Complex upper extremity vascular trauma in an urban population

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.     

Management of upper extremity arterial injuries at an urban level I trauma center

Although relatively uncommon, upper extremity arterial injuries are serious and may significantly impact the outcome of the trauma patient. Management of upper extremity arterial injuries at an urban level I trauma center was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. Upper extremity trauma patients with arterial injury who presented between January 2005 and December 2006 were included in this retrospective review. Data collected included age, gender, race, mechanism of injury, type of injury, associated upper extremity injuries, concomitant injuries, injury severity score (ISS), diagnostic modalities employed, surgical procedures and interventions, mortality, length of stay, and discharge disposition. Statistical analysis between blunt and penetrating arterial injuries as well as between proximal and distal arterial injuries also was conducted. During a 2-year period, 28 patients with 30 upper extremity arterial injuries were admitted, yielding an incidence of 0.48%. The study population was comprised primarily of young Caucasian males, with a mean ISS of 9.0. The majority (89.3%) of patients suffered concomitant upper extremity injuries. Twenty-two nerve injuries were identified in 16 (57.1%) patients. The most common injury mechanism was cut by glass (39.3%). Arterial injuries were categorized into 18 (60.0%) penetrating and 12 (40.0%) blunt injuries. Involved artery distribution was as follows: 12 (40.0%) brachial, eight (26.7%) ulnar, seven (23.3%) radial, and three (10.0%) axillary. Over half (56.7%) of the injuries resulted from lacerations. Injuries were managed as follows: 14 (46.7%) primary repairs, eight (26.7%) ligations, six (20.0%) saphenous vein graft bypasses, and two (6.7%) endovascular procedures. Eleven (39.3%) patients required intensive care unit (ICU) admission. The overall mean length of hospitalization for these patients was 7.4 days compared to a mean length of hospitalization of 2.0 days for the 17 (44.7%) patients who did not require ICU admission. The overall limb salvage rate was 96.4% as arterial injuries were successfully repaired in 27 of 28 patients. No patients expired and all were discharged home. Equivalent demographics, mechanisms of injury, surgical management approaches, and successful hospital outcomes were demonstrated between penetrating and blunt injuries as well as between proximal and distal arterial injuries. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after upper extremity arterial injuries and will continue to be utilized.     

The natural history of clinically occult arterial injuries: a prospective evaluation

Nineteen patients with 20 clinically occult arterial injuries were prospectively followed without surgery in order to define the natural history of these lesions. The patients were predominantly male (74%), with a mean age of 31 years. The mechanism of injury was penetrating in 13 cases and blunt in seven cases. The arterial injuries were located in the lower extremity (45%), upper extremity (35%), neck (15%), and abdominal aorta (5%). Neurologic trauma (55%) and musculoskeletal trauma (40%) were the most common associated injuries. There was no clinical manifestation of vascular injury in any case. All lesions were identified by arteriography, which was performed for high-risk blunt trauma and proximity of penetrating wounds to major vessels. Intimal flap was the most commonly demonstrated form of injury (65%), followed by focal narrowing (30%) and false aneurysm (5%). Followup of 19 injuries (95%) was obtained for periods ranging from 3 days to 19 months (mean, 3.8 months). Arteriographic followup was obtained in 15 cases (79%). One injury (5%), a false aneurysm, enlarged after 10 weeks and was surgically repaired without clinical sequelae. All other lesions either resolved (53%), improved (16%), or remained unchanged (26%). These results suggest that nonoperative observation may be a safe and feasible method of managing clinically occult arterial injuries.     

Upper extremity arterial injuries: Factors influencing treatment outcome

Objective

The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries.

Methods

This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed.

Results

The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p < 0.01).

Conclusion

Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability.     

Civilian arterial trauma of the upper extremity: An 11 year experience in 267 patients

Two hundred ninety-eight arterial injuries in 269 upper extremities were reviewed. Penetrating agents accounted for 250 injuries (93 percent) and blunt trauma for 19 (7 percent). Fifty-nine axillary, 126 brachial, 65 radial, and 48 ulnar arteries were damaged. Twenty-six extremities had more than one artery injured. The initial vascular examination revealed no abnormalities or was equivocal in 16 percent of all patients and in 32 percent of those with axillary artery injuries. Adjacent upper extremity structures were injured in 195 limbs (73 percent).Resection and primary anastomosis (54 percent) or vein interposition grafting (26 percent) were the most frequent methods of repair. Two deaths (0.7 percent) occurred and four amputations (1.5 percent) were required. Distal pulses were present at discharge in 93 percent of the evaluable extremities. Despite excellent success with arterial reconstruction, functional results were limited by associated nerve injuries. One hundred fifty patients (49 percent) had nerve deficits at discharge, and 71 (27 percent) had serious functional limitations.     

Should trauma surgeons render definitive vascular repair in peripheral vascular injuries?

Our hypothesis is that in an established Level I trauma center general trauma surgeons should repair peripheral vascular injuries even in stable patients when there is time for a vascular consult. We reviewed all penetrating peripheral vascular injuries in stable patients operated on by nine experienced general trauma surgeons (1993-1996). Outcome measures were amputation, nerve damage, and vascular complications. There were 43 patients with 44 peripheral vascular injuries identified. Sixty per cent were from stab wounds. There were 27 arterial injuries (carotid four, subclavian one, vertebral two, axillary three, brachial eight, ulnar one, radial two, femoral five, and anterior tibial one). There were three venous injuries (one each subclavian, axillary, and popliteal). There were 14 combined injuries (vertebral two, femoral nine, and popliteal three). There were no mortalities. Morbidity was limited to patients with lower extremity injuries. In the nine patients with combined femoral vessel injury there were three complications (nerve damage, thrombosed arterial repair, and thrombosed venous repair). In the four patients with popliteal venous injuries there were two complications, both venous thrombosis. Our early arterial patency rate was 97.6 per cent. These data support the hypothesis that general surgeons with trauma experience can provide effective treatment of peripheral vascular injuries. The significance of these findings in improving the image of trauma surgery as a career is discussed.     

Determinates of functional disability after complex upper extremity trauma

This is a retrospective chart review of 71 patients who were operated on for presumed upper extremity arterial trauma between June 1992 and June 1998. Penetrating trauma occurred in 50 (70%) patients, and blunt trauma in 21 (30%). There were 2 innominate, 6 subclavian, 13 axillary, 26 brachial, 5 radial, 6 ulnar, and 6 multiple arterial injuries. There were 7 negative explorations (4 venous injuries, 2 false-positive angiograms, and 1 branch artery injury). In addition to the vascular injury, 44 patients (69%) had another injury in the extremity, including 8 (12.5%) orthopedic injuries, 12 (19%) nerve injuries, and 24 (37.5%) combination nerve and orthopedic injuries. There were three arterial thromboses, one arterial disruption, and four amputations, resulting in a patency rate and limb salvage rate of 94%. Persistent disability was more common in those patients with blunt injury (p = 0.02) and in those patients with associated neurologic and orthopedic injuries (p < 0.05). Full functional recovery was seen in 21 (33%) patients, while some form of disability was noted in the remaining 67%. The magnitude of the concomitant neurologic injury was the major determinate of functional outcome in this patient population. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

Vascular injuries of the axilla.

Between January 1970 and December 1980, 65 patients sustaining 85 vascular injuries of the axillary artery and/or vein were managed at the Ben Taub General Hospital in Houston, Texas. Concomitant injuries of the subclavian and/or brachial vessels were noted in 34 per cent of patients. A variety of exposure techniques was used in approaching the axillary vessels. Emphasis upon preservation of collateral vessels led to an increased use of substitute vascular conduits over end-to-end anastomosis. The ready availability of prosthetic conduits, absence of graft infection, and excellent short-term patency have made them a primary choice for axillary arterial reconstruction in our recent experience. Associated brachial plexus injury (35%) accounted for the most significant long-term morbidity. The operative mortality was 3.1%, and one patient required upper extremity amputation following failure of repeated revascularization attempts.     

臂丛神经合并血管损伤的显微外科治疗

目的 探讨臂丛神经合并血管损伤的诊断,显微外科治疗及临床效果。方法 针对不同损伤部位,采取臂丛神经血管探查,进行神经修复,移植及血管修补和自体静脉及人工血管移植同时修复神经损伤及血管损伤。结果 本组７例,经上述方法处理后患肢血液循环良好,经１年以上随访,部分病例恢复神经功能,优良率为５７．１％。结论明确臂丛神经合并血管损伤的诊断,采用有效的     

Vascular injuries after extremity trauma

The aim of the present examination was to analyse extremity trauma with additional vascular injuries. Between 1973-2000 78 patients with traumatic peripheral vascular injuries have been treated at the Surgical Department of the University Hospital of Mannheim. In addition to clinical examination Doppler-Duplex ultrasonography (cw-Doppler) was routinely performed. In selected cases either conventional or magnetic resonance angiography completed the diagnostic procedure. Vascular injuries to the upper extremities were found in 46.2 % (n = 36) whereas 53.8 % (n = 42) of the patients suffered from trauma of the lower extremities. The popliteal artery was affected in 28.2 % followed by the brachial artery with 23.1 %. 52.6 % of the patients had interposition of autologous vein for reconstruction. Only 7.7 % of the cases needed interposition of alloplastic material. In general the injured extremity was immobilised by external fixation, followed by secondary vascular reconstruction. An efficient trauma management reduced amputation rate as low as 2.6 %.     

An epidemiological view of vascular trauma in Western Australia: a 5-year study

Background : Although Australia encounters vascular injury less frequently than countries such as the USA, the predominance of blunt trauma with associated complex injuries continues to pose problems for clinicians. The present paper reviews Royal Perth Hospital’s experience of vascular trauma epidemiology. Methods : All individuals who presented to the Royal Perth Hospital (RPH) with a vascular injury between August 1994 and January 2000 were identified from a prospective trauma database. Injuries were classified using the Abbreviated Injury Score (AIS 90 code). The five major vascular injury groups as defined by AIS 90 (neck, thorax, abdomen, upper limb and lower limb) were analysed in turn to determine which injuries were most frequent, what the common causes were, effects of alcohol and drugs, common associated injuries, investigations performed, mortality, proportion of rural vascular trauma with transfer details and lengths of hospital stay. Results : During the study period, 153 patients (1% of total trauma workload) sustained 175 vascular injuries. The commonest causes of injury for each group were stabbing (neck and lower limb), motor vehicle accident (thorax and abdomen) and work machinery (upper limb). Mortality was highest for thoracic injury (14/32; 44%) followed by abdominal injury (10/29; 34%). The ratio of blunt to penetrating vascular trauma is high and is increasing, as is the ratio of truncal to extremity vascular trauma. The most common artery–vein combination injury was to the femoral vessels. Conclusions : The injury patterns emerging from the present study will hopefully help all medical personnel to recognize the potential for vascular injury in a trauma setting.     

Lower extremity vascular trauma: a comprehensive, aggressive approach

During this study, 25 patients (26 limbs) incurred 37 vascular injuries to the lower extremity. The majority were young males injured by penetrating trauma (84%). There were 25 arterial and 12 venous injuries (two isolated). Sixteen patients had soft-tissue injuries, 12 had fractures, and six had peroneal nerve damage. Twenty-two arterial injuries were repaired, the majority (17) by saphenous vein bypass. Three tibial vessels were ligated. All major venous injuries were repaired. No synthetic material was used. Vascular repair took precedence in all but two cases. After repair, the vascular surgeon assisted with stabilization. Thirteen limbs required fasciotomy; nine required subsequent debridements and later plastic reconstruction. Limb salvage was 96%. More important, 21 patients can ambulate independently on the injured extremity (84%). These results support an aggressive approach to lower extremity vascular trauma with repair of all major arterial and venous injuries in conjunction with aggressive debridement and soft-tissue repair.     

Traumatische Extremitätenverletzung mit Knochen- und Gefäßbeteiligung: Prioritätentriage, Interdisziplinäres Management

The development of trauma surgery, especially vascular reconstruction in limb-threatening vascular and bone injuries, is closely related to the multiple military conflicts over the past 50 years. In civilians, such trauma surgery is an infrequent but difficult management problem.The aim of an interdisciplinary procedure – with adequate bone stabilization, arterial and venous revascularization (autologous) and soft tissue reconstruction – should be a functional extremity. The time taken for diagnosis, transport and bone stabilization should be as short as possible as time is of predictive value for limb salvage. Our experience with 120 patients who underwent simultaneous bone and vascular surgery for traumatic extremity injuries is reported.The incidence of arterial injury was lower than 1%, limb salvage after bone and arterial reconstruction was between 89 and 95%. The repair rather than the ligation of complex vascular injuries in severe extremity trauma is recommended for limb salvage.An interdisciplinary approach should be used, taking into account soft tissue management (debridement, fasciotomy, soft tissue reconstruction, monitoring). Our trauma management procedure is described.The extremity injury severity scores proved to be of little clinical value.Thus limb-threatening vascular injuries will always be a challenge for interdisciplinary management as well as for the vascular and trauma surgeon!     

Treatment of vascular lesions associated with open fractures]

Vascular injuries associated with open fractures occur rarely, in about 1% of the cases. Brachial and popliteal arteries are the most exposed vessels in combination with humeral, femoral and tibial fractures. Vascular lesions are first diagnosed clinically: hard signs of arterial trauma (for instance, a pulseless extremity) certainly indicate the injury. Soft signs (for instance, a wound adjacent to a great vessel) only suggest the vascular trauma. Doppler signal allows to distinguish an ischemic extremity from a member still perfused by collaterals. Preoperative arteriography is indicated in patients presenting with soft signs of arterial injury. It is also indicated in patients with hard signs when further information can help the plan of reconstruction. Fracture stabilization is generally carried out before vascular repair. Arteries are prepared in healthy segments and, in most cases, a venous bypass is performed. Veins proximal to the tibial trifurcation are sutured. Specific differences between upper and lower limb in the evaluation and treatment of vascular injuries associated with open fractures are mentioned.     

Management of acute and chronic vascular injuries to the arm and forearm. Indications and technique.

Acute arterial injuries of the upper extremity account for half of civilian arterial injuries in the United States. The great majority of these injuries are due to penetrating trauma, with stab wounds and gunshot wounds being the most common cause. The history of the injury and a careful physical examination will identify most injuries. Arteriography should be performed when a vascular injury is suspected but not confirmed by physical examination. Reconstruction of critical vascular lesions is essential for restoration of flow distally. Noncritical lesions may be repaired in most cases, with long-term patency rates averaging 50% to 68%. Although amputation is uncommon after upper-extremity vascular injury, long-term disability can be significant in those patients with concomitant nerve injury. Chronic upper-extremity ischemia may be secondary to atherosclerotic occlusive disease, aneurysms, or arteriovenous fistulas. Angiography will delineate the diseased or occluded arterial segment, allowing bypass to be successful in more than 90% of cases. With careful attention to proper diagnosis and treatment, good to excellent long-term relief of symptoms can be obtained.     

Upper extremity injuries associated with all terrain vehicle accidents: A multicenter experience and case review

BackgroundAll terrain vehicle accidents are a common cause of trauma admission and often associated with extremity injuries. However specifics of injury patterns to the upper extremity has not previously been described. A multicenter, retrospective study was conducted to determine the frequency and distribution of upper extremity injuries sustained from ATV accidents.MethodsMedical records of all patients presenting to two trauma centers with ATV related upper extremity trauma from 2001 to 2013 were reviewed. Patient records and radiographic data were analyzed for detailed extremity injury data. The identified injuries were classified by: anatomic location (shoulder, arm, elbow, forearm, wrist, hand) and structures involved (fracture/dislocation, amputation, nerve, artery, soft tissue). In addition, patient demographic information, length of stay (LOS), airway status, intensive care unit (ICU) stay, Glasgow coma scale (GCS), use of safety equipment, and associated injuriesResultsTwo hundred seventy-seven patients with upper extremity injuries secondary to ATV accidents presented from 2001 to 2013. The frequency and distribution of ATV related upper extremity injuries classified by anatomic location demonstrated 18% of injuries involving the shoulder, 20% arm, 16% elbow, 18% forearm, 40% wrist, and 24% hand, with 30% of patients having injuries that involved more than one anatomic location. Injuries classified by structure involved indicated 73% of injuries were fracture/dislocations, 4% nerve injury, 2% vascular injury, and 36% soft tissue injury.ConclusionThe most common upper extremity injuries experienced in ATV injuries were fractures/dislocations with one third of patients having injuries that involved more than one anatomical location. Less than half of the patients were documented as having worn safety equipment, illustrating a need for increased awareness and enacted of measures to improve safety and prevent accidents.     

Clinical outcome and quality of life after upper extremity arterial trauma

We assessed the long-term clinical outcome of 33 patients treated for arterial trauma of the upper extremity at the Regensburg University Medical Center between 1996 and 2004. Along with clinical parameters, the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Short Form-36 Health Survey (SF-36) score of each patient were collected at the time of follow-up. Findings of the clinical assessment were compared to results obtained with the DASH score and the SF-36 questionnaire. The median follow-up time was 42 months. All arterial injuries had been reconstructed and were open at the time of follow-up. The prevalence of concomitant neural and/or orthopedic injuries was high (24/33, 72%). The influence of neural injury was by far greater than the impact of other factors on the long-term functional outcome. Furthermore, blunt trauma and the need for immediate fasciotomy were further markers for deficient functional recovery. Both the DASH and the SF-36 scores correlated with the clinical assessment of the severity of functional deficits. Upper extremity vascular trauma is almost always associated with severe concomitant orthopedic and/or neural injuries. The involvement of the brachial plexus and the peripheral nerves of the upper extremity is a predictor of worse long-term functional outcome.     

Management of upper limb arterial injury without angiography--Chennai experience

We present our experience and observations in the management of upper limb arterial injury in a tertiary trauma care centre of a University Hospital in a developing country from January 2000 to January 2002. In this retrospective study, we had treated 27 patients (identified from trauma register) with upper extremity vascular injuries. Clinical examination and Doppler pressure studies were our prime modalities of investigation. Angiography was not employed. Our immediate limb salvage rate was 100%. Two patients developed complications during a mean follow up of 70 days with one requiring amputation. We thereby emphasise the fact that good results can be obtained by thorough clinical examination and Doppler evaluation and prompt surgery without the need for angiography in upper limb vascular trauma.     

The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year

All cases of penetrating extremity trauma (PET) seen at an urban trauma center were prospectively studied to determine the accuracy and safety of physical examination as the sole mode of evaluation for vascular injury. All patients with PET producing obvious or "hard" signs of vascular injury underwent immediate surgery. All asymptomatic proximity wounds were observed in hospital for 24 hours before discharge to outpatient followup. Patients with non-proximity wounds were discharged immediately. Patients with shotgun wounds and thoracic outlet injuries also underwent arteriography. Of 2,674 trauma patients evaluated during the 1-year study period, 310 (11.6%) had 366 penetrating extremity wounds, most (71%) occurring in the lower extremities. Gunshots caused most (82%) of the wounds, followed by stabs or lacerations (14.5%), and shotguns (3%). Clinically occult wounds in proximity to major limb vessels were the most common (78%) category of clinical presentation, followed by asymptomatic non-proximity wounds (16%), and wounds producing hard signs (6%). There were two missed vascular injuries, both in the asymptomatic proximity group (0.7% false negatives). Every patient taken immediately to surgery for hard signs had major arterial injury requiring repair, for a 100% positive predictive value for physical examination. No mortality or morbidity were related to protocol management. These results to date support prior reports of a negligible incidence of significant vascular injury following clinically occult proximity PET, and further suggest that the overall predictive value of physical examination of PET for vascular injury approaches 100%.