(1733) Reaching for Gold: Upper Extremity Management and Limb Rescue After Prolonged Entrapment

Introduction: Prolonged limb entrapment causes vascular compromise requiring prompt management of acute compartment syndrome to prevent impending tissue ischemia. Literature suggests soft tissue remains viable for up to six hours before irreversible ischemia occurs - thereafter revascularization introduces risk of reperfusion injury. Currently, there is no defined consensus on extremity management following prolonged entrapment. We present a challenging case of an upper extremity that was entrapped in a sewage pipe for over nine hours.

Description: An 82 year old male presented to the trauma bay after his arm had been trapped in a sewage pipe requiring extensive extrication efforts lasting over nine hours. A segment of tubing at the mid-humerus was unable to be removed by the emergency team and there were no distal pulses or sensorimotor function on initial exam. Options of shoulder disarticulation versus limb rescue options were considered. Due to hemodynamic stability, limb rescue was attempted. Initial management included two grams of intravenous calcium gluconate for cardioprotection. An orthopedic cast saw was used to bi-valve and successfully remove the remaining tubing from the arm. Immediate return of radial and ulnar pulses were noted however lack of sensorimotor function persisted. He was taken for an emergent upper extremity fasciotomy and was subsequently admitted to the ICU for aggressive intravenous hydration, antibiotics, and vigilant wound care. He ultimately underwent staged plastic reconstruction with excellent functional outcomes and no in-hospital complications.

Discussion: Prolonged limb entrapment causes acute compartment syndrome and tissue ischemia. Revascularization is complicated by reperfusion injury risk and its sequelae. We successfully mitigated these with aggressive hydration, cardioprotection, and fasciotomy for our patient with full functional recovery.