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| Category #14 - The elbow joint |
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| Question: |
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We used a continuous infraclaviclar catheter for a total elbow recently with great success. Unfortunately, our surgeon no longer wants us to use this technique since he states that he cannot monitor for a compartment syndrome. I believe that we can turn off the infusion if a surgeon wants to perform a neurological assessment. I am interested to know if you have been confronted with this problem and how you would handle it?
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| Answer: |
André Boezaart writes:
I do not have the answer for you. Obviously this has not been studied, so there will not be any data out there to guide our practice. One will have to go with your gut feeling and what makes good sense. I will bounce this off the surgeon whom I work with. He does a lot of elbow replacements and he is very much supportive of our efforts to provide proper analgesia. We routinely place catheters for his patients. The question that I cannot answer, which I hope Dr Brian Adams can answer for us, is how prevalent and relevant is compartment syndrome with "cold" elbow surgery. It is certainly an issue with trauma, especially supracondilar fractures. I also wonder about the neurological exam that the surgeons want to do. In that case a catheter would be absolutely ideal, because you can use a short acting drug like 2-chloroprocaine or lidocaine or even nothing for the surgery, do the neuro exam postop and then block the thing properly for postop pain relief if the neuro exam is negative. Sometimes I also wonder what they will do when they do find a nerve that is not so great. Will they explore immediately? I have been doing ortho anesthesia for 30 odd years now and I have never seen a surgeon going back immediately. But I do have respect for this. For these cases I think one should place a catheter, and depending on the planned duration of the surgery, use it or don't use it intra-operatively and then, after a negative neuro exam use it for postop analgesia.
I hope this helps some, but I will ask Dr Adams. He is a real expert on this topic. Can you please help us Brian. What do you think?
Dr Brian Adams, hand surgeon writes:
Compartment syndrome after total elbow replacement must be extremely rare. I have never heard it reported, and I certainly haven't seen it. If the surgeon suspected he might have done something to worry about this eventuality, then there would be other ways to monitor immediately post op while the block is wearing off. I think a catheter is the best care for these patients, and quite safe. The real question we have after elbow replacement, which may be masked by a block, is the function of the nerves, i.e., did we stretch the ulnar or cut the radial, or bruise or stretch the median. However, I probably wouldn't do anything immediate anyway.
Brian Adams
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