Vascular Occlusive Syndromes of the Upper Extremity Follow-up
- Author: Bradon J Wilhelmi, MD; Chief Editor: Harris Gellman, MD more...
Acute trauma with ensuing vascular compromise of distal extremity tissue must be treated on an emergency basis to minimize distal tissue loss. Partial vascular compromise left untreated may result in muscular fibrosis and contractures of varying severity. Without vascular supply, the involved limb may be lost within hours.
More often, partial vascular compromise is left untreated, in which case the patient may develop an intrinsic plus hand deformity associated with intrinsic muscle contraction. Signs of intrinsic contracture include MCP joint flexion and IP joint extension; passive hyperextension of the MCP joint decreases active flexion capacity of IP joints (Bunnell sign).
Noncritical arterial injury may lead to pseudoaneurysm, arteriovenous fistulation, or endothelial injury with mural thrombosis and seeding of emboli. Traumatic, noncritical vascular injuries involve cases in which tissue perfusion is not compromised, despite vascular injury. Such injuries may result in pseudoaneurysm formation, creation of an arteriovenous fistula, or acute thrombosis with distal embolization.
Raynaud disease usually occurs in persons aged 30-50 years, with increased prevalence in women. Symptoms generally last longer than 2 years. Patients demonstrate bilateral hand involvement with pallor of digits secondary to cold exposure or psychologic stressors. Complications include intermittent complaints of dysesthesia of involved digits. In contrast, CREST syndrome represents disease processes involving symptoms of generalized calcinosis, esophageal dysfunction, scleroderma, telangiectasia, and Raynaud phenomenon.
Symptoms specific to Raynaud phenomenon include digital ischemic pain, nonhealing ulcers, and the development of gangrene. Patients present with progressive joint contractures, including adduction contracture of the thumb and fixed flexion contractures of proximal IP (PIP) joints, with secondary extension contracture of MCP joints. Ulcers may develop over PIP joints, secondary to ischemia, pressure, minor trauma, or a combination of factors.
Vaso-occlusive diseases give rise to variable morbidity in patients, depending on the pathophysiology of the underlying condition. Vascular flow is determined by multiple factors, including environmental events, metabolic demands, sympathetic nervous tone, and local or circulating humoral mediators. When vascular flow is compromised, symptoms, including dysesthesias, paresthesias, pallor, cold intolerance, and ulceration associated with tissue necrosis, may be present. Thus, vaso-occlusive diseases result in significant morbidity.
Causes of vascular compromise include acute trauma or chronic modalities, such as repetitive microtrauma and systemic diseases involving metabolic processes, autoimmune processes, or both. Environmental factors as trivial as arsenic exposure may lead to severe, chronic peripheral vasospasm.
Patient history and physical examination, as well as multiple diagnostic modalities, may be used to diagnose the cause of vascular compromise. Depending on the etiology of the vascular compromise, numerous conservative measures, as well as more aggressive surgical interventions, may be indicated.
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