Tourniquets are widely used in extremity surgery to create a bloodless surgical field, thereby enhancing surgical visualization and reducing intraoperative blood loss. Several techniques exist for limb exsanguination. The most commonly employed method uses a thin, wide elastic bandage, typically referred to as the Esmarch bandage, though it also appears in the literature as Esmark . Alternatively, exsanguination can be achieved with limb elevation, though this may increase intraoperative time as the limb passively exsanguinates before tourniquet inflation.

Pulmonary embolism (PE) following limb exsanguination with an Esmarch bandage is a rare but often fatal complication. Limb exsanguination with an Esmarch bandage acutely increases venous return, which may dislodge pre-existing deep venous thrombi and result in embolization to the pulmonary circulation. Given its severity and high associated mortality, this study aims to identify contributing factors, inform prevention strategies, and raise awareness of this poorly recognized but severe complication.

To our knowledge, limited prior research exists that has examined factors contributing to intraoperative PE following lower limb exsanguination, specifically. This review focused on contributing factors of intraoperative PE. All case reports or series pertaining to the lower leg were noted to be in traumatic cases, including injuries at or distal to the tibial plateau. All of the included patients underwent open reduction internal fixation of the tibia or fibula following lower extremity trauma, and an esmarch and/or tourniquet was used during these procedures. A secondary objective of this study was to evaluate factors associated with intraoperative PE occurring after tourniquet deflation in lower extremity trauma cases. Post-deflation PE is theorized to result from thrombus formation during surgery with subsequent embolization upon tourniquet release and the rapid restoration of venous flow. This is similar to the proposed mechanism for PE following exsanguination.

PE is a multifactorial pathology with numerous associated risk factors. Given the high mortality associated with intraoperative PE resulting from limb exsanguination and tourniquet deflation, risk stratification and prevention are critical. When considering factors related to deep vein thrombosis (DVT) formation, Virchow’s triad provides a useful framework. Virchow’s triad describes three key contributors to thrombosis: endothelial injury, altered blood flow, and hypercoagulability. Traumatic fractures directly disrupt the endothelium, while immobilization and prolonged operative times exacerbate venous stasis. Additionally, fracture reduction and hardware placement may further disrupt the endothelium and mobilize thrombotic material. These factors are often compounded by systemic inflammatory and hypercoagulable responses to injury. These predictable physiologic effects provide a mechanistic rationale for recommendations against the use of elastic bandage exsanguination in patients with traumatic injury or recent immobilization (e.g. cast or splint).

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, PubMed, Web of Science, and CINAHL were searched from database inception through September 2025 using the terms Esmarch OR Esmark OR tourniquet AND pulmonary embolism OR lung embolism. Search terms were applied to title and abstract fields, and controlled vocabulary was used where appropriate. The primary author (BR) extracted search results from each database and uploaded them to Covidence, a web-based systematic review management tool.

Inclusion criteria consisted of case reports and case series available in the English language describing patients who underwent surgery at or below the level of the tibial plateau and experienced an intraoperative PE caused by thrombus. Exclusion criteria included studies unavailable in English, surgeries performed above the level of the tibial plateau, and cases in which emboli were identified as fat or air.

During study review, cases were categorized based on the presumed mechanism of embolism. Cases classified as exsanguination-related required the use of an Esmarch bandage or a similar elastic exsanguination device. In this group, the PE occurred during the intraoperative period. Cases classified as tourniquet deflation–related required the use of a pneumatic tourniquet, regardless of whether an Esmarch bandage was used. In all of these cases, the timing of the embolism occurred during the intraoperative period or in the immediate postoperative period. Pulmonary embolism diagnosis was established using a variety of modalities, including post-mortem examination, chest radiography, electrocardiography, d -dimer testing, transthoracic echocardiography, and others.

A total of 690 studies were identified, of which 258 were duplicates and removed ( Fig. 1 ). The remaining 432 studies underwent title and abstract screening by two reviewers (BR and KS), with 379 excluded as irrelevant. Both reviewers met to resolve any discrepancies. When consensus could not be reached, alternate reviewers (MV and JR) were consulted for input. Fifty-three studies underwent full-text review, of which 41 were excluded. Ultimately, 12 case reports and case series met the inclusion criteria, encompassing a total of 13 patient cases ( Fig. 1 ). The references of the 12 case reports and case series were manually screened to identify additional studies, but none were found.

Flow diagram illustrating the identification, screening, eligibility, and inclusion of studies.

Data extracted from each case study included patient sex, patient age, diagnosis, time from injury to surgery, symptom onset, and outcome. When available, information regarding anticoagulation, anesthesia, tourniquet location/pressure/time, and comorbidities was extracted. These data points are summarized in Tables 1 and 2 and discussed in the results section. Given the inclusion of case reports and case series, a standardized risk-of-bias assessment tool was not applied; however, key methodological features, including diagnostic confirmation, timing of events, and completeness of clinical data, were qualitatively assessed.

Table 2

Case reports of pulmonary embolism following tourniquet deflation of lower extremity.

Primary Author	Year	Age	Sex	Diagnosis	Time from injury to surgery	Symptom onset after deflation	Outcome	Anticoagulation	Anesthesia Type	Tourniquet level and/or pressure	Tourniquet time	Comorbidities
Gielen	1991	40	M	ankle fracture	7 days of immobilization	within minutes	fatal	unknown	general	thigh	20 min
Cohen	1994	56	F	comminuted fracture of tibial plateau	2 days of immobilization followed by 8 days of passive ROM and ambulating with walking frame	immediate	non-fatal	none	general	thigh	90 min	NIDDM and mild asthma
Liao	2022	47	F	comminuted fracture of tibia and fibula	13 days of immobilization	5 min	non-fatal	unknown	spinal	unknown	60 min	treated splenic rupture and haemorrhagic shock
Bharti	2009	55	M	fracture of tibial tuberosity and lateral condyle	unknown	5 min	fatal	unknown	spinal	thigh	57 min

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