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Brimo Alsaman MZ, Sawas MN, Al Mohamad HC, Hajkhalaf FM, Mokresh M, Alerr FM. Successful management of an amputated hand at the distal row level of carpal bones in low-resources country: A case report. Int J Surg Case Rep 2023; 110:108627. [PMID: 37574633 PMCID: PMC10428068 DOI: 10.1016/j.ijscr.2023.108627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION Hand replantation (HR) surgery is a delicate and complex procedure that requires a multidisciplinary team (MT) and specialized equipment, as well as factors such as ischemia time and injury mechanism that can impact the procedure's potential complications and success rate. We present the first case of successful management within a low-resources setting of an amputated hand in Syria. PRESENTATION OF CASE A 20-year-old male presented to the emergency department with an amputated left hand at the distal row of carpal bones (CB) with sharp edges. We first managed the condition by stopping the bleeding and washing the hand with saline. The MT performed a ten-hour surgery to reattach the hand using external fixation and vascular, orthopedic, and neurosurgical procedures. The patient was discharged seven days after surgery and had regular follow-ups for two years and seven months, which showed normal sensory evaluation and mild numbness in the ulnar side of the dorsal side of the palm. DISCUSSION HR surgery is challenging and requires an MT and appropriate equipment. Also, amputated hand management requires a specialized center, which was absent in our settings. Hence, the outcome of the surgery was excellent, considering the traditional and old-fashioned techniques followed to establish such an operation in a low-resources country. CONCLUSION Precise preoperative, intraoperative, and postoperative procedures, besides long-term follow-up, are crucial to ensure HR surgery success and effectiveness, in addition to the patient's recovery.
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Affiliation(s)
| | | | | | | | | | - Fadi Mwafak Alerr
- Cardiovascular Surgery Department, Al-Basel Center for Cardiac Diseases and Surgery, Aleppo, Syria
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2
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Chipman AM, Ottochian M, Ricaurte D, Gunter G, DuBose JJ, Stonko DP, Feliciano DV, Scalea TM, Morrison J. Contemporary management and time to revascularization in upper extremity arterial injury. Vascular 2023; 31:284-291. [PMID: 35418267 DOI: 10.1177/17085381211062726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.
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Affiliation(s)
- Amanda M Chipman
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Marcus Ottochian
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Daniel Ricaurte
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Grahya Gunter
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph J DuBose
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - David P Stonko
- Department of Surgery, 160877Johns Hopkins Hospital, Baltimore, MD, United States
| | - David V Feliciano
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas M Scalea
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jonathan Morrison
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
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Mabarak D, Behzadi F, Yang M, Wozniak A, Patel P, Aulivola B. Concomitant Orthopedic Injury is the Strongest Predictor of Amputation in Extremity Vascular Trauma. Ann Vasc Surg 2023; 91:161-167. [PMID: 36563845 PMCID: PMC10068617 DOI: 10.1016/j.avsg.2022.12.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although the risk of extremity amputation related to an isolated vascular injury is low, it increases significantly with concomitant orthopedic injury. Our study aims to evaluate and quantify the impact of risk factors associated with trauma-related extremity amputation in patients with vascular injury. We sought to determine whether there are other potential predictors of amputation. METHODS A retrospective review of patients with extremity vascular injury presenting to a single level 1 academic trauma center between January 1, 2007, and December 31, 2018, was performed. All patients diagnosed with major vascular injury to the upper or lower extremity were included. Data on patient demographics, medical comorbidities, anatomic location of vascular injury, and the presence of soft tissue or orthopedic injury were collected. The main outcome measure was major amputation of the affected extremity. Major amputation included below-the-knee amputation, above-the-knee amputation, as well as any amputation of the upper extremity at or proximal to the wrist. RESULTS We identified 250 extremities with major vascular injury in 234 patients. Of these, 216 (86.4%) were male and 34 (13.6%) female. The mean age was 32.2 years (range 18-79 years) and mean follow-up was 6.9 (standard deviation: 3.3) years. Just over half of injuries, 130 (52.0%) involved the lower extremity. Forty extremities (29 lower and 11 upper), or 16.0%, of total injured extremities, required major amputation during the follow-up period. Concomitant orthopedic injury was present in 106 of 250 (42%) injured extremities. Using univariable logistic regression models, variables with a significant association with major amputation included older age, higher body mass index, blunt mechanism of injury, concomitant orthopedic injury, soft tissue injury, and nerve injury, and the need for fasciotomy (P < 0.05). In multivariable analyses, blunt mechanism of injury (odds ratio [OR] (confidence ratio {CI}): 6.51 (2.29, 18.46), P < 0.001) and concomitant orthopedic injury (OR [CI]: 7.23 [2.22, 23.55], P = 0.001) remained significant predictors of amputation. CONCLUSIONS Concomitant orthopedic injury and blunt mechanism in the setting of vascular injury are associated with a higher likelihood of amputation in patients with extremity vascular injury. Further development of a vascular extremity injury protocol may be needed to enhance limb salvage. Findings may guide patient discussion regarding limb-salvage decision-making.
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Affiliation(s)
| | | | - Maelee Yang
- Department of Plastic and Reconstructive Surgery, Loyola University Medical Center, Maywood, IL
| | | | - Purvi Patel
- Department of Trauma, Surgical Critical Care, and Burns, Loyola University Medical Center, Maywood, IL
| | - Bernadette Aulivola
- Department of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL.
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Dreizin D, Smith EB, Champ K, Morrison JJ. Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity. Radiographics 2022; 42:E50-E67. [PMID: 35230918 PMCID: PMC8906352 DOI: 10.1148/rg.210092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- David Dreizin
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Elana B. Smith
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Kathryn Champ
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Jonathan J. Morrison
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
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5
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Robla-Costales J, Rodríguez-Aceves C, Martínez-Benia F, Socolovsky M. State of the Art and Advances in Peripheral Nerve Surgery. Adv Tech Stand Neurosurg 2022; 45:245-283. [PMID: 35976453 DOI: 10.1007/978-3-030-99166-1_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This review is intended to describe and actualize the basic knowledge of the three basic entities that affect the peripheral nerve system and can be treated by surgery: nerve trauma, chronic nerve compressions, and tumors.Regarding trauma, emphasis is given on the timing of surgery, given the fact that the moment in which the surgery is performed and the employed microsurgical reconstruction technique are the most important factors in the final result. Open lesions with associated nerve injury should be managed with an early exploration carried out before 7 days. Closed injuries are usually deferred, with few exceptions, from 3 to 6 months after the trauma.In turn, chronic compressions require an appropriate clinical, neurophysiological, and imaging diagnosis. Isolated sensory symptoms can be treated actively though without surgery: motor signs like atrophy should be regarded as a sign for immediate surgery, as a deferred treatment might cause an irreversible nerve and muscular damage. Endoscopic approaches are a valuable tool for treatment in selected neuropathies.Finally, nerve tumors demand a thorough preoperative evaluation, as benign tumors are treated in a very different way when compared to malignant lesions. Benign tumors can usually be safely and completely resected without sacrificing the nerve of origin. When malignancy is confirmed, extensive resection to optimize patient survival is the main objective, potentially at the expense of neurological function. This may then be followed by adjuvant radiation and/or chemotherapy, depending on the nature of the tumor and the completeness of resection attained. The role of nerve biopsy remains controversial, and several modern diagnostic techniques might be helpful.
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Affiliation(s)
| | - Carlos Rodríguez-Aceves
- Neurological Center, The American British Cowdray Medical Center campus Santa Fe, Mexico City, Mexico
| | - Fernando Martínez-Benia
- Department of Neurosurgery, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Mariano Socolovsky
- Department of Neurosurgery, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina.
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Haney LJ, Bae E, Pugh MJV, Copeland LA, Wang CP, MacCarthy DJ, Amuan ME, Shireman PK. Patency of arterial repairs from wartime extremity vascular injuries. Trauma Surg Acute Care Open 2020; 5:e000616. [PMID: 33409373 PMCID: PMC7768973 DOI: 10.1136/tsaco-2020-000616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability. METHODS Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency. RESULTS The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency. CONCLUSIONS Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Lauren J Haney
- Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Esther Bae
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Mary Jo V Pugh
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA,Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Daniel J MacCarthy
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Megan E Amuan
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Paula K Shireman
- Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,Surgery, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Keck KJ, Adams TJ, Day KM. Radial Recurrent Artery: Autologous Patch Graft for Acute Brachial Artery Laceration. Cureus 2020; 12:e10682. [PMID: 33133848 PMCID: PMC7593123 DOI: 10.7759/cureus.10682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/15/2020] [Indexed: 11/06/2022] Open
Abstract
Brachial artery injury is the most common vascular disruption in upper extremity penetrating trauma, usually treated by primary repair or saphenous vein interposition graft. We report the case of a young male who presented after assault with stab wound to the right antecubital fossa, an asymmetric vascular exam, and unknown depth contaminated wound that warranted operative exploration. We performed open exploration through a triangular flap extension of his oblique linear laceration for both exposure and flexor surface scar contracture prophylaxis. Exploration revealed brachial artery laceration with loss of approximately 30% of vessel circumference proximal to the radial and ulnar artery bifurcation. A near-complete transection of the recurrent radial artery was also present, leading to the decision to sacrifice this vessel for use as an autologous patch graft of the injured brachial artery. Distal vascular flow was re-established, and the vessel was slightly ectatic with no evidence of stenosis. Patient suffered no complications and was discharged at post-operative day four after perioperative heparin drip on anti-platelet therapy. Autologous patch grafting in the acute setting is a less-often considered surgical option that is effective for arterial bifurcation reconstruction, which may be employed through the sacrifice of injured and redundant local branch vessels. Patch grafts are commonly utilized in planned vascular surgery, such as carotid endarterectomy, but this is the first report of autologous patch graft to an acute brachial artery injury. By combining knowledge of the lateral arm flap with the plastic surgery principles of "like replaces like", this technique avoids the stenosis associated with primary repair, the multiple anastomoses necessary for interposition grafting, the need for a secondary donor site, and provides a theoretical blood-flow advantage.
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Affiliation(s)
- Kendall J Keck
- Plastic Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Thomas J Adams
- Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Kristopher M Day
- Plastic Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
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8
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Huang AE, Noland SS, Spinner RJ, Bishop AT, Shin AY. Outcomes of Reconstructive Surgery in Traumatic Brachial Plexus Injury with Concomitant Vascular Injury. World Neurosurg 2019; 135:e350-e357. [PMID: 31837496 DOI: 10.1016/j.wneu.2019.11.166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions. METHODS A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular group) and without (control group) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome. RESULTS Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. The vascular group was more likely to have pan-plexus lesions (P < 0.0001), with significantly more associated upper extremity injuries (P < 0.0001). The control group underwent more nerve transfers, whereas the vascular group underwent more nerve grafting (P = 0.003). Complete outcome data were obtained in 139 patients, which included 111 control (43% of all control subjects) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the 2 groups. However, 73% of control subjects had grade 3 or greater postoperative elbow flexion, whereas only 43% of vascular patients achieved this strength (P = 0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (P = 0.004). Shoulder external rotation strength was grade 0 in most patients, with no difference between the 2 groups. CONCLUSIONS Concomitant vascular injury leads to worse functional outcome after reconstructive surgery of traumatic brachial plexus injury.
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Affiliation(s)
- Alice E Huang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shelley S Noland
- Department of Plastic Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Vuoncino M, Soo Hoo AJ, Patel JA, White PW, Rasmussen TE, White JM. Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat. Ann Vasc Surg 2019; 62:98-103. [PMID: 31344461 DOI: 10.1016/j.avsg.2019.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/05/2019] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss. METHODS The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed. RESULTS Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12). CONCLUSIONS The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.
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Affiliation(s)
- Matthew Vuoncino
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Andrew J Soo Hoo
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Jigarkumar A Patel
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Paul W White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Todd E Rasmussen
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD.
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Successful Hand Replantation in a Case of Total Avulsion without Vein Graft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1637. [PMID: 29464166 PMCID: PMC5811296 DOI: 10.1097/gox.0000000000001637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
Abstract
Replantation is the reattachment of a severed body part, with attempts to restore neurovascular and musculoskeletal integrity, function, and aesthetics. On September 7, 1964, the first extremity replantation—a completely amputated hand—by vascular anastomosis technique was successfully performed.1 Soon after, the first replantation of a complete thumb amputation using microvascular anastomosis in a human was successfully conducted by Komatsu et al.2 in 1968. The overall success rate of limb replantation surgery is around 83.2%.3 The mechanism of injury plays a role in the outcome; guillotine amputations—for example—carry a better prognosis than crush amputations.4 We present a case report of a 36-year-old male patient who presented with a total avulsion of the right hand with multiple fracture levels at the level of trans-carpal, distal radius extra-articulation fracture, and total avulsion of the hand. The patient was managed by a multidisciplinary team who were able to reattach his hand successfully with good functional outcome.
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11
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Evans C, Chaplin T, Zelt D. Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed. Emerg Med Clin North Am 2017; 36:181-202. [PMID: 29132576 DOI: 10.1016/j.emc.2017.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Vascular injuries represent a significant burden of mortality and disability. Blunt injuries to the neck vessels can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiography and managed with either antiplatelet medications or anticoagulation. In contrast, patients with penetrating injuries to the neck vessels require airway management, hemorrhage control, and damage control resuscitation before surgical repair. The keys to diagnosis and management of peripheral vascular injury include early recognition of the injury; hemorrhage control with direct pressure, packing, or tourniquets; and urgent surgical consultation.
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Affiliation(s)
- Chris Evans
- Trauma Services, Department of Emergency Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada.
| | - Tim Chaplin
- Department of Emergency Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - David Zelt
- Division of Vascular Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
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Giladi AM, Ranganathan K, Chung KC. Measuring Functional and Patient-Reported Outcomes After Treatment of Mutilating Hand Injuries: A Global Health Approach. Hand Clin 2016; 32:465-475. [PMID: 27712748 PMCID: PMC5061136 DOI: 10.1016/j.hcl.2016.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Understanding the global burden of trauma, particularly upper extremity trauma, is necessary in addressing the need for surgical services. Critical to that mission is to understand, and accurately measure, disability and related disability-adjusted life-years from massive upper extremity trauma. The impact of these injuries is magnified when considering that they frequently occur to young people in prime working years. This article discusses these social and medical system issues and reviews components of a comprehensive approach to measuring outcomes after these injuries. Patient-reported outcomes are highlighted. Methods of optimizing outcomes measurements and studies, disability assessments, and associated research are also discussed.
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Affiliation(s)
- Aviram M Giladi
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Kavitha Ranganathan
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Frech A, Pellegrini L, Fraedrich G, Goebel G, Klocker J. Long-term Clinical Outcome and Functional Status After Arterial Reconstruction in Upper Extremity Injury. Eur J Vasc Endovasc Surg 2016; 52:119-23. [DOI: 10.1016/j.ejvs.2016.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/26/2016] [Indexed: 10/21/2022]
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Davins M, Llagostera S, Lamas C, López S. Role of Temporary Arterial Shunt in the Reimplantation of a Traumatic Above-Elbow Amputation. Vascular 2016; 15:176-8. [PMID: 17573026 DOI: 10.2310/6670.2007.00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although the feasibility of reimplantation has increased greatly with the development of new surgical techniques, long-term functional prognosis is unpredictable. Injury to a major nerve is an important factor in long-term outcome, and prolonged ischemia time also has a negative effect. We present a 26-year-old woman whose right arm was sectioned above the elbow in an accident. The limb presented a complete section, with soft tissue loss of the humeral artery and vein, basilic vein, and cephalic vein. Median and radial nerve tissue was missing, and a supracondylar fracture with substantial loss of the humerus was also observed. During reimplantation surgery, a temporary arterial shunt reduced ischemia time. A venous and arterial bypass was performed, and the 12-month results were good.
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Affiliation(s)
- Meritxell Davins
- Department of Vascular Surgery, Sana Creu i Sant Pau Hospital, Barcelona, Spain.
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15
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Rasulic L, Cinara I, Samardzic M, Savic A, Zivkovic B, Vitosevic F, Micovic M, Bascarevic V, Puzovic V, Mandic-Rajcevic S. Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome. Neurosurg Rev 2016; 40:241-249. [PMID: 27241068 DOI: 10.1007/s10143-016-0755-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/04/2016] [Accepted: 05/11/2016] [Indexed: 11/29/2022]
Abstract
Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.
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Affiliation(s)
- Lukas Rasulic
- Faculty of Medicine, University of Belgrade, Dr Koste Todorovica 4, Belgrade, Serbia. .,Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia.
| | - Ilijas Cinara
- Clinic for vascular and endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Miroslav Samardzic
- Faculty of Medicine, University of Belgrade, Dr Koste Todorovica 4, Belgrade, Serbia.,Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia
| | - Andrija Savic
- Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia
| | - Bojana Zivkovic
- Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia
| | - Filip Vitosevic
- Center for Radiology and MRI, Clinic of Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Mirko Micovic
- Faculty of Medicine, University of Belgrade, Dr Koste Todorovica 4, Belgrade, Serbia.,Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia
| | - Vladimir Bascarevic
- Faculty of Medicine, University of Belgrade, Dr Koste Todorovica 4, Belgrade, Serbia.,Clinic of Neurosurgery, Clinical Center of Serbia, Dr Koste Todorovica 4, Belgrade, Serbia
| | - Vladimir Puzovic
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Stefan Mandic-Rajcevic
- Innovation Centre of the Faculty of Technology and Metallurgy, University of Belgrade, Belgrade, Serbia
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Martins RS, Bastos D, Siqueira MG, Heise CO, Teixeira MJ. Traumatic injuries of peripheral nerves: a review with emphasis on surgical indication. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:811-4. [DOI: 10.1590/0004-282x20130127] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 05/27/2013] [Indexed: 12/12/2022]
Abstract
Traumatic peripheral nerve injury is a dramatic condition present in many of the injuries to the upper and lower extremities. An understanding of its physiopathology and selection of a suitable time for surgery are necessary for proper treatment of this challenging disorder. This article reviews the physiopathology of traumatic peripheral nerve injury, considers the most used classification, and discusses the main aspects of surgical timing and treatment of such a condition.
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Affiliation(s)
- Roberto Sergio Martins
- University of Sao Paulo School of Medicine, Brazil; Hospital do Servidor Publico do Estado de Sao Paulo, Brazil
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17
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A Five-Year Review of Management of Upper-Extremity Arterial Injuries at an Urban Level I Trauma Center. Ann Vasc Surg 2012; 26:655-64. [DOI: 10.1016/j.avsg.2011.11.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/07/2011] [Indexed: 11/24/2022]
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18
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Klocker J, Peter T, Pellegrini L, Mattesich M, Loescher W, Sieb M, Klein-Weigel P, Fraedrich G. Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries. J Vasc Surg 2012; 56:410-4. [PMID: 22560312 DOI: 10.1016/j.jvs.2012.01.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 01/24/2012] [Accepted: 01/30/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this report was to present abnormal posttraumatic cold intolerance in patients that previously underwent repair of arterial injuries after civilian upper limb trauma in our institution. METHODS All patients who underwent repair of arterial lesions after upper limb trauma since 1990 were reviewed, and clinical follow-up studies were performed. Patients were asked to complete the cold intolerance symptom severity (CISS) questionnaire to evaluate presence and severity of self-reported cold sensitivity, and the disabilities of arm, shoulder, and hand (DASH) questionnaire to analyze functional disability. Abnormal cold intolerance was defined as a CISS score over 30. Further analysis included evaluation of epidemiologic, clinical, and perioperative data for factors predisposing to abnormal cold intolerance. RESULTS A total of 87 patients with previous repair of upper limb arterial injuries were eligible to answer the CISS and DASH questionnaires, and 56 patients (64%; 43 men; median age: 31.9 years) completed both. In our cohort, blunt trauma was the predominant cause of injury (n = 50; 89%). Accompanying lesions of nerves (n = 22; 39%) and/or orthopedic injuries (n = 36; 64%) were present in 48 patients (86%). After a median follow-up period of 5.5 years (range, 0.5-19.7), 23 patients (41% of 56) reported on abnormal cold intolerance. Patients with cold intolerance had worse functional results (as measured by the DASH questionnaire; mean ± SD, 42.7 ± 29.7 vs 11.5 ± 23.9; P < .001) when compared with patients without. Cold intolerance was more frequently seen in patients with previous nerve lesion (P = .027) and in proximal injuries (subclavian or axillary vs brachial or forearm arteries: P = .006), but was not correlated to gender, age, involvement of the dominant or nondominant arm, and the presence of ischemia, bone injury, or an isolated vascular injury. CONCLUSIONS Abnormal cold intolerance is frequently seen in patients with a history of arterial repair in upper limb trauma. It is associated with significant functional impairment. Concomitant nerve injury and involvement of the subclavian or axillary artery are the major predisposing factors for development of cold intolerance after upper limb trauma.
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Affiliation(s)
- Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
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Klocker J, Falkensammer J, Pellegrini L, Biebl M, Tauscher T, Fraedrich G. Repair of Arterial Injury after Blunt Trauma in the Upper Extremity – Immediate and Long-term Outcome. Eur J Vasc Endovasc Surg 2010; 39:160-4. [DOI: 10.1016/j.ejvs.2009.11.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 11/17/2009] [Indexed: 10/20/2022]
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20
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Töpel I, Pfister K, Moser A, Stehr A, Steinbauer M, Prantl L, Nerlich M, Schlitt HJ, Kasprzak PM. Clinical Outcome and Quality of Life after Upper Extremity Arterial Trauma. Ann Vasc Surg 2009; 23:317-23. [DOI: 10.1016/j.avsg.2008.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 03/10/2008] [Accepted: 05/08/2008] [Indexed: 11/16/2022]
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21
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Clouse WD, Rasmussen TE, Perlstein J, Sutherland MJ, Peck MA, Eliason JL, Jazerevic S, Jenkins DH. Upper extremity vascular injury: a current in-theater wartime report from Operation Iraqi Freedom. Ann Vasc Surg 2006; 20:429-34. [PMID: 16799853 DOI: 10.1007/s10016-006-9090-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 05/04/2006] [Accepted: 05/05/2006] [Indexed: 11/29/2022]
Abstract
Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.
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Affiliation(s)
- W Darrin Clouse
- 332nd Expeditionary Medical Group (EMDG)/Air Force Theater Hospital, Balad Air Base, Iraq.
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22
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Gilmer-Hill HS, Beuerman R, Ma Q, Jiang J, Tiel RL, Kline DG. Response of GAP-43 and p75 in human neuromas over time after traumatic injury. Neurosurgery 2002; 51:1229-37; discussion 1237. [PMID: 12383368 DOI: 10.1097/00006123-200211000-00019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2001] [Accepted: 06/25/2002] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE GAP-43 and p75 are proteins that promote growth cone and neurite formation, elongation, and arborization in regenerating nerve axons. The objectives of this study were to determine whether GAP-43 and the low-affinity nerve growth factor receptor p75 are elevated in traumatic neuromas and whether there is a correlation between the relative amount of GAP-43 or p75 and demographic characteristics such as time elapsed between injury and repair. METHODS Traumatic neuromas from 21 randomly selected patients were studied, and the charts were reviewed. Specimens were collected at the time of nerve resection and grafting. Immunohistochemical analysis was performed on each sample and normal human nerve with antibodies to GAP-43 and p75. Western blot and computerized gel analyses were performed. RESULTS All neuroma specimens harvested within 13 months of injury exhibited markedly elevated GAP-43 levels compared with normal nerve. Specimens harvested at 14 months or more after injury showed precipitously lower GAP-43 levels, similar to or less than those of normal nerve. The correlation between the amount of intra-axonal GAP-43 and postinjury time interval was statistically significant, P = 0.0038. High GAP-43 levels were also correlated with transection injury, high postoperative sensory grade, and pain. p75 levels were elevated, without consistent variation in our population. CONCLUSION These preliminary data suggest that the expression of intra-axonal GAP-43 may vary over time after injury, remaining elevated for approximately the first year, then decreasing abruptly to normal or subnormal levels. These results correlate with clinical experience, indicating that peripheral nerves should be repaired relatively early if repair is indicated.
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Affiliation(s)
- Holly S Gilmer-Hill
- Department of Neurological Surgery, University of California-Davis Medical Center, Davis, California, USA.
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Brown KR, Jean-Claude J, Seabrook GR, Towne JB, Cambria RA. Determinates of functional disability after complex upper extremity trauma. Ann Vasc Surg 2001; 15:43-8. [PMID: 11221943 DOI: 10.1007/s100160010016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- K R Brown
- Department of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
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25
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Surgical diseases of the great vessels. Curr Probl Surg 2000. [DOI: 10.1016/s0011-3840(00)80019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
The salvage of upper limbs mangled by industrial machinery became possible with the development of predictable techniques of vascular and microvascular anastamosis. Unfortunately, many of these salvaged limbs are associated with fair and poor functional outcomes. The quality of the skeletal fixation can have a substantial effect on the functional outcome and should be a major focus of the limb repair process. Internal plate fixation facilitates wound care and limb mobilization without tethering muscle-tendon units and is safe in the majority of severe upper limb injuries provided that all devitalized tissue is debrided and, if necessary, reconstructed using microvascular tissue transfers. Injury patterns, especially those which involve associated injury of the elbow or forearm ligaments, must be identified and treated appropriately. Internal fixation should restore anatomical alignment and provide sufficient stability to allow immediate active mobilization of the limb without contributing to devascularization of the soft tissues or skeleton.
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Affiliation(s)
- D Ring
- Massachusetts General Hospital, Boston 02114, USA
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Hyre CE, Cikrit DF, Lalka SG, Sawchuk AP, Dalsing MC. Aggressive management of vascular injuries of the thoracic outlet. J Vasc Surg 1998; 27:880-4; discussion 884-5. [PMID: 9620140 DOI: 10.1016/s0741-5214(98)70268-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries. METHODS The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1). RESULTS No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died. CONCLUSIONS The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating.
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Affiliation(s)
- C E Hyre
- Department of Surgery, Indiana University Medical Center, Indianapolis, USA
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