Upper-extremity vascular injuries

Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.     

Spontaneous brachial plexus hemorrhage-case report

BACKGROUND: Shoulder hemorrhage resulting in brachial plexus neuropathy is a rare occurrence most often seen in cases of traumatic injury or anticoagulation therapy. We report a unique case of spontaneous brachial plexus hemorrhage. CASE DESCRIPTION: This is the first report of a spontaneous shoulder hemorrhage in which a 48-year-old jackhammer operator presented to the emergency department with a sudden onset of right shoulder pain and upper extremity pain and numbness. Imaging studies revealed a hematoma in the right axilla and chest wall. Without evidence of active bleeding or worsening neurologic deficit, this patient was treated conservatively with pain control and observation and eventually experienced a full recovery. Had there been persistent neurologic deficit, however, surgical evacuation would have been indicated. CONCLUSIONS: Cases of nerve compression caused by a hematoma should be analyzed on the basis of the severity of the neurologic deficit and not on the underlying cause of bleeding. Conservative treatment may be indicated in cases of mild or improving neurologic deficit, but regardless of its etiology, a hematoma that results in severe or worsening neurologic symptoms must be surgically evacuated to prevent permanent nerve damage.     

Axillary sheath hematomas causing neurologic complications following arterial access

Iatrogenic brachial plexus injuries secondary to expanding hematomas and pseudoaneurysms have been described in limited nature in previously published data. We present the case of a 55-year-old woman who developed neurologic deficits because of a compressive hematoma after axillary arteriography. She underwent emergent exploration of her left arm with decompression of the axillary sheath and brachial artery repair with complete recovery. We describe the presentation, relevant anatomy, and importance of this condition and stress the need for early recognition and surgical intervention to prevent permanent neurologic deficits.     

创伤继发臂丛神经急性卡压征

目的　总结创伤继发臂丛神经急性卡压征的病因、症状与体征、治疗及预后。方法　 12例因创伤引起肩锁区肿胀、瘀血、压痛、畸形外 ,肩锁区存在搏动感及血管杂音 ;臂丛下干支配区感觉及 /或功能障碍。伴肋骨、锁骨、多处骨折 7例 ;锁骨下血管损伤 (破裂、假性动脉瘤、动静脉瘘 ) 9例 ,血肿 3例。诊断为创伤继发臂丛神经急性卡压征。采用假性动脉瘤切除动脉直接缝合或静脉移植 3例 ,血管吻合、修补术 4例 ,血管结扎 2例 ,血肿去除 3例。骨折切开复位内固定 8例 ,臂丛神经松解术 12例。结果　 12例术后平均随访 2 6个月 ,患侧的桡动脉搏动良好 ,肩胛带骨折已骨性愈合。臂丛神经功能恢复按中华医学会手外科学会上肢部分功能评定试用标准评定[1] :优 11例 ,可 1例。结论　创伤继发臂丛神经急性卡压的病例起病急 ,在伤后 2～ 3h或 1～ 2d内发生。除有臂丛神经损伤症状外 ,还伴有肩胛带骨折及锁骨下血管损伤。早期手术预后较好。     

Subclavian arterial injury associated with blunt trauma.

Blunt subclavian artery trauma is an uncommon but challenging surgical problem. The purpose of this study was to retrospectively review the management of blunt subclavian artery injuries treated by the Trauma and Vascular Surgery Services at the East Tennessee State University-affiliated hospitals between 1992 and 1998. Six patients with seven blunt subclavian artery injuries were identified. Physical signs indicating blunt subclavian artery injury were pain or contusion around the shoulder joint; fractures of the clavicle, scapula, or ribs; periclavicular hematomas; and ipsilateral pulse or neurologic deficits. Seven subclavian artery injuries were treated-two arterial transections, two pseudoaneurysms, and three intimal dissections. Associated injuries included four clavicle fractures, one humerus fracture, one combined rib and scapular fractures, and two pneumothoraxes. Vascular surgical treatment included three primary arterial repairs, two saphenous vein interposition grafts, and one polytetrafluoroethylene (PTFE) graft. One patient was treated nonoperatively with anticoagulation. No deaths occurred. Morbidity occurred in two patients with chronic upper extremity neuropathy producing prolonged disability from pain and weakness; one patient had reflex sympathetic dystrophy, and the other had a brachial plexus injury. In conclusion, blunt subclavian artery trauma can be successfully managed with early use of arteriography and prompt surgical correction by a variety of vascular techniques. Vascular morbidity is usually low, but long-term disability because of chronic neuropathy may result from associated brachial plexus nerve injury despite a successful arterial repair.     

Supraclavicular approach for thoracic outlet decompression

Supraclavicular decompression of the thoracic outlet was performed in 40 patients with symptoms arising from brachial plexus compression were irritation. Both osseous and soft tissue structures responsible for this nerve compression were identified and removed without significant neurologic morbidity despite a 25% incidence of secondary operative procedures in this series. The cure or improvement rate matched what we previously reported for combined transaxillary and supraclavicular approach. Further follow-up will allow a determination of the durability of this technique, which, if acceptable, will justify a confident recommendation for its adoption in patients having thoracic outlet decompression.     

Bilateral brachial plexus injury

Brachial plexus injuries can occur as a result of various mechanisms such as stretching, direct and indirect trauma or following childbirth. Bilateral brachial plexus injuries are uncommon and associated with a poor functional outcome. We report a case of bilateral brachial plexus injury resulting from prolonged immobilization of the arms in hyper-abducted position resulting in compression of the brachial plexus on both sides. The injuries were treated conservatively and following 4 months of active rehabilitation in our unit, the patient still had poor arm functions and required care and support in the community on discharge.     

锁骨下血管合并臂丛损伤的处理

目的 探讨锁骨下动脉合并臂丛神经损伤的诊断和处理。方法 5例锁骨下动脉损伤合并臂丛损伤，其中锁骨下动脉第一段损伤1例，第三段损伤4例；2例合并动脉瘤，1例动脉瘤加动静脉瘘．2例血管纤维化自行闭塞。根据锁骨下动脉损伤性质，分别采用静脉移植、直接缝合、血管结扎处理，损伤臂丛神经采取直接缝合、神经松解。结果 3例开放性损伤患者早期手术修复动脉和神经，术后伤肢无疼痛，神经功能有不同程度恢复；2例闭合钝器伤晚期患者，1例行血管、神经松解术，仅疼痛减轻，1例血管臂丛神经广泛粘连，神经松解术后无任何恢复。结论 除原发性损伤外，进行性增大的血肿或假性动脉瘤压迫可加重臂丛神经损害．如能早期处理血肿或动脉瘤，解除压迫，可减轻神经损害，有利于臂丛神经功能恢复。     

急诊和亚急诊手术治疗有合并伤的臂丛损伤

目的 在急诊处理锁骨骨折、肩胛骨骨折、锁骨下动脉损伤及肩关节脱位、骨盆骨折等创伤的同时或2～3周内进行臂丛神经离断伤或部分离断伤的手术修复，以提高其术后的优良率。方法 1993年2月～2003年1月，我们对怀疑有臂丛损伤的患者，尽快进行MRI等检查，根据临床表现和检查结果，对其中明确为离断伤或部分离断伤的29例患者，在伤后急诊或2～3周内实施了臂丛探查，神经直接缝接，颈丛、膈神经、副神经移位，臂丛神经交叉移位及侧侧缝合等手术。结果 其中21例患者术后得到6个月～6年(平均3年)的随访，按照顾玉东的臂丛损伤功能评定标准，本组患者观察总体优良率达70.6％。结论 对有合并伤的臂丛神经离断伤或部分离断伤患者，急诊或2～3周内进行手术探查和修复，可减少手术次数和难度，提高臂丛损伤修复术的优良率。     

A 32-year experience with the surgical treatment of selected brachial plexus lesions with emphasis on its reconstruction

Twenty-five patients with brachial plexus injury were treated by anastomosis, neurolysis, and calvicular decompression. The patients treated by anastomosis are described in detail because evidence of regrowth of axons across the anastomosis can be documented, whereas the effects of neurolysis are difficult to judge. The techniques of brachial plexus reconstruction are illustrated. Clinical improvement occurred in 93% of patients treated with anastomosis, 89% of those treated with neurolysis, and 100% of those treated with decompression. Electromyographic studies provided valuable information in assessment before and after surgery. The benefits of surgical therapy of brachial plexus injuries outweigh the risks in carefully selected patients.     

Brachial plexus root avulsions

The majority of adult brachial plexus palsies are posttraumatic injuries caused by high-energy forces, usually involving motor vehicles. In infants, brachial plexus palsies commonly represent obstetrical injuries following excessive traction on the plexus during complex or difficult delivery. Most adult injuries, and occasionally those in infants, represent brachial plexus root avulsion injuries that carry serious ramifications from the standpoint of permanent disability of a paralyzed extremity, prolonged recuperation, and significant socioeconomic impact. Modern-day management of root avulsions should focus on early, aggressive microsurgical reconstruction of the brachial plexus, combining various neurotizations with intraplexus and extraplexus ipsilateral and contralateral nerve donors, utilization of vascularized nerve grafts, and finally the use of free vascularized and neurotized muscles. When these multistage microsurgical management techniques are applied early (with complete avulsions) they may often result in significant return of neurologic function, especially in young patients. Amputation should be looked upon as an option only when these newer microsurgery techniques have failed.     

Acute subdural hematoma: morbidity and mortality related to timing of operative intervention

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).     

Blunt versus penetrating subclavian artery injury: presentation, injury pattern, and outcome

BACKGROUND: Subclavian artery (SCA) injuries are rare vascular injuries and may be difficult to manage. The majority of SCA injuries are secondary to penetrating trauma. The purpose of this report is to examine the injury patterns, diagnostic and therapeutic approaches, and outcome of patients with blunt and penetrating SCA injuries. METHODS: Retrospective review RESULTS: Fifty-six patients sustained SCA injuries (25 blunt, 31 penetrating). SCA injury location was evenly distributed between the proximal, middle, and distal SCA after penetrating trauma; proximal injuries were rare (2 of 25) with blunt mechanisms. A radial arterial pulse deficit was present in only 3 of 25 blunt injuries and 9 of 31 penetrating injuries. Complications occurred more commonly in both groups of patients with initial systolic blood pressures less than 90 mm Hg. Survival was 76% in blunt and 81% in penetrating groups; limb salvage was similar (92% in blunt and 97% in penetrating groups). Complete brachial plexus injuries were more common with blunt injuries. CONCLUSION: SCA injuries are rare vascular injuries with an associated high morbidity and mortality, regardless of mechanism. Blunt mechanisms result in more middle and distal injuries and more frequent complete brachial plexus injuries. Complications are related to the hemodynamic status of the patient upon presentation, and not to mechanism of injury.     

Injuries associated with serious brachial plexus involvement in polytrauma among patients requiring surgical repair

Background

Brachial plexus injury occurs in up to 5% of polytrauma cases involving motorcycle crashes and in approximately 4% of severe winter sports injuries. One of the conditions for the success of operative therapy is early detection, ideally within three months of injury. The aim of this study was to evaluate associated injuries in patients with severe brachial plexus injury and determine whether there is a characteristic concomitant injury (or injuries), the presence of which, in the polytrauma, could act as a marker for nerve structures involvement and whether there are differences in severity of polytrauma accompanying specific types of brachial plexus injury.

Methods

We evaluated retrospectively 84 surgical patients from our department, from 2008 to 2011, that had undergone brachial plexus reconstruction. For all, an injury severity scale (ISS) score and all major associated injuries were determined.

Results

72% of patients had an upper, 26% had a complete and only 2% had a lower brachial plexus palsy. The main cause was motorcycle crashes (60%) followed by car crashes (15%). The average ISS was 35.2 (SD = 23.3), although, values were significantly higher in cases involving a coma (59.3, SD = 11.0). The lower and complete plexus injuries were significantly associated with coma and fractures of the shoulder girdle and injuries of lower limbs, thoracic organs and head. Upper plexus injuries were associated with somewhat less severe injuries of the upper and lower extremities and less severe injuries of the spine.

Conclusion

Serious brachial plexus injury is usually accompanied by other severe injuries. It occurs in high-energy trauma and it can be stated that patients involved in motorcycle and car crashes with multiple fractures of the shoulder girdle are at high risk of nerve trauma. This is especially true for patients in a primary coma. Lower and complete brachial plexus injuries are associated with higher injury severity scale.     

Traumatic duodenal hematoma in the pediatric patient

Twenty children with duodenal hematomas secondary to blunt trauma were treated between 1953 and 1983. The duodenal injury was isolated in ten cases and associated with intra-abdominal injuries in the others. In ten, the duodenal injury was suspected on admission and the diagnosis was confirmed within 24 hours by radiographic contrast studies. All ten were managed successfully with nasogastric suction and intravenous fluids. Ten patients underwent laparotomy for increasing abdominal tenderness and guarding. An isolated duodenal hematoma was found in four and treated by evacuation and/or gastroenterostomy. In five of the remaining six surgical patients, all of whom had multiple intra-abdominal injuries, the duodenum was left untouched. Three of these patients had postoperative contrast studies that showed early resolution of the duodenal hematoma. No duodenal stricture or leak developed in any patient. The children with isolated duodenal hematomas who were treated conservatively had a mean hospital stay of six days, whereas those treated surgically had a mean stay of 17 days. The ten patients with multiple intra-abdominal injuries had a mean hospital stay of 32 days. In this group, eight required total parenteral nutrition or nasojejunal feeds for nutritional support. In these patients, an isolated duodenal hematoma resulted in minimal morbidity and nonoperative management was usually successful. The presence of associated intra-abdominal injuries was responsible for the prolonged hospitalization and delayed return of normal intestinal function in some patients.     

Upper root brachial plexus trauma; patient selection and reconstruction

Injury to the brachial plexus is increasingly common and the initial management of these patients is usually focused on associated life threatening injuries. Appreciation of the management of the brachial plexus injury can greatly assist with subsequent reconstruction and thus we review our experience in this field. A total of nine patients who underwent upper root brachial plexus reconstruction over the period 1980-1998 were reviewed. Causes of injury included road traffic accidents (n=6), open injuries (n=2) and the remaining case was iatrogenic. All patients had cabled grafting of the plexus while one patient had neurotization of the plexus in addition to grafting. Sixty six percent (n=6/9) of patients had a good outcome with return of elbow flexion. Patients with an open injury to the plexus had a better prognosis than those who had a closed injury. Polytrauma patients and those with penetrating neck injuries should be assessed to exclude brachial plexus injury. Baseline assessment and early involvement of surgeons with an interest in this area will help select those patients who will benefit from brachial plexus reconstruction.     

"Other" neurologic complications after cardiac surgery

Compared to the neurologic morbidity of stroke and cognitive dysfunction, "other" neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.     

Combined brachial plexus and spinal cord trauma

The clinical features of combined injuries of the brachial plexus and spinal cord in 31 patients are described. Diagnosis of the brachial plexus lesion was delayed in 17 instances, and the reasons for this are discussed. Early diagnosis is important so that definitive treatment and long-term plans can be instituted without delay. This dual lesion constitutes a very severe disability; as a direct result of their brachial plexus paralysis, 9 paraplegics did not achieve their predicted level of independence. Possible mechanisms of injury are suggested. Motorcycle accidents are particularly likely to cause these injuries, and a plea is made for further legislation to reduce the risks of injuries to young motorcyclists.     

Giant intraspinal pseudomeningoceles cause delayed neurological dysfunction after brachial plexus injury: report of three cases

OBJECTIVE AND IMPORTANCE: Delayed neurological dysfunction after a brachial plexus injury is uncommon. We present the cases of three patients with a history of significant brachial plexus trauma and late neurological deterioration secondary to giant intraspinal extradural pseudomeningoceles. CLINICAL PRESENTATION: Three patients, each with a remote history of brachial plexus trauma, presented with slowly progressive upper-limb weakness. An examination revealed bilateral lower motor neuron weakness in the upper extremities in all patients and evidence of spastic paraparesis in one. Magnetic resonance imaging and postmyelogram computed tomographic scans demonstrated large anterior extradural cerebrospinal fluid collections extending from the upper cervical to lower thoracic and lumbar levels in each patient. Myelograms demonstrated a connection with the subarachnoid space in two patients. INTERVENTION: Direct obliteration of the connection between the cyst and the subarachnoid space was completed in two patients, and a cystoperitoneal shunt was placed in the third. Postoperative imaging demonstrated complete resolution of the extradural collections. Arrest of progression of upper-limb deterioration was observed in all patients, and dramatic improvement of long tract symptoms occurred in one. CONCLUSION: Giant intraspinal pseudomeningoceles are a rare complication of brachial plexus root injuries or avulsion, capable of causing significant morbidity. Early intervention can improve symptoms related to long tract involvement and prevent further deterioration of lower motor neuron disease. The pathophysiology of neurological dysfunction caused by these giant collections is unclear; however, vascular and mechanical factors thought to be important in the pathogenesis of cervical myelopathy also may have a role.     

Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine

On the one hand, out of 115 patients admitted to hospital with 162 various fractures of the cervical spine without injury to the spinal cord, only 3 (2.6%) had an associated lesion to the brachial plexus or nerves in the vicinity. On the other hand, among 500 consecutive patients with injuries to the brachial plexus, 55 (11%) presented fractures of the cervical spine (including T1 and the 1st rib), whiplash injuries, severe distortions and dislocations, and contusions of that vertebral segment. Five (1% resp. 9%) had spinal cord injuries, including four patients with partial Brown-Sequard's syndrome, which was caused by multilevel root avulsions of the brachial plexus. In rather severe trauma to the lower cervical spine and concomitant brachial plexus lesion, root avulsions must be expected in 83% of cases, and in almost half of these patients three or more roots are avulsed from the spinal cord. Fractures around the shoulder-girdle as well as arterial ruptures are also significant for this severe nerve injury. Of these patients 39 (71%), were victims of motorcycle accidents.