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Vascular Hand Injury Workup

  • Author: Zubin J Panthaki, MD, CM, FACS, FRCSC; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
 
Updated: Apr 09, 2015
 

Laboratory Studies

Please see Indications section above.

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Imaging Studies

Conventional arteriography (CA) remains the criterion standard for radiologic evaluation of the peripheral vascular system.[27]

Advantages to CA include the following:

  • May demonstrate arterial lesions that can undergo sequential endovascular treatment; diagnostic and therapeutic modality
  • Can provide accurate localization of the lesion, which can assist with surgical planning
  • Can distinguish between intimal disruption and spasm through the use of vasodilators

Disadvantages to CA include the following:

  • It is an invasive diagnostic procedure.
  • It is a time-intensive procedure.
  • It requires transfer to a specialized angiography suite for evaluation.
  • It is a costly procedure.
  • Iatrogenic injuries can result, especially contrast-induced nephropathy and arterial access injuries (1-3%).

However, CA is usually unnecessary for the diagnosis of upper extremity vascular injuries. Some patients, such as those with shotgun injuries or complex wounds and fractures at multiple levels, may need to undergo arteriography to define the precise anatomic location of the arterial injury. In the trauma setting, most arteriographic evaluations can be completed intraoperatively once proximal and distal vascular control is obtained.

Noninvasive diagnostic modalities including duplex ultrasonography and CT angiography can aid in the diagnosis of peripheral vascular injuries, particularly those with equivocal, or “soft” signs.

Duplex sonography is a portable, rapid, and inexpensive tool that can be as accurate as conventional arteriography. Duplex sonography additionally aids in the diagnosis of major venous injuries. Performed by expert operators, duplex ultrasonography is an accurate and noninvasive study that allows the diagnosis of occult arterial injuries. According to Meissner and colleagues, no major injuries were missed in 60 scans.[28] Fry and colleagues reported that duplex ultrasonography offered 100% sensitivity and 97% specificity for identifying major extremity arterial injuries.[29] The limitations of duplex sonography are its expert operator dependence and the potential for missed injuries due to open wounds, large hematomas, bulky dressings, or splints that hinder access of the ultrasound probe. A recent large cohort study suggests that color-flow duplex sonography is of low yield in the diagnosis of upper extremity vascular injuries.[30]

Helical CT angiography (CTA) is rapidly gaining crucial ground as an alternative noninvasive, diagnostic modality in the management of suspected extremity vascular trauma.[27] Advancements in the scanning technology of helical CT scanners allow acquisition of detailed images that rival those of CA.[31, 32] Current studies suggest that CT angiography (CTA) may replace conventional angiography as the diagnostic study of choice for vascular injuries of the extremities. Sensitivity (95.1%) and specificity (98.7%) of diagnostic CT angiography for the detection of clinically significant extremity vascular injury in blunt and penetrating trauma was noted in one study.[33] In addition to providing high-resolution vascular images comparable to conventional arteriograms (see image below), helical CT scanners can simultaneously provide detailed images of the bone and soft tissue.[34]

Arteriogram demonstrates obstruction of flow in th Arteriogram demonstrates obstruction of flow in the upper extremity.

CTA simplifies the logistics of monitoring the trauma patient with potential extremity vascular injury, eliminates the risks associated with arterial puncture seen with CA, and results in a substantial cost savings to the patient and hospital. Cost analysis of the study conducted at Temple University by Seamon et al demonstrated a reduction of patient charges by $12,922 and reduction in hospital costs by $1166 compared to conventional arteriography.[31] Busquets and colleagues reported 97 cases evaluated for extremity vascular injury with CT angiography without any missed injury.[27]

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Contributor Information and Disclosures
Author

Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital

Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers Association

Disclosure: Nothing to disclose.

Coauthor(s)

Charles R Volpe, MD Fellow, Department of Plastic Surgery, University of Miami Miller School of Medicine

Charles R Volpe, MD is a member of the following medical societies: American Medical Association, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Ali M Soltani, MD Attending Surgeon, Plastic and Reconstructive Surgery, Hand and Microsurgery, Kaiser Permanente Orange County

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Additional Contributors

Anthony E Sudekum, MD Consulting Staff, Department of Plastic Surgery, St John's Mercy Health Center of St Louis

Anthony E Sudekum, MD is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, Missouri State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Nadeem Chaudhry, MD, FACS, Khaled F Salhab, MD, and Ian C Marrero, MD, to the development and writing of this article.

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Arterial anatomy of the upper extremity. a = artery; br = branch.
Arteriogram demonstrates obstruction of flow in the upper extremity.
Decompression of fascial compartments (fasciotomy).
Prolonged limb ischemia resulting in tissue necrosis.
Amputation of a hand because of tissue necrosis.
 
 
 
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