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The Effect of Skin Pigmentation on Clinical Exam for Determination of Limb Ischemia in Healthy Controls
Elizabeth M. Polfer, MD1; Ryan M. Zimmerman, MD2; Eshetu Tefera, MS3; Ryan D. Katz, MD4; James P Higgins, MD5; Kenneth R Means Jr, MD4
1Walter Reed National Military Medical Center, Bethesda, MD, 2Greater Chesapeake Hand Specialists, Lutherville, MD, 3MedStar Health Research Institute, Hyattsville, MD, 4Union Memorial Hospital, Baltimore, MD, 5Curtis National Hand Center, Baltimore, MD
Background: The clinical effect of not recognizing ischemia in post-traumatic and post-operative free tissue transfer can be devastating. Time-to-identification of flap ischemia is critical for revascularization success. Success of re-exploration is inversely related to the time between detection of ischemia and return to the operating room in which there is a point of irreversibility/ultimate flap death. The importance of clinical monitoring for ischemia is well recognized as demonstrated by reports of 0% salvage rate in unmonitored flaps. While anecdotally it has been suggested that it is difficult to clinically monitor flaps in patients with darker skin pigmentation, little is published on this effect. The purpose of this study is to determine if there is a difference in the diagnosis of ischemia related to skin pigmentation.
Methods: A prospective study of healthy patients exposed to limb ischemia was conducted. Patients were classified based on skin pigmentation using a defined skin type assessment tool (Fitzpatrick Scale), a visual color scale (Von Luschan), and self-description of race, followed by tourniquet insufflation and physical exam by board-certified orthopaedic/plastic surgeons. Patients were randomized; surgeons were blinded to the tourniquet application and status. The surgeons monitored the arms at two, six, and ten minutes based on appearance of ischemia in three locations (skin territory of the posterior interosseous artery (PIA) flap, skin territory of the radial forearm (RF) flap, and the fingers).
Results: We found a significant difference in the ability to detect ischemia in patients with increased skin pigmentation, as documented by the Fitzpatrick Score, Von Luschan Score, and self-described race, when evaluating the PIA flap and the RF flap at all time points. For example, when monitoring the PIA flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified as being ischemic (p<0.0001). We noted that this difference did not hold true when evaluating the digits.
Conclusion: We found that a patient’s skin pigmentation can significantly impact the ability of experienced hand surgeons to determine skin flap perfusion based on clinical exam. When applied to clinical scenarios, this difference can lead to a delay in determination of ischemia as related to skin pigmentation and ultimate tissue and flap loss. This information can be used to implement policies to allow for better monitoring of post-traumatic and post-operative ischemia.
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