The Effect of Skin Pigmentation on Determination of Limb Ischemia

Elizabeth M. Polfer, Ryan M. Zimmerman, Eshetu Tefera, Ryan D. Katz, James P. Higgins, Kenneth R. Means

Research output: Contribution to journalArticlepeer-review


Purpose Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia. Methods We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits). Results We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery 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. Conclusions Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissue transfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation. Type of study/level of evidence Diagnostic II.

Original languageEnglish (US)
Pages (from-to)24-32.e1
JournalJournal of Hand Surgery
Issue number1
StatePublished - Jan 2018


  • Skin pigmentation
  • ischemia
  • tourniquet

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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