Date: Mon, 19 Apr 1999 15:10:27 PDT
'Doughnut of Pillows' for Limb Elevation
Introduction
Elevation of the limb is standard practice in postoperative care of
hand and foot surgery (Semple). The aim of limb elevation is to
allow for improved venous drainage and decreased arterial
pressure.
Prolonged edema in an extremity can lead to fibrosis, contracture,
pain, and loss of function (Giudice 1990, Hunter 1984). Several
approaches have been proposed for the treatment of arm edema and
reduction of fluid volume, including electrotherapy, pneumatic
compression, compression bandaging, massage, and mobilization
(Boland 1998, Griffin 1990). Elevation of the extremity following surgery
is generally considered to be an effective prophylactic measure against
swelling and edema.
The hydrostatic force of gravity has been demonstrated to
influence the limb volume (Boland 1998, Matalon 1979). Positioning
the limbs above the level of the heart allows for increased venous
drainage and reduced limb volume (Boland 1998, Sims 1986).
Elevation of the hand and arm 30 above the level of the heart for 2
hours leads to an approximately 50ml reduction in hand volume
(Boland 1998). Even 30 minutes of elevation postoperatively has been shown
to greatly reduce hand volume when combined with active excersize
(Brand 1985). Recumbency in the head-up-tilted position, however,
has no effect of hand volume (Boland 1998).
Compression hand dressings are sometimes combined with arm
elevation in order to minimize posttraumatic and postoperative
swelling. Elevation and compression have been shown to reduce the
local transcutaneuous PO2, particularly when used in combination
(Matsen 1982). However, in most post operative cases, arterial
inflow is often not as great of a concern as is venous outflow.
Therefore, in a carefully monitored setting with a properly applied
wound dressing, the benefits of elevation and reduced edema may
outweigh the risk of ischemic damage due to decreased oxygen
supply.
Our 'doughnut of pillows' splint technique is soft and non-
compressive, and does not lead to significant hand compression.
Method
The 'doughnut of pillows' requires 2-4 pillows and adhesive
tape of any kind. One pillow is place beneath the extremity and one
above. A circular doughnut is formed and taped (as we say, ìa
doughnut of pillows taped around the wristî) using several strips of
tape. The fingers (or toes) should be visible for monitoring. If
additional elevation is desired, depending of the case involved, one
or two additional pillows can be taped in place beneath the
extremity as needed (Figure1).
Discussion
Several different approaches for elevation of the hand
postoperatively have been reported. While the previously described
techniques have their advantages, they also present specific
challenges. Some elevation devices require significant assembly of
mechanical parts including springs and pulleys for elevation (Semple
1969). Other hand slings may impart additional cost and training
(Tegmeier 1979). The 'Sky Hook' elevation technique includes
fitting and adjustment of a wire coat hanger within a wet plaster hand
splint (Sunde 1990). A 'vacuum splintage' technique has been described
which may need additional investment of resources, time, and
expertise to implement (Ward 1977). Some devises require multiple
components including velcro, webbing, tape, canvas, and buckles,
which may be technically challenging to assemble (Gardner
1969,1970). The 'wooden crutch elevation' design involves the
sawing of a wooden crutch, molding of a thermoplastic foam, brass brazing,
rubber bands, and a leather finger cuff (Brown 1978). It also
requires the patient to actively grasp the devise for extended
periods of time.
Patient compliance with limb elevation at home is also of
significant concern. This has led to different attempts to remind the patient
of the need for elevation, including merely placing a reminder sticker
on the wound dressing (Cassel 1990). This inexpensive and easy
method may increase compliance. We feel that making a splint that
is easy, effective and comfortable, like the 'doughnut of pillows'
approach also imparts improvements in comfort and versatility that
has led to increased compliance in our experience. Furthermore, it
does not require a conscious effort on the part of the patient to
elevate the limb, or to maintain positions of discomfort.
The various techniques described in the literature are all effective
methods for elevation. The issues of cost, difficulty of assembly,
comfort of the patient, and time usage remain as concerns. The
reliable, effective and inexpensive approach described by us is a
modification of previously described elevation. Our design of 2-4
pillows may offer the added benefits of ease of assembly and
increased comfort, as well as other helpful features (Table 1).
Though our technique may not appear as elegant as the more complex
approaches described in the literature, we believe that its elegance
lies in its simplicity, comfort, reliability, cost effectiveness and
versatility. Sometimes, the most simple ways to accomplish our
goals are also the most elegant.
The features of the doughnut of pillows elevation technique:
1. Proper elevation of the hand above the level of the elbow and
the heart (Green)
2. Allows for elevation of the hand at all times and in all
positions in bed and when sitting.
3. Extreme positions of the hand, elbow, and shoulder are avoided,
resulting in less stiffens and strain.
4. Compression and vascular compromise of the limb are minimal.
5. The patient has the versatility to place the limb in a
comfortable position, while always maintaining the proper elevation
relationships.
6. There is no requirement for purchase of any additional equipment
of devises, and there is no additional cost to the patient or the
hospital.
7. The technique can be properly used to elevate the arm in
approximately 2 minutes.
8. The simple design can be easily learned by the staff and patient
resulting in increased compliance compared to more complex devises.
9. The procedure does not require a orthopedic bed, or IV pole, and
can be used in any hospital bed or at home.
10. The doughnut of pillows is equally efficacious for patients of
all ages, including infants, and the elderly.
11. The doughnut of pillows is equally effective for use in the
lower and upper extremities.
12. The doughnut of pillows can be maintained throughout an entire
hospitalization including transfers from bed to bed and floor to
floor, and can be sent with the patient home.
13. Any combination of wound dressings, or cast may be used within
the pillow doughnut.
14. The digital extremities can be maintained in complete field of
view, allowing for the patient and staff to notice ischemic fingers,
which may be otherwise not be easily detected in a nerve blocked
limb.
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