ‍ ‍ ‍ healed well and without by the appearance of the hand. Two The previously reported cases of complication. patients (patients 2 and 5) reported ’ dressing-induced ischemic injury some hypersensitivity of the injured We were able to contact all 5 have occurred in patients of all9, 13,ages,14 patients families for long-term digits. None of the patients had with many involving children. ‍ ‍ follow-up at a range of 6 months persistent pain or difficulty using the Four examples of ischemic injury to 8 years after injury (mean injured hand. occurring in individuals aged 10 Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 141, number 1, January 2018 3 and younger9,13, were14 found in the literature. ‍ In the majority of these cases (3 of 4), the children complained of pain before the injury was discovered. This is in contrast to our findings in which only 1 of 5 patients complained of discomfort. Our observations may be due to pediatric patients being unable to

fully communicate1 the severity of their pain or may be the result of parents and practitioners having

difficulty monitoring and interpreting20 the signs of pain in children. In addition, if pain is experienced, children are less likely to be able

to remove2 a painful dressing than an adult, making children more likely to develop ischemic injury to FIGURE 3 nerves that further interferes with Clinical images of patient 3. A and B, Seven days after injury and C and D, follow-up 7 years later at pain perception. It is also possible age 10 years. ’ that the anatomy and physiology of children s vasculature makes them more susceptible to compression,

with smaller vessel diameter,21 lower mean arterial pressures,22,23 and higher vessel compliance. ‍ In addition to being a more common injury in pediatric patients, this group often has more severe outcomes compared with their adult counterparts. All cases of dressing- induced ischemic injury in children aged 10 and younger reported in the

literature required surgery, 9,and13, 14 3 of the 4 resulted in amputation. ‍ ‍ Among our 5 patients, 2 required surgical intervention with amputation. The remaining 3 patients were observed with minimal remaining functional deficit or disfiguration. This is possibly due to the fact that for most of our patients, parents were performing daily dressing changes and caught the ischemia early on. Our preferred management once digital ischemia from circumferential FIGURE 4 Clinical images of patient 4. A, Eight days and B, 22 days after injury and C and D, 2 years status bandages is identified is to observe postamputation at age 4 years. the tissues and allow them to demarcate, as long as there are no signs of infection. We feel that this allows maximal tissue recovery. After demarcation, Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 Makarewich et al manner under minimal tension. This is in contrast to wrapping while simultaneously unrolling, which can lead to excessive tightness. 3. The wrap is overlapped by .25 to .5 in. 4. The overlapping wrap is pressed lightly to allow it to adhere. 5. The process is repeated until the desired area is covered, by using as few overlapping layers as possible.

When dressing fingers, the wrap should be brought down to include the hand to prevent rolling of the proximal edge. In pediatric patients, the placement of a well-padded splint before wrapping should be considered to further help prevent tight constriction. This technique can be taught to caregivers to perform dressing changes at home as needed. Patients and families are also instructed in monitoring for the signs and symptoms of digit ischemia, including observing for increasing pain and checking distal capillary refill FIGURE 5 and sensation. Clinical images of patient 5. A and B, Ten days after injury, C and D, intraoperatively at time of amputation, and E and F, 8 years status post amputation at age 10 years. The arrow in image C shows damage to the digital vessels in the zone of compression injury. Through these 5 cases, we have outlined the complication of dressing-induced digital ischemia in pediatric patients and have nonviable tissue is debrided and To prevent these injuries, elastic described treatment and proper amputations performed as needed. and/or circumferential self-adherent dressing application techniques. In cases of acute ischemia, a local dressing should be avoided if simpler When self-adherent elastic wrap or regional sympathetic block can dressings suffice and no compression dressings are the dressing of choice, be considered. In 1 of our cases, an is needed. When simpler dressings do all medical professionals using axillary block was administered in not suffice, our approach to dressing these materials should be aware an attempt to improve blood flow application using self-adherent of this potential complication and make sure patients and families are to the affected digit. This patient elastic wrap is as follows: educated on proper dressing use did not ultimately require surgery, 1. After a sterile dressing is applied, and instructed on the caveats that but it is unclear if the block to his the leading edge of the wrap is would prompt immediate dressing sympathetic input improved his placed on the affected area and the removal. outcome. Although not done in end held still while a wrap at least Abbreviations our series, the use of leeches has 12 in long is unrolled and allowed to fully relax. been proposed5,24 to alleviate venous congestion, ‍ and early surgical 2. Moving from distal to proximal, DIPJ: distal interphalangeal joint intervention has been described the wrap is gently laid over 4,18 ED: emergency department with incision and fasciotomy. ‍ the dressing in a controlled Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 141, number 1, January 2018 5 References West J Emerg Med. 2009;10(3): 19. 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