Vascular Hand Injury Treatment & Management
- Author: Zubin J Panthaki, MD, CM, FACS, FRCSC; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
Conservative, nonsurgical management of arteriographically detected, nonocclusive, and asymptomatic arterial injuries in the upper extremity remains controversial. Injuries such as intimal flaps, vessel narrowing, small false aneurysms, and arteriovenous fistulae in which the artery and its runoff remain intact may be amenable to observation alone. Frykberg and colleagues reported an 89% rate of resolution or stability of minimal injuries without surgical treatment over 10 years.
Initial evaluation and management
Initial evaluation and management of upper extremity vascular injuries follow the Advanced Trauma Life Support (ATLS) guidelines established by the American College of Surgeons. The management of life-threatening injuries always takes precedence over the management of limb-threatening injuries.
Repair of peripheral vascular injuries
Repair of peripheral vascular injuries remains a challenging task. The operative sequence consists of access, exposure, control, and repair. Temporary vascular control can usually be accomplished with the application of digital pressure or a blood pressure cuff. An attempt to blindly clamp a bleeding vessel is not recommended because of the hazard of injuring peripheral structures such as nerves. For the upper extremity, the patient should be positioned supine with the arm extended and abducted 90°. A contralateral unaffected limb should always be included in the surgical field in the event that an autogenous vein graft is necessary. Incisions in the extremities are designed longitudinally over the injured vessel and are extended proximally and distally as necessary. If initial repair of associated nerve and tendon injuries is not feasible, they should be tagged with sutures or surgical clips for later repair.
Gaining access and exposure without causing iatrogenic injury is a fundamental goal of the operative procedure. The axillary artery is approached through an infraclavicular incision that extends to the deltopectoral groove. Proximal supraclavicular control is sometimes necessary, but resection of the middle third of the clavicle adds little benefit. Endovascular control may be possible when active extravasation is identified during arteriography.
The proximal brachial artery is approached through a medial incision in the upper arm at the groove between the biceps and the triceps. The distal brachial artery and its bifurcation are exposed at the antecubital fossa beneath the biceps tendon through an S-shaped incision.
Distal forearm vessels can be exposed with longitudinal incisions over the course of the artery. Controversy exists with regard to repair of the radial and ulnar artery in the forearm, especially at the level of the wrist. Common sense would dictate that repair of an injured radial or ulnar artery is mandatory if the palmar arch is incomplete or if the ulnar or radial vessel was previously interrupted. However, in a traumatic setting, assessment of the patency or communication of the palmar arches may not be possible.
Review of the literature would suggest that ligation of an isolated radial or ulnar artery is appropriate. Though Rothkopf et al demonstrated an 82% patency rate after repair of single vessels, multiple other studies demonstrate overall patency rates of single vessel repairs at 46-48%.[37, 38] Johnson et al go further to point out that claudication did not result in any of their patients treated with ligation, though hand weakness and cold insensitivity were noted in 50% and 12%, respectively of those patients who had concomitant nerve injury. These results would suggest that ligation of a single vessel injury at the level of the distal forearm and wrist is appropriate in most situations. When both are injured, the ulnar artery repair takes precedence due to role as the dominant arterial supply to the hand.
Proximal and distal control should be obtained before the injury is exposed. An intraluminal Foley balloon catheter is a useful adjunct, especially in injuries to the proximal axillary artery. After the artery is exposed and controlled, areas of contusion, subintimal hematoma, and devitalized segments of the vessel are debrided. Gentle thrombectomy with a Fogarty catheter and flushing with heparinized saline solution, proximal and distal in the vessel lumina, are performed subsequently. Systemic anticoagulation is rarely used in acute trauma. Overinflation of the Fogarty balloon should be avoided because this can potentially tear the intima, resulting in thrombosis of the affected vessel. Topical lidocaine or papaverine is useful to relieve spasm, especially in the small vessels of the distal forearm and hand.
Temporary intraluminal shunting with restoration of distal perfusion may also be of great value if associated unstable fractures are present, as it prevents prolonged distal ischemia of the extremity during fixation prior to definitive vascular repair.
The type of vascular repair depends on the extent of arterial damage. Primary repair with an end-to-end anastomosis is performed with a running or interrupted nonabsorbable monofilament suture, depending on the size of the vessel. A meticulous surgical technique must be used to avoid a purse-string effect. If a large gap prevents tension-free repair, reversed saphenous or cephalic-vein autogenous interposition grafts must be used for reconstruction. Although polytetrafluoroethylene (PTFE) grafts have been used successfully in trauma, synthetic conduits should be avoided if possible because they increase the risk for infection and for an inferior patency rate, especially in small vessels. Feliciano and colleagues reported an increased rate of thrombosis with small-bore PTFE grafts.
All repairs must be covered with viable soft tissue, and external compression of the vascular repair must be avoided. Intraoperative completion arteriography must be performed, and palpable distal pulses should be documented after repair. Venous injury to the upper extremity rarely requires repair because the collateral network is extensive. Ligation of the venous injury is typically well tolerated.
Since 1991, an increasing variety of vascular injuries are proving amenable to endovascular treatment. Endovascular procedures are effective and decrease morbidity. They are attractive alternatives to standard surgical techniques, which require wide exposure and dissection, especially in proximal injuries. Transcatheter embolization with coils can be used to manage selected arterial injuries, such as low-flow arteriovenous fistulas and active bleeding from noncritical arteries. Endoluminal repair of false aneurysms, large arteriovenous fistulas, intimal flaps, and focal lacerations, has been performed using stent-graft technology. Castelli and colleagues reported a 100% immediate success rate in managing 9 axillosubclavian arterial injuries. However, careful patient selection must be emphasized. Studies monitoring the long-term patency of these stent-grafts are still needed.
Management of compartment syndrome
Although the incidence of compartment syndrome is lower in the upper extremity than in the lower extremity, fasciotomy should be considered with any arterial repair. The clinical manifestation of reperfusion injury and increased fascial compartment pressure must be identified promptly and treated aggressively. Compartment syndrome is caused by increased pressure in the fascial compartment that results in muscle and nerve ischemia. Early physical findings and symptoms suggestive of compartment syndrome include extreme pain that is disproportionate to the level of injury and increased pain with passive movement of the affected compartmental muscles. Other suggestive though less reliable signs and symptoms of compartment syndrome include paralysis, paresthesia, pallor, swollen compartments, and decreased sensation.
Pulselessness of the extremity is a late and unreliable sign of compartment syndrome, as pulses are commonly present during the early stages of compartment syndrome. Normal tissue pressure is generally agreed to be less than 10 mm Hg. Many authors recommend fasciotomies when the tissue pressure is 10-30 mm Hg less than the diastolic blood pressure. When borderline tissue pressure measurements exist, serial examinations should be conducted at one-hour intervals. Repeat examinations should be conducted by the same examiner in an effort to maintain consistency of the readings. If tissue pressure 10-30 mm Hg less than the diastolic pressure occurs, then fasciotomy should be performed.
The upper extremity includes the compartments of the arm, forearm, and hand. The arm has 2 compartments: anterior and posterior. The forearm contains 3 compartments: the volar, dorsal, and mobile wad compartments. The hand contains 4 compartments: the central, thenar, hypothenar, and interossei compartments.
Straight lateral and medial incisions are used to decompress the anterior and posterior arm compartments, respectively. Dorsal and volar incisions are used in the forearm. The dorsal incision should be straight, whereas the volar incision should follow a lazy S-shape to avoid scar contracture. The incision may extend over the midproximal wrist to decompress the carpal tunnel at the same time. Five incisions are typically used to decompress the hand: 2 incisions placed on the dorsum of the hand over the 2nd and 4th metacarpals, 1 volar incision over the carpal tunnel, and 2 volar incisions, one each on the thenar and hypothenar eminences, respectively.
Occlusion and bleeding from thrombosis are common early complications in the postoperative period. These complications necessitate an immediate reoperation.
Muscle edema that increases compartmental pressure is another complication of vascular injury; pain is the most important symptom. Decompression of the fascial compartments (fasciotomy) is performed to treat this process (see image below).
Nerve injury that causes motor or sensory deficits is another complication that may lead to limb disability. Tissue death and necrosis are complications of prolonged vascular compromise and limb ischemia (see image below).
Amputation of the necrotic part is usually the method of treatment (see image below).
Another serious complication of vascular injury is infection, which requires immediate debridement and antibiotic treatment. Late complications of arterial injury include arteriovenous fistulas and false aneurysms. These complications are usually managed with operative repair.
Outcome and Prognosis
The prognosis of patients with upper extremity vascular injury is typically good but depends on early and aggressive diagnosis and repair of the injured vessels in a timely, tension-free manner. Vigilant monitoring for compartment syndrome with early fasciotomies can prevent long-term disability and promote full functional recovery. Long term follow-up studies in children who underwent vascular reconstructions of the upper extremity showed similar-sized limbs and blood supply. However, they did have a high incidence of asymptomatic enlargement of the reconstructed arteries. Lastly, many of these patients with arterial reconstruction of the upper extremity can suffer from cold intolerance long term, which can be problematic.
In a study of the long-term results of vascular reconstruction in patients with hypothenar hammer syndrome, Endress et al found that 14 out of 18 grafts (78%) were occluded after a mean postoperative period of 118 months. The study involved 16 patients, in whom a total of 18 vein graft reconstructions of the ulnar artery were performed. Although patients with a patent reconstruction had significantly better outcomes with regard to cold intolerance and pain severity than did the other patients, patient scores associated with patent or occluded grafts did not differ statistically on the Disabilities of the Arm, Shoulder and Hand questionnaire.
A study by Wegmann et al suggested that in cases of vascular compromise caused by supracondylar humeral fracture, patients who, after fracture reduction, have a pulseless hand with good capillary refill time may benefit from a strategy of “watchful waiting” rather than vascular surgery. The study included 14 pediatric patients who remained without peripheral pulse following fracture reduction. Although four of the patients (three of whom had prolonged peripheral capillary refill times) underwent vascular surgery, watchful waiting was used in the remaining 10 patients, with blood flow having recovered in all 10 of them by 2- to 6-year follow-up.
Future and Controversies
Treatment of upper extremity vascular injuries has evolved over the past 200 years from mandatory amputation to complex procedures that allow the reconstruction and revascularization of the injured extremity. Functional recovery from devastating vascular injuries of the upper extremity is the norm rather than the exception today. Despite this, technological advances continue to be made that will allow modern surgeons to improve patient outcomes in regards to vascular injuries of the upper extremity. Drug-eluting stents to prevent vessel thrombosis, pharmacologic treatments to prevent ischemia-reperfusion injury and implantable continuous monitoring devices to detect flow abnormalities are a few of the technological advances under investigation and research at this time.
Perhaps, one or all of these advances will allow surgeons to treat upper extremity vascular injuries with decreased morbidity and improved functional outcome. Until then, rapid diagnosis, prompt treatment, and hypervigilant monitoring for compartment syndrome will remain the standard of care for these potentially devastating injuries.
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