this slide was presented to department of Orthopedics, Shree Birendra Army Hospital , Nepal

1. Tourniquet in
Orthopaedics
Dr. ELIZ ACHHAMI
INTERN
NAIHS-TU,NEPAL

2. Definition
• A tourniquet is a constricting or compressing
device used to control venous and arterial
circulation to an extremity for a period of
time.
• Pressure is applied circumferentially upon the
skin and underlying tissues of a limb; this
pressure is transferred to the walls of vessels,
causing them to become temporarily
occluded.

3. History
• Jean Louis Petit coined the word
“Tourniquet” from theFrench word
tourner (to turn) in 1718 when he
used them for lower limb
amputations to reduce blood loss.
• In 1873 , Johan friedrich august von
esmarch introduced flat rubber
tube wrapped repeatedly around
the limb as tourniquet
• In 1904 Harvey cushing introduced
pneumatic tourniquet to limb
surgery
Johan friedrich august von
esmarch

4. Esmarch
Pneumatic – microprocessor
controlled
Pneumatic manual
Petit original

5. TOURNIQUET
SURGICAL EMERGENCY
TOURNIQUET TOURNIQUET
• Surgical Tourniquets prevent blood flow to a limb and
enable surgeons to work in a bloodless operative field
and are frequently used in orthopaedic surgery.
• Emergency Tourniquets are used in emergency bleeding
control to prevent severe blood loss from limb trauma.

6. Uses in Orthopedics
Reduction of certain fractures.
Kirschner wire removal.
Replacement or revision of the joints of the
knee, wrist, digits, hand, or elbow.
Arthroscopy of the knee, elbow, wrist, hand, or
digits.
Repair of traumatic nerve damage.

7. Cont’d
Bone grafts.
Graft and repair of lacerated tendons.
Subcutaneous fasciotomy.
Carpal tunnel release.
Traumatic or non traumatic amputation.
Correction of a hammer toe.

8. Parts of tourniquet
• Inflatable cuff
• Gas source ( nitrogen
or air )
• Pressure display
• Pressure regulator
(within 2-6 mmHg)
• Connection tubing

9. Proper application
• should be applied very carefully to the
proximal part of the limb at the greatest
circumference.
• Adequate padding should be done at that site
but no loose cotton .
• 3 inches to 6 inches overlap.

10. Exsanguination
• Exsanguination before inflation of the tourniquet improves
the quality of the bloodless field and minimizes pain.
• Normally done by limb elevation, maximal exsanguination can
be achieved by elevation of the arm or leg for 5 min at 90◦and
45◦ respectively, without mechanical compression.
• or using an elastic wrap of the extremity.
• Malignancy, infection thrombi, fracture – simple elevation or
nothing – no wrapping

11. Tourniquet Cuff Pressure
• LOP can be defined as the minimum pressure
required to stop the flow of arterial blood into the
limb distal to the cuff.( limb occlusion pressure)
Not well defined
Preop LOP
Safety in kids - ??

12. Inflation or occlusion time
• One hour
• Not yet defined but may be up to three hours
• 10 minute deflation interval every one hour
• Pediatric patients – better less than 75
minutes

13. Tourniquet related complications

14. Local
• Normal physiological conduction block in fifteen
minutes
Nerve injuries – 0.37%
• The radial nerve, followed by the ulnar and median
nerves in the upper limb.
• The sciatic nerve in the lower limb are most commonly
involved.
• Large diameter nerve fibers are more commonly
affected.

15. Muscle injury
• Tends to be greatest beneath the tourniquet
because of the combination of ischaemia and
mechanical deformation.
• May persist after tourniquet deflation as a
result of micro- vascular congestion
• Post tourniquet syndrome – weakness palsy
without anesthesia
• Three weeks – usually normalize.

16. Excess bleeds intra op
• under-pressurized cuff, insufficient exsanguination,
improper cuff selection, loosely applied cuff, calcified
vessels or too slow inflation or deflation.
• Bleeding may occur despite a properly applied and
inflated tourniquet, in a patient with noncalcified
vessels. (the phenomenon of tourniquet ooze.)

17. • Vessel bypasses the tourniquet through the
medulla of the humerus or femur.
• It typically starts about 30 minutes after
tourniquet inflation
• Increasing the tourniquet pressure does not
help

18. Tourniquet pain
• The smaller unmyelinated C-fibers are more resistant
to LA induced conduction block as compared A-fibers
• C-fibers start conducting impulses before the A-fibers,
resulting in a Dull aching poorly localized tight pain.
• Increased HR and BP ( tourniquet hypertension)
• Difficult to prevent and treat this – even in spinal and
dense blocks

19. Tourniquet pain
• Eutectic mixture of local anesthetic (EMLA)
cream application, LAs given via the neuraxial
route with or without opioids have been used
to attenuate tourniquet-induced pain.
• Adjuvants – Magnesium sulfate, ketamine,
ketorolac and clonidine
• Alternative techniques like electro puncture
and meditation.

20. Pre-application precautions
• The pressure source, cuff, regulator, tubing,
and connectors need to be checked before use
• as wide a cuff as possible should be used.
• The cuff should not directly overlie bony
prominences.
• The cuff should overlap at least 3 inches, but
not more than 6 inches as it may cause
generation of high pressures.

21. • The extremity should be exsanguinated before
inflation of the tourniquet.
• Tourniquet inflation pressure should be kept
to the minimum effective pressure.

22. Bruner's ten rules for the safe use

23. Contraindications
• Peripheral vascular disease
• Arteriovenous (AV) fistula
• Peripheral neuropathy
• DVT in the limb
• Severe infection of the limb
• Severe trauma to the limb
• Poor skin condition of the limb
• Sickle cell haemoglobinopathy

24. Conclusion
• Tourniquets are useful aids for limb procedures.
• Pre-determination of LOP and inflating
tourniquets accordingly can help reduce the
complications.
• Proper patient monitoring and care after
deflation for neurological deficit postoperatively
can minimize the complications.