55.3 The cold blue injured limb

If a patient’s limb is cold and blue (if he is Caucasian), its circulation is impaired and he is in danger of gangrene or the compartment syndrome followed by Volkmann’s ischaemic contracture (70.4). The commonest causes of these disasters are: (1) An unsplit cast on a forearm fracture. (2) A supracondylar racture in a child. (3) A fractured tibia causing obstruction to the anterior compartment of the leg (81.14). (4) Any badly treated fracture, a crush injury, or a bullet wound.

The compartment syndrome is the easiest cause to treat. The vessels of a patient’s limb may be so tightly compressed by exudate, blood, or swollen muscle that blood cannot pass through them. Toileting his wound, incising the fascia, and exposing his artery is often all that is necessary to restore his circulation. Or, a local injury may be causing an artery to contract down so tightly that no blood can pass through it. A tightly contracted artery like this looks like a piece of solid cord. The distal part of the brachial artery, the femoral, the popliteal, and the posterior tibial arteries can all contract like this.

THE COLD BLUE INJURED LIMB

See elsewhere for ischaemia following a supracondylar fracture (72.8), or the compartment syndrome in a patient’s forearm (73.7) or lower leg (81.14). If his injury is elsewhere, expose his injured vessel through an adequate incision. This alone may be enough to make it start pulsating again.

If it does not start pulsating, and part of it looks like a piece of whipcord, expose the healthy artery above and below the cord–like section. Expose it on all sides, so that there is no tissue surrounding it.

If it fails to dilate, open an ampoule of 2% papaverine, or less satisfactorily, pethidine, or 2% lignocaine (without adrenaline), and flood this onto its contracted segment. Then lay a warm moist pack on it, and wait 10 minutes. When you return, you will probably find that the artery will have increased in size and will have started to pulsate.

If it is still not pulsating, apply an arterial clamp above the constriction, and inject 2% lignocaine with a little heparin, between the clamp and the constriction. This may distend it enough to make it start pulsating. Wait 10 minutes while the heparin acts.

If it is torn, repair it (55.6). Only if these measures fail consider tying it, or if possible, resetting and anastomosing it.

CAUTION! When you close the wound make sure that the injured vessel is not exposed to the air; cover it with adjacent tissue, or if necessary with split skin.