I read with interest the article “Extensor Tendon Repair by Emergency Physicians” by Erin Dooley, MD, and J. Michael Smith, MD, in ACEP Now in March 2026 and found it to be a helpful review of extensor tendon lacerations/repair. However, the article recommends the use of a forearm blood pressure cuff to achieve hemostasis during single-digit extensor tendon repair. While this approach is effective, it may not represent the safest and most physiologically targeted method for isolated digital procedures. 

The hand surgery and emergency medicine literature consistently emphasizes that [physicians] should always use the lowest effective pressure over the smallest necessary anatomic region to achieve a bloodless field.^1,2 In the case of single-digit repair, forearm tourniquets—whether pneumatic or improvised—create ischemia in tissues not involved in the procedure, including intrinsic hand muscles and forearm compartments. This broader ischemic exposure introduces avoidable risks, including nerve compression, muscle ischemia, and patient discomfort, without clear procedural advantage in limited-field cases. 

Digital tourniquets, by contrast, are widely used for isolated finger procedures and provide localized hemostasis at substantially lower occlusion pressures. Their use aligns more closely with the principles of minimizing tissue ischemia and pressure related neurovascular injuries. The literature appropriately warns of the highly variable and commonly excessive pressures applied by makeshift digit tourniquets, while also highlighting the importance of proper technique, time awareness, and
reliable removal protocols to mitigate the well-described risks of digital tourniquets.³  

For single-digit procedures, consideration should be given to digit-specific hemostatic methods that minimize pressure and confine ischemia to the operative field, reserving proximal limb tourniquets for cases requiring broader exposure. 

Disclosure: The author is the inventor of the T-RING digital tourniquet device. 

References

1. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic Tourniquets in Extremity Surgery. J Am Acad Orthop Surg. 2001; 9(5):345‐351.
2. Tuncali B, Karci A, Tuncali BE, et al. A New Method for Estimating Arterial Occlusion Pressure in Optimizing Pneumatic Tourniquet Inflation Pressure. Anesth Analg. 2006;102:1752-1757.
3. Lahham S, Tu K, Ni M, et al. Comparison of Pressures Applied by Digital Tourniquets in the Emergency Department. West J Emerg Med. 2011; 12(2):242-249.