Matching limb protection sleeves

Matching limb protection sleeves are matched to the personalized tourniquet cuff to help protect the soft tissues underneath the cuff by reducing wrinkling, pinching, and mechanical shearing of the tissue. These sleeves are formed from elastic, low-lint, and soft material designed and sized to give optimal protection to limbs within the recommended size range of the matching cuff. Some tourniquet cuff manufacturers color code their matching limb protection sleeves to help ensure that the correct sleeve is used with the selected cuff. As this color coding is specific to each manufacturer, tourniquet cuffs and sleeves from different manufacturers should never be mixed.

In terms of safety and effectiveness, a sleeve that is not specifically matched to the cuff being used may not optimally protect the underlying tissues, may impair the performance of the cuff, and may interfere with venous blood flow when the cuff is deflated, as explained below. In addition, materials that may shed loose fibers, such as cotton cast padding or sheet padding, should be avoided, as lint from these materials can become embedded in the fasteners and reduce the effectiveness, potentially leading to an unexpected release of the cuff from the limb during the procedure.

Evaluation of different limb protections in literature

Tredwell et al. [1] conducted a quantitative analysis of wrinkling and pinching of the skin in a cuff-limb interface study in children. In a total of 44 trials on the upper arms and thighs of two healthy child volunteers, one type of pediatric cuff with a matching limb-protection sleeve designed and recommended by the manufacturer produced significantly fewer, and less severe pinches and wrinkles in the skin surface than a second type of tourniquet cuff with or without two layers of commonly available cast padding, and a third type with padding. With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin.

Based on a total of 55 trials of five different limb protection types on the upper arms and thighs of five adults, stretched sleeves made of two-layer tubular elastic material and matched to specific tourniquet cuffs produced significantly fewer and less severe pinches and wrinkles in the skin surface than all other padding types tested [2]. With cast padding and no limb protection, the most severe wrinkling and pinching usually occurred at the cuff overlap. The matching sleeve was designed to stretch a controlled amount when applied to the limb, applying light compression and in effect “artificially” improve the tone of the skin under the cuff and make the skin resistant to being fathered up into a pinch by the cuff, particularly at the cuff overlap. Using a molding and digital measurement technique, the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under four different cuff and padding configurations were measured.

Olivecrona, et al. [3] conducted a randomized study to confirm that padding under a pneumatic tourniquet cuff protected against the development of blisters during total knee arthroplasty. The study included 92 patients who were divided into three groups. In group one the limb was protected by a two-layer elastic stockinette (n=33). In group two the limb was protected by cast padding (n=29) and in group three no protective material was used (n=30). The tourniquet used for all patients was a 140-mm-wide contoured cuff or a 100 mm-wide cylindrical cuff. Cuff pressure was determined by the surgeon but 70-100 mm Hg above the patients’ blood pressure was recommended for the contoured cuff. For the cylindrical cuff 100-150 mm Hg above the systolic pressure was recommended. Findings indicated that the two groups with skin protection had fewer skin injuries and no patient with the stockinette had blisters. A total of 10 blisters occurred in the 92 patients. Seven were in patients with no protection and three in patients with cast-padding.

Figure 2 shows a comparison of molds taken under a typical tourniquet cuff with no underlying limb protection, with only cast padding used as limb protection, and with a limb protection sleeve specifically matched to the tourniquet cuff being used.

(a)	(b)	(c)
Figure 2. Comparison of molds taken under a typical cuff with: a) no limb protection sleeves b) cast padding c) a limb protection sleeve matched to the cuff being used.

These studies provide evidence that limb protection sleeves improve safety by protecting the skin underlying tourniquet cuffs during tourniquet use, and further provide evidence that greatest safety is achieved through the use of matching limb protection sleeves, designed as described in an above section.

Sources

[1] Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use. Journal of Pediatric Orthopaedics. 2001 Sep 1;21(5):671-6.

[2] McEwen JA, Inkpen K. Tourniquet safety: preventing skin injuries. Surgical Technologist. 2002;34(8):6-15.

[3] Olivecrona C, Tidermark J, Hamberg P, Ponzer S, Cederfjäll C. Skin protection underneath the pneumatic tourniquet during total knee arthroplasty: a randomized controlled trial of 92 patients. Acta orthopaedica. 2006 Jan 1;77(3):519-23.