eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Vascular Occlusive Syndromes of the Upper Extremity: Follow-up

Author: Arian Mowlavi, MD, FACS, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach
Coauthor(s): Bradon J Wilhelmi, MD, Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Jan 19, 2010

Follow-up

Complications

  • Acute trauma with ensuing vascular compromise of distal extremity tissue must be treated emergently to minimize distal tissue loss. Partial vascular compromise left untreated may result in muscular fibrosis and contractures of varying severity. The patient may risk loss of the involved limb within hours without vascular supply. More often, partial vascular compromise is left untreated, in which case the patient may develop an intrinsic plus position hand deformity associated with intrinsic muscle contraction. Signs of intrinsic contracture include metacarpal phalangeal joint flexion and interphalangeal joint extension; passive hyperextension of the metacarpal phalangeal joint decreases active flexion capacity of interphalangeal 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 interphalangeal joints, with secondary extension contracture of metacarpophalangeal joints. Ulcers may develop over proximal interphalangeal joints, secondary to ischemia, pressure, minor trauma, or a combination of factors.

Prognosis

  • 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. As such, 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.

Miscellaneous

Medicolegal Pitfalls

  • It is of utmost importance to stress to patients with vaso-occlusive disease that their vascular pathology may or may not be curable. In general, generalized vaso-occlusive disorders cannot be cured, whereas focal vascular disorders often are curable. Therefore, any treatments provided, whether conservative or surgical, may only be temporizing measures.
 


More on Vascular Occlusive Syndromes of the Upper Extremity

Overview: Vascular Occlusive Syndromes of the Upper Extremity
Differential Diagnoses & Workup: Vascular Occlusive Syndromes of the Upper Extremity
Treatment & Medication: Vascular Occlusive Syndromes of the Upper Extremity
Follow-up: Vascular Occlusive Syndromes of the Upper Extremity
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Jones MA, Lee DY, Segall JA, Landry GJ, Liem TK, Mitchell EL, et al. Characterizing resolution of catheter-associated upper extremity deep venous thrombosis. J Vasc Surg. Oct 29 2009;[Medline].

  2. Kim JY, Buck DW 2nd, Forte AJ, Subramanian VS, Birman MV, Schierle CF, et al. Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients. J Trauma. Dec 2009;67(6):1339-44. [Medline].

  3. White PW, Gillespie DL, Feurstein I, Aidinian G, Phinney S, Cox MW, et al. Sixty-four slice multidetector computed tomographic angiography in the evaluation of vascular trauma. J Trauma. Jan 2010;68(1):96-102. [Medline].

  4. Murray AK, Moore TL, Manning JB, Taylor C, Griffiths CE, Herrick AL. Noninvasive imaging techniques in the assessment of scleroderma spectrum disorders. Arthritis Rheum. Aug 15 2009;61(8):1103-11. [Medline].

  5. O'Doherty J, McNamara P, Clancy NT, Enfield JG, Leahy MJ. Comparison of instruments for investigation of microcirculatory blood flow and red blood cell concentration. J Biomed Opt. May-Jun 2009;14(3):034025. [Medline].

  6. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient's quality of life. J Vasc Surg. Mar 2009;49(3):630-5; discussion 635-7. [Medline].

  7. Steen V, Denton CP, Pope JE, Matucci-Cerinic M. Digital ulcers: overt vascular disease in systemic sclerosis. Rheumatology (Oxford). Jun 2009;48 Suppl 3:iii19-24. [Medline].

  8. Kowal-Bielecka O, Landewé R, Avouac J, Chwiesko S, Miniati I, Czirjak L, et al. EULAR recommendations for the treatment of systemic sclerosis: a report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann Rheum Dis. May 2009;68(5):620-8. [Medline].

  9. Dalinka MK, Meyer S, Kricun ME, et al. Magnetic resonance imaging of the wrist. Hand Clin. Feb 1991;7(1):87-98. [Medline].

  10. Disa JJ, Chung KC, Gellad FE, et al. Efficacy of magnetic resonance angiography in the evaluation of vascular malformations of the hand. Plast Reconstr Surg. Jan 1997;99(1):136-44; discussion 145-7. [Medline].

  11. Edwards EA. Organization of the small arteries of the hand and digits. Am J Surg. Jun 1960;99:837-46. [Medline].

  12. el-Gammal TA, Blair WF. Digital periarterial sympathectomy for ischaemic digital pain and ulcers. J Hand Surg [Br]. Nov 1991;16(4):382-5. [Medline].

  13. Flatt AE. Digital artery sympathectomy. J Hand Surg [Am]. Nov 1980;5(6):550-6. [Medline].

  14. Goldberg I, Bahar A, Yosipovitch Z. Gangrene of the upper extremity following intra-arterial injection of drugs. A case report and review of the literature. Clin Orthop Relat Res. Sep 1984;188:223-9. [Medline].

  15. Greenfield AD, Shepherd JT, Whelan RF. The part played by the nervous system in the response to cold of the circulation through the finger tip. Clin Sci (Lond). Aug 1951;10(3):347-60. [Medline].

  16. Ho PK, Weiland AJ, McClinton MA, et al. Aneurysms of the upper extremity. J Hand Surg [Am]. Jan 1987;12(1):39-46. [Medline].

  17. Holder LE, Merine DS, Yang A. Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the hand. Hand Clin. Feb 1993;9(1):85-113. [Medline].

  18. Ikeda A, Ugawa A, Kazihara Y, et al. Arterial patterns in the hand based on a three-dimensional analysis of 220 cadaver hands. J Hand Surg [Am]. Jul 1988;13(4):501-9. [Medline].

  19. Joyce JW. Buerger's disease (thromboangiitis obliterans). Rheum Dis Clin North Am. May 1990;16(2):463-70. [Medline].

  20. Kleinert HE, Burget GC, Morgan JA, et al. Aneurysms of the hand. Arch Surg. Apr 1973;106(4):554-7. [Medline].

  21. Kleinert HE, Volianitis GJ. Thrombosis of the palmar arterial arch and its tributaries: etiology and newer concepts in treatment. J Trauma. Jul 1965;83:447-57. [Medline].

  22. Koman LA, Bond MG, Carter RE, et al. Evaluation of upper extremity vasculature with high-resolution ultrasound. J Hand Surg [Am]. Mar 1985;10(2):249-55. [Medline].

  23. Koman LA, Koman LA, et al. Diagnostic study of vascular lesions. Hand Clin. May 1985;1(2):217-31. [Medline].

  24. Koman LA, Nunley JA, Goldner JL, et al. Isolated cold stress testing in the assessment of symptoms in the upper extremity: preliminary communication. J Hand Surg [Am]. May 1984;9(3):305-13. [Medline].

  25. Koman LA, Smith BP, Pollock FE Jr, et al. The microcirculatory effects of peripheral sympathectomy. J Hand Surg [Am]. Sep 1995;20(5):709-17. [Medline].

  26. Koman LA, Urbaniak JR. Ulnar artery insufficiency: a guide to treatment. J Hand Surg [Am]. Jan 1981;6(1):16-24. [Medline].

  27. McClinton MA. Tumors and aneurysms of the upper extremity. Hand Clin. Feb 1993;9(1):151-69. [Medline].

  28. McNamara TO, Bomberger RA. Factors affecting initial and 6 month patency rates after intraarterial thrombolysis with high dose urokinase. Am J Surg. Dec 1986;152(6):709-12. [Medline].

  29. Merritt WH. Comprehensive management of Raynaud's syndrome. Clin Plast Surg. Jan 1997;24(1):133-59. [Medline].

  30. Miller LM, Morgan RF. Vasospastic disorders. Etiology, recognition, and treatment. Hand Clin. Feb 1993;9(1):171-87. [Medline].

  31. Rich NM, Hobson RW, Collins GJ. Traumatic arteriovenous fistulas and false aneurysms: a review of 558 lesions. Surgery. Dec 1975;78(6):817-28. [Medline].

  32. Strandness DE, Schultz RD, Sumner DS, et al. Ultrasonic flow detection. A useful technique in the evaluation of peripheral vascular disease. Am J Surg. Mar 1967;113(3):311-20. [Medline].

  33. Troum SJ, Smith TL, Koman LA, et al. Management of vasospastic disorders of the hand. Clin Plast Surg. Jan 1997;24(1):121-32. [Medline].

  34. Wilgis EF. Digital sympathectomy for vascular insufficiency. Hand Clin. May 1985;1(2):361-7. [Medline].

  35. Zimmerman NB. Occlusive vascular disorders of the upper extremity. Hand Clin. Feb 1993;9(1):139-50. [Medline].

  36. Zimmerman NB, Zimmerman SI, McClinton MA, et al. Long-term recovery following surgical treatment for ulnar artery occlusion. J Hand Surg [Am]. Jan 1994;19(1):17-21. [Medline].

[ CLOSE WINDOW ]

Keywords

vascular disorders, vascular compromise, vasospastic disorders, vascular insufficiency, hypothenar hammer syndrome, chronic vascular occlusive disease, thoracic outlet syndrome, embolism, Raynaud disease, Raynaud's disease, Raynaud syndrome, Raynaud's syndrome, Raynaud phenomenon, Raynaud's phenomenon, peripheral vasculitis, Wegener granulomatosis, Wegener's granulomatosis, Churg-Strauss syndrome, Takayasu vasculitis, Buerger disease, Buerger's disease, thromboangiitis obliterans, giant cell arteritis, aneurysm, pseudoaneurysm, CREST syndrome

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Arian Mowlavi, MD, FACS, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach
Arian Mowlavi, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Bradon J Wilhelmi, MD, Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine
Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph E Sheppard, MD, Associate Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare
Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Clinical Orthopaedic Society, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.