Tourniquet compression of a Norplant device

Abstract

A 23-year-old right-handed White woman sustained an injury to her left gloved thumb in a collision during a recreational softball game. Examination the next day revealed tenderness about the ulnar collateral ligament and complete instability of the joint to stress of the ligament. She elected to have an ulnar collateral ligament repair to her left thumb under an axillary block. A tourniquet was padded well and placed over the patients Norplant device which was located in the medial aspect of the arm. The tourniquet calibrated immediately before the operation was elevated to 250 mmHg after exsanguination. Total tourniquet time was 72 minutes. The surgery proceeded uneventfully and the patient was placed in a thumb spica splint. Postoperatively the patient complained of pain over the area of the Norplant device. The moderately severe pain and tenderness persisted for 10 days. Based on the recommendation of the manufacturer (Wyeth Ayerst Laboratories Philadelphia PA) a xeroradiograph was obtained to evaluate the integrity of the capsules (Blood tests to determine if an implant had been ruptured are not commercially available). There was no evidence of damage to the Norplant device and the patients pain resolved on its own 10 days postoperatively. Before surgery the patient had regular menstrual cycles; one year postoperatively she has had two irregular menses and is not pregnant. She has a stable mobile thumb and is back to full activities with no further complaints of pain. There is no reference in the literature concerning tourniquet irritation of a Norplant device. The only study on tourniquet use and a Norplant device concerned the use of a tourniquet placed proximal to the device; it did not influence plasma concentration of levonorgestrel. Three cases of localized skin reaction immediately after implantation have been reported; in the case discussed here the device had been in place for over a year with no local tissue reaction. To avoid this complication the presence of subdermal implants should be noted in the preoperative history when considering upper extremity surgery.