TECHNIQUE

Refinement of a Simple Technique With

New Relevance for Exsanguination of the
Upper Limb
Srinivasan Iyer, FRCS(Plast),* Amit Pabari, MBBS, MRCS,w
and Olivier Alexandre Branford, MBBS, MA, MRCSw

Abstract: Many techniques have been described for exsanguination

of the upper limb before the application of a pneumatic tourniquet.
These require additional equipment such as the Esmarch bandage, the
Urias bag, the Pomidor roll-cuff, the Northwick Park exsanguinator, or
the Rhys-Davies exsanguinator. At a time of increasing demand on
scarce resources and increasing medico-legal claims, these techniques
have a number of disadvantages: increasing tourniquet and theater
time, having cost implications, posing a risk of transmission of
infection such as methicillin-resistant Staphylococcus aureus and
Group A Streptococcus, being contraindicated in certain upper limb
pathologies, and causing potential injury or even fatal pulmonary
embolism. Some of these techniques continue to be in common usage
but a review of the literature suggests that they may be unnecessary
in routine practice, and should be reserved for select situations. The
present article describes the formalization and refinement of a simple
technique with new relevance, 101 years after Bier first mentioned it
in the literature, where the brachial artery is compressed in the cubital
fossa before elevation of the arm and then the tourniquet is inflated.
This method is simple, cost-effective, time-saving, and most
importantly safe and fomite free.
Key Words: arterial compression, brachial artery, exsanguination
(Tech Hand Surg 2011;15: 82--83)

HISTORICAL PERSPECTIVE
Many techniques have been described for exsanguination
of the upper limb before the application of a pneumatic
tourniquet. These require additional equipment such as the
Esmarch (von Langenbeck) bandage, the Urias bag,
the Pomidor roll-cuff,1 the Northwick Park exsanguinator, or
the Rhys-Davies exsanguinator.2 The Rhys-Davies exsanguinator, which cannot be adequately decontaminated, has been
shown to be a haven for bacteria,3 and should not be used in
those with latex allergies. Though an effective technique, the
torsional and shearing forces associated with the use of the
Esmarch bandage may cause degloving in fragile skin4 or
radial nerve injury. Techniques that produce pressure may be
contraindicated in rheumatoid arthritis and in the painful
limb. The milking effect of such techniques also make them
contraindicated in the septic arm, where tumor is present, or
where there is the risk of dislodging a deep venous thrombosis
From the *Wexham Park Hospital, Wexham, Slough, Berkshire; and
wRoyal Free Hospital NHS Trust, Pond Street, London, UK.
No external sources of support, funding, or benefits were received for this
project by any of the authors.
Address correspondence and reprint requests to Olivier Alexandre
Branford, MBBS, MA, MRCS, Royal Free Hospital NHS Trust,
Pond Street, London, NW3 2QG, United Kingdom. E-mail:
olivier.branford@totalise.co.uk.
Copyright r 2011 by Lippincott Williams & Wilkins

82 | www.techhandsurg.com

causing pulmonary embolus5 (after traumatic injury or if a

limb has been immobilized in a cast). A single disposable
Esmarch costs in the region of $250 for 20 rolls, and some are
latex based. However, the Esmarch technique is 50% more
effective in reducing blood volume than elevation alone.1 A
simple technique using digital pressure for exsanguination
of the hand without additional equipment has recently been
described.6 However, the technique is not effective in forearm
exsanguination, requires the patient to be awake, and is
contraindicated in injured or stiff hands, severely restricting
its use. The present article describes the formalization and
refinement of a simple technique with new relevance, 101
years after Bier7 first mentioned it in the literature, where the
brachial artery is compressed in the cubital fossa before
elevation of the arm and then the tourniquet is inflated.

INDICATIONS/CONTRAINDICATIONS
The technique described in this article is indicated where a
bloodless field is required during surgery to the hand and upper
limb. It may be particularly useful where other exsanguination
techniques, described above, are contraindicated, such as during
surgery to the septic arm, where tumor is present, or where there
is the risk of dislodging a deep venous thrombosis.
The technique may be difficult in very muscular8 or obese
patients, due to problems in effectively compressing the
brachial artery. We therefore use a pulse oximeter on the finger
to assess the occlusion of pulsatile flow in these situations and
have found this to be a satisfactory guide to exsanguination. In
our experience, there are no contraindications to the use of the
technique described in this article.

TECHNIQUE
The technique may be used in association with local, regional, or
general anesthesia. The patient is placed supine. A tourniquet cuff
is tied on to the patients upper arm with the forearm and hand
flat on the arm table.
The brachial artery is palpated in the cubital fossa, medial
to the biceps tendon (Fig. 1). Digital pressure is then applied to
the brachial artery at this site. Then, with compression on the
artery being maintained, the arm is immediately elevated into
the high vertical position (Fig. 2).8,9 During regional or general
anesthesia, this is achieved by holding the patients fingertips
if these are uninjured: otherwise the wrist is held. If the
procedure is performed under local anesthesia the patient may
elevate their arm. After only 30 s of elevation1 the tourniquet is
inflated to the appropriate pressure. The arm is then returned to
the arm board. Effective exsanguination of the upper limb is
thus rapidly achieved (Fig. 3).

Techniques in Hand & Upper Extremity Surgery  Volume 15, Number 2, June 2011

Techniques in Hand & Upper Extremity Surgery  Volume 15, Number 2, June 2011

Exsanguination of the Upper Limb

FIGURE 3. The arm with tourniquet inflated, demonstrating good

exsanguination with clearly empty veins and skin pallor.

COMPLICATIONS
FIGURE 1. Diagrammatic representation of pertinent anatomy:
The position of the brachial artery and its bifurcation (in black)
and the biceps tendon (in white) are shown in the cubital fossa.
The artery is palpated here before compression being applied
from the medial side of the biceps tendon.

We have not experienced any complications using this

technique.

SUMMARY
We have formalized and refined a simple technique that
requires no additional equipment and is safely used in all the
scenarios described for surgery to the hand, wrist, and forearm,
giving it broad, current, and acceptable application in both the
elective and trauma setting, where other established techniques
may be contraindicated. The nature and speed of the technique
make it very suitable to facilitating operations where the
tourniquet has to be applied more than once. This technique
has been used in hundreds of cases by the authors, who feel
that, with regard to creating a bloodless field, it is superior to
elevation alone, with comparable results to use of the Esmarch
bandage, confirming the findings of a previous randomized
blind subjective study where brachial artery compression
above the elbow was assessed.9 The authors in the present
article found that the brachial artery is more reliably
compressed in the cubital fossa. In a small study of 5 patients,
Warren and colleagues8 found that 1 patient had a vasovagal
episode with elevation and arterial compression. However, this
is certainly not our clinical experience, and we recommend
that this safe and reliable procedure should be the default
technique used for exsanguination of the upper limb.
REFERENCES
1. Blond L, Madsen JL. Exsanguination of the upper limb in healthy young
volunteers. J Bone Joint Surg Br. 2002;84:489491.
2. Rhys-Davies NC, Stotter AT. The Rhys-Davies exsanguinator. Ann
R Coll Surg Engl. 1985;67:193195.
3. Ballal MS, Emms N, ODonoghue M, et al. Rhys-Davies exsanguinator:
a haven for bacteria. J Hand Surg Eur. 2007;32:452456.
4. Marshall PD, Patil M, Fairclough JA. Should Esmarch bandages be used
for exsanguination in knee arthroscopy and knee replacement surgery?
A prospective trial of Esmarch exsanguination versus simple elevation.
J R Coll Surg Edinb. 1994;39:189190.
5. Darmanis S, Papanikolaou A, Pavlakis D. Fatal intra-operative
pulmonary embolism following application of an Esmarch bandage.
Injury. 2002;33:761764.
6. Bilku DK, Downing ND. A simple technique for exsanguination of the
hand. Surgeon. 2009;7:379380.
7. Bier A. A new method of producing local anaesthesia in the extremities.
Arch Klin Chir. 1908;86:10071016.

FIGURE 2. After application of digital pressure to the brachial

artery, the arm is elevated while compression is maintained. The
tourniquet is inflated at 30 s.

2011 Lippincott Williams & Wilkins

8. Warren PJ, Hardiman PJ, Woolf VJ. Limb exsanguinations. I. The arm:
effect of angle of elevation and arterial compression. Ann R Coll Surg
Engl. 1992;74:320322.
9. Colville J, Small JO. Exsanguination of the upper limb in hand surgery
comparison of four methods. J Hand Surg Br. 1986;11:469470.

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