Vascular Upper Extremity Injury 

Updated: Jan 28, 2021
Author: Zubin J Panthaki, MD, CM, FACS, FRCSC; Chief Editor: Joseph A Molnar, MD, PhD, FACS 

Overview

Practice Essentials

The upper extremity is defined as the anatomic region distal to the deltoid muscle. This area is composed of the arm, anatomic structures from the shoulder to the elbow; the forearm, anatomic structures from the elbow to the wrist; and the hand, anatomic structures distal to the wrist.

Vascular trauma of the upper extremity has become increasingly common and can be subcategorized into penetrating trauma, blunt force trauma, and iatrogenic injuries. Vascular trauma can cause a high degree of morbidity, with severe consequences on function.[1] Successful management with good outcomes depends on early diagnosis and prompt intervention. The surgeon must be knowledgeable of the relevant vascular anatomy and of the surgical techniques available to treat upper extremity vascular injuries. In addition, the surgeon must be able to intervene in a systematic approach garnered by a high index of suspicion based upon the mechanism of injury.[2]

Workup in vascular upper extremity injuries

Conventional arteriography (CA) remains the criterion standard for radiologic evaluation of the peripheral vascular system.[3]

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

Management of vascular upper extremity injuries

Conservative, nonsurgical management of arteriographically detected, nonocclusive, and asymptomatic arterial injuries in the upper extremity remains controversial. Injuries such as intimal flaps, vessel narrowing, small false aneurysms, and arteriovenous fistulas in which the artery and its runoff remain intact may be amenable to observation alone.[4]

For surgical repair of peripheral vascular injuries, the operative sequence consists of access, exposure, control, and repair.

Since 1991, an increasing variety of vascular injuries have been found to be amenable to endovascular treatment. Transcatheter embolization with coils can be used to manage selected arterial injuries such as low-flow arteriovenous fistulas and active bleeding from noncritical arteries. Endoluminal repair of false aneurysms, large arteriovenous fistulas, intimal flaps, and focal lacerations has been performed using stent-graft technology.

Although the incidence of compartment syndrome is lower in the upper extremities than in the lower extremities, fasciotomy should be considered with any arterial repair.[1]

History of the Procedure

Early methods for treating bleeding vessels included the use of chemical styptic, cauterization, and ligation. Ligature of major arteries was the mainstay treatment during extremity amputation throughout the 18th century.

The first documented arterial repair of the brachial artery is credited to Hallowell in 1762, acting upon a suggestion by his colleague Richard Lambert in 1759. The method of repair involved the elevation of the edges of the lacerated artery with a half-inch steel pin followed by a figure-of-eight suture about the pin to coapt the arterial walls. The pin and suture were eventually extruded, leaving a viable extremity with a palpable pulse at the wrist. Despite the documented success of this lateral arteriorrhaphy, the procedure fell out of favor for more than a century. It was not until 1886 that Postempski reported a second successful lateral arteriorrhaphy. By 1910, more than 100 cases of lateral arteriorrhaphy and 46 repairs by using end-to-end anastomosis and vein grafts were reported.[5]

Treatment of upper extremity vascular injuries has evolved considerably during wartime conflict. During the US Civil War, options for repair of upper extremity vascular injury failed to exist, resulting in amputation of the affected extremity(s). The mortality rate for upper extremity amputation ranged from 10-40% during that conflict.[6]

Interestingly, ligation of major arteries would remain the mainstay of treatment for upper extremity vascular injuries until the Korean War. Rapid advances in vascular surgery techniques in the 1950s combined with aggressive antibiotic treatment revolutionized the management of wartime vascular injuries. During the Korean War, the overall amputation rate was lowered to 13% compared with 49% in World War II. In Vietnam, the overall extremity amputation rate remained at 13%, but approximately 5% for associated brachial artery injuries. Only 2% of brachial artery injuries required ligation; however, nearly 60% of radial artery and 75% of ulnar artery injuries were ligated during the Vietnam conflict.[7]

In the past several decades, most surgical experience has come from the civilian population. The incidence of vascular injuries has risen due to the increased rates of automobile accidents, firearm-related urban violence, and the expansion of interventional cardiovascular diagnostic and therapeutic procedures.[8] One modern study of upper extremity vascular injury reported a primary amputation rate of 5.7% and a secondary amputation rate (amputation following primary revascularization procedure) of 8.2%.[9] More recent wartime data collected during the Iraqi conflict (Operation Iraqi Freedom) demonstrate an upper extremity amputation rate of 9.3%.[10] This increased rate of upper extremity amputation may reflect the devastating impact of improvised explosive devices (IEDs) rather than changes in surgical techniques and treatment methods.

Using data from The Joint Theater Trauma Registry, one study evaluated the epidemiology of vascular injury in the wars of Iraq and Afghanistan by identifying the categorization of anatomic patterns, management of casualties, and mechanism of injury, including explosive, gunshot, and other injuries. The study found that the rate of vascular injury in modern combat is 5 times higher than in previous wars and varies according to operational tempo, mechanism of injury, and theater of war. Newer methods of reconstruction, including endovascular surgery, are now applied to nearly half the vascular injuries and should be a focus of training for combat surgery.[11]

Epidemiology

Frequency

Upper extremity injuries constitute approximately 40% of all peripheral vascular injuries, with more than 67% resulting from penetrating trauma.[12, 13] Injuries to the brachial artery are most commonly reported; they account for 40-55% of all upper extremity arterial injuries. Injuries to the axillary artery represent 6-23% of upper extremity arterial injuries, and radial and ulnar arterial injuries make up 4-36% of upper extremity arterial injuries.[9, 12, 13, 14, 15]

Modern series continue to demonstrate low mortality rates and upper extremity amputation rates of 0.8-2% for civilian penetrating trauma and 6-24% for civilian blunt trauma.[16] The mortality rate of patients with upper extremity vascular trauma is primarily related to other associated severe injuries (eg, closed-head injuries, intra-abdominal trauma). Morbidity related to upper extremity vascular injuries frequently correlates with associated injuries, such as peripheral nerve injury and/or long bone fracture.

Etiology

The most common cause of upper extremity vascular injury is penetrating trauma secondary to gunshot wounds, stab wounds, and lacerations from broken glass. However, iatrogenic trauma secondary to the widespread use of diagnostic and therapeutic intravascular techniques has also contributed to an increased incidence of upper extremity vascular injury. Although vascular injury following blunt trauma of the upper extremity is less common, it deserves emphasis because it can be easily overlooked unless the clinician maintains a high index of suspicion.[17] This type of injury is more commonly seen after automobile accidents and athletic injuries, most of which result in intimal tears and subsequent thrombosis of the vessels.

Injuries to the axillary artery are occasionally associated with proximal humeral fractures and anterior dislocations of the shoulder. These injuries are also associated with athletes who perform repetitive, high-stress, overhead arm motions.[18] Supracondylar fractures of the humerus or elbow dislocations should raise the suspicion for a possible brachial artery injury. Hypothenar hammer syndrome results from repetitive palmar trauma leading to injury of the ulnar artery as it passes around the hook of the hamate bone in the wrist (see image below for artery anatomy).[19]

Arterial anatomy of the upper extremity. a = arter Arterial anatomy of the upper extremity. a = artery; br = branch.

Presentation

Please see Indications below.

Indications

A thorough history and careful physical examination for signs of vascular injury are the first and most important steps in making the diagnosis. Fractures and dislocations should be reduced before thorough examination of the upper extremity. Clinical signs for the prediction of an arterial extremity injury include both "hard" and "soft" signs.[20]

Hard signs include the following:

  • Active or pulsatile hemorrhage

  • Pulsatile or expanding hematoma

  • Thrill or bruit (suggesting an AV fistula)

  • Evidence of ischemia (pallor, paresthesia, paralysis, pain, and poikilothermia)

  • Diminished or absent pulses

These obvious signs almost always indicate an underlying arterial injury and are indications for immediate surgical intervention.

Soft signs include the following:

  • Moderate hemorrhage occurring at the scene of the injury

  • Stable and nonpulsatile hematoma

  • Proximity of a wound to a major vessel

  • Peripheral neurological deficit

  • Asymmetric extremity blood pressures

  • Presence of shock/hypotension

  • Associated fracture or dislocation

These soft, or equivocal, signs may indicate the need for further evaluation with Doppler studies, CT angiography, contrast arteriography, or surgical exploration to confirm or exclude vascular injury.

Note that a palpable radial pulse does not exclude a proximal vascular injury. The rich collateral networks around the shoulder and elbow in combination with the paired major vessels at the forearm may result in normal physical findings though an underlying arterial injury may be present.

In the hand, the collateral circulation should be objectively assessed by performing a modified Allen's test.[21] The modified Allen's test is performed by applying firm occlusive pressure simultaneously to both the ulnar and radial arteries at the level of the patient's wrist. The patient is asked to clench his/her fist several times during this occlusive period until the palmar skin blanches. The patient is then instructed to unclench the fist avoiding wrist and finger hyperextension (which can lead to falsely abnormal results).[22]

At this point, the ulnar artery occlusive pressure is released while maintaining occlusive pressure on the radial artery. The time required for capillary refill of the palmar skin is noted. The test is then repeated releasing the radial arterial occlusion while maintaining occlusion of the ulnar artery (the inverse modified Allen's test). Return of color to the palmar skin should occur in 5-10 seconds for the test to be considered negative (implying an intact palmar arch).

Based upon this subjective and highly operator-dependent technique, up to 27% of the general population demonstrates a discontinuous palmar arch where direct communication between the radial and ulnar arteries is absent.[23] With the advent of Doppler ultrasonography, diagnostic accuracy of the modified Allen's test has come into question. Jarvis et al found the diagnostic accuracy of the modified Allen's test, compared with ultrasonography, was only 80%, with a sensitivity of 76% and a specificity of 82% occurring with a 5-second recovery time.[24]

Glavin and Jones compared the modified Allen's test with Doppler ultrasonography in 75 patients and found that 80% of all abnormal modified Allen's test results in their study were incorrect.[25] These results would suggest that patients with an abnormal or positive modified Allen's test result should have more objective studies performed to determine the true anatomy of the superficial and deep arterial system in the hand. Despite this, no standard criteria for Doppler ultrasonographic findings that define abnormal hand collateral perfusion are established.

In an effort to address the inadequacies and shortcomings of the modified Allen's test, evaluation of the ulno-palmar arterial arches with pulse oximetry and plethysmography has been described. In a cohort of 1010 patients, Barbeau et al found 1.5% of patients with unsuitable anatomy for transradial cardiac catheterization.[26] Arterial patency can be assessed objectively by monitoring the oxygen saturation and waveform while performing the modified Allen's test. Obvious advantages to this technique are that it does not rely upon the subjective assessment of color change in the palm, it can easily be performed in the operating room, and it can be performed in sedated and obtunded patients without difficulty. Disadvantages to this technique include the theoretical concern that normal pulse oximetry saturation may not ensure adequate tissue perfusion[27] and that plethysmography suffers from the inability to quantify blood flow.[28]

The arterial pressure index (API) or arm-arm pressure index (A-A index) measured with a hand-held Doppler unit is a useful adjunct to the physical examination. The systolic pressure in the noninjured upper extremity (denominator) is compared with the systolic pressure in the injured upper extremity (numerator). Johansen and colleagues found that an API of less than 0.90 had 95% sensitivity and 97% specificity for occult arterial injury.[29] An API of greater than 0.90 had a negative predictive value of 99%.[29]

Relevant Anatomy

Vascular injuries of the upper extremity are defined as those occurring distal to the lateral border of the first rib. The axillary artery is a continuation of the subclavian artery and extends from the lateral margin of the first rib to the lateral margin of the teres major muscle. It is divided into 3 segments by the pectoralis minor muscle and gives off 6 arterial branches that contribute to the rich collateral circulation around the shoulder girdle (see image below). These branches are the superior thoracic, thoracoacromial, lateral thoracic, subscapular, and anterior and posterior circumflex arteries. The close proximity of the axillary artery to the axillary vein and brachial plexus provides the anatomic basis for the development of arteriovenous fistulas and high incidence of concomitant nerve injuries.

Arterial anatomy of the upper extremity. a = arter Arterial anatomy of the upper extremity. a = artery; br = branch.

The brachial artery is a continuation of the axillary artery. It begins at the lateral margin of the teres major muscle and terminates one inch below the elbow crease at its bifurcation. The profunda brachii, superior ulnar collateral, and inferior ulnar collaterals are the main arterial branches of the brachial artery. These vessels provide important collateral circulation around the elbow (see image above). In the distal aspect, the brachial artery lies next to the median nerve. The relatively superficial and exposed location of the vessel makes it highly susceptible to injury.

Within the forearm the brachial artery bifurcates into the radial and ulnar arteries. The main arterial branches, which contribute to the collateral network around the elbow, include the radial recurrent a. originating off the radial artery, the ulnar recurrent a. and the interosseous a. originating from the ulnar artery.

The radial and ulnar arteries course through the forearm and terminate as the deep and superficial palmar arches, respectively. The ulnar artery is the larger of the two vessels and the major source of blood flow to the digits. As mentioned previously, the superficial arch is incomplete in approximately 20% of patients.

 

Workup

Laboratory Studies

Please see Indications section above.

Imaging Studies

Conventional arteriography (CA) remains the criterion standard for radiologic evaluation of the peripheral vascular system.[3]

Advantages to CA include the following:

  • May demonstrate arterial lesions that can undergo sequential endovascular treatment; diagnostic and therapeutic modality

  • Can provide accurate localization of the lesion, which can assist with surgical planning

  • Can distinguish between intimal disruption and spasm through the use of vasodilators

Disadvantages to CA include the following:

  • It is an invasive diagnostic procedure.

  • It is a time-intensive procedure.

  • It requires transfer to a specialized angiography suite for evaluation.

  • It is a costly procedure.

  • Iatrogenic injuries can result, especially contrast-induced nephropathy and arterial access injuries (1-3%).

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

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

Duplex sonography is a portable, rapid, and inexpensive tool that can be as accurate as conventional arteriography. Duplex sonography additionally aids in the diagnosis of major venous injuries. Performed by expert operators, duplex ultrasonography is an accurate and noninvasive study that allows the diagnosis of occult arterial injuries. According to Meissner and colleagues, no major injuries were missed in 60 scans.[30] Fry and colleagues reported that duplex ultrasonography offered 100% sensitivity and 97% specificity for identifying major extremity arterial injuries.[31] The limitations of duplex sonography are its expert operator dependence and the potential for missed injuries due to open wounds, large hematomas, bulky dressings, or splints that hinder access of the ultrasound probe. A recent large cohort study suggests that color-flow duplex sonography is of low yield in the diagnosis of upper extremity vascular injuries.[32]

Helical CT angiography (CTA) is rapidly gaining crucial ground as an alternative noninvasive, diagnostic modality in the management of suspected extremity vascular trauma.[3] Advancements in the scanning technology of helical CT scanners allow acquisition of detailed images that rival those of CA.[33, 34] Current studies suggest that CT angiography (CTA) may replace conventional angiography as the diagnostic study of choice for vascular injuries of the extremities. Sensitivity (95.1%) and specificity (98.7%) of diagnostic CT angiography for the detection of clinically significant extremity vascular injury in blunt and penetrating trauma was noted in one study.[35] In addition to providing high-resolution vascular images comparable to conventional arteriograms (see image below), helical CT scanners can simultaneously provide detailed images of the bone and soft tissue.[36]

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

CTA simplifies the logistics of monitoring the trauma patient with potential extremity vascular injury and eliminates the risks associated with arterial puncture seen with CA. Busquets and colleagues reported 97 cases evaluated for extremity vascular injury with CTA without any missed injury.[3]

 

Treatment

Medical Therapy

Conservative, nonsurgical management of arteriographically detected, nonocclusive, and asymptomatic arterial injuries in the upper extremity remains controversial. Injuries such as intimal flaps, vessel narrowing, small false aneurysms, and arteriovenous fistulas in which the artery and its runoff remain intact may be amenable to observation alone. Frykberg and colleagues reported an 89% rate of resolution or stability of minimal injuries without surgical treatment over 10 years.[37]

Surgical Therapy

Initial evaluation and management

Initial evaluation and management of upper extremity vascular injuries follow the Advanced Trauma Life Support (ATLS) guidelines established by the American College of Surgeons. The management of life-threatening injuries always takes precedence over the management of limb-threatening injuries.

Repair of peripheral vascular injuries

Repair of peripheral vascular injuries remains a challenging task. The operative sequence consists of access, exposure, control, and repair. Temporary vascular control can usually be accomplished with the application of digital pressure or a blood pressure cuff. An attempt to blindly clamp a bleeding vessel is not recommended because of the hazard of injuring peripheral structures such as nerves. For the upper extremity, the patient should be positioned supine with the arm extended and abducted 90°. A contralateral unaffected limb should always be included in the surgical field in the event that an autogenous vein graft is necessary. Incisions in the extremities are designed longitudinally over the injured vessel and are extended proximally and distally as necessary. If initial repair of associated nerve and tendon injuries is not feasible, they should be tagged with sutures or surgical clips for later repair.

Gaining access and exposure without causing iatrogenic injury is a fundamental goal of the operative procedure. The axillary artery is approached through an infraclavicular incision that extends to the deltopectoral groove. Proximal supraclavicular control is sometimes necessary, but resection of the middle third of the clavicle adds little benefit. Endovascular control may be possible when active extravasation is identified during arteriography.[38]

The proximal brachial artery is approached through a medial incision in the upper arm at the groove between the biceps and the triceps. The distal brachial artery and its bifurcation are exposed at the antecubital fossa beneath the biceps tendon through an S-shaped incision.

Distal forearm vessels can be exposed with longitudinal incisions over the course of the artery. Controversy exists with regard to repair of the radial and ulnar artery in the forearm, especially at the level of the wrist. Common sense would dictate that repair of an injured radial or ulnar artery is mandatory if the palmar arch is incomplete or if the ulnar or radial vessel was previously interrupted. However, in a traumatic setting, assessment of the patency or communication of the palmar arches may not be possible.

Review of the literature would suggest that ligation of an isolated radial or ulnar artery is appropriate. Though Rothkopf et al demonstrated an 82% patency rate after repair of single vessels,[39] multiple other studies demonstrate overall patency rates of single vessel repairs at 46-48%.[40] Johnson et al go further to point out that claudication did not result in any of their patients treated with ligation, though hand weakness and cold sensitivity were noted in 50% and 12%, respectively, of those patients who had concomitant nerve injury.[41] These results would suggest that ligation of a single vessel injury at the level of the distal forearm and wrist is appropriate in most situations.

Similarly, a literature review by Schippers et al indicated that in patients with injury to a single forearm artery whose hand remains perfused, no significant difference exists in the prevalence of cold sensitivity between individuals who undergo repair of the artery, with patency maintained, and those in whom the vessel is ligated (or in whom the repaired artery occludes); cold sensitivity rates were 17.27% and 19.82%, respectively.[42]

When both the radial and ulnar arteries are injured, ulnar artery repair takes precedence due to its role as the dominant arterial supply to the hand.

Proximal and distal control should be obtained before the injury is exposed. An intraluminal Foley balloon catheter is a useful adjunct, especially in injuries to the proximal axillary artery. After the artery is exposed and controlled, areas of contusion, subintimal hematoma, and devitalized segments of the vessel are debrided. Gentle thrombectomy with a Fogarty catheter and flushing with heparinized saline solution, proximal and distal in the vessel lumina, are performed subsequently. Systemic anticoagulation is rarely used in acute trauma. Overinflation of the Fogarty balloon should be avoided because this can potentially tear the intima, resulting in thrombosis of the affected vessel. Topical lidocaine or papaverine is useful to relieve spasm, especially in the small vessels of the distal forearm and hand.

Temporary intraluminal shunting with restoration of distal perfusion may also be of great value if associated unstable fractures are present, as it prevents prolonged distal ischemia of the extremity during fixation prior to definitive vascular repair.

The type of vascular repair depends on the extent of arterial damage. Primary repair with an end-to-end anastomosis is performed with a running or interrupted nonabsorbable monofilament suture, depending on the size of the vessel. A meticulous surgical technique must be used to avoid a purse-string effect. If a large gap prevents tension-free repair, reversed saphenous or cephalic-vein autogenous interposition grafts must be used for reconstruction. Although polytetrafluoroethylene (PTFE) grafts have been used successfully in trauma, synthetic conduits should be avoided if possible because they increase the risk for infection and for an inferior patency rate, especially in small vessels. Feliciano and colleagues reported an increased rate of thrombosis with small-bore PTFE grafts.[43]

All repairs must be covered with viable soft tissue, and external compression of the vascular repair must be avoided. Intraoperative completion arteriography must be performed, and palpable distal pulses should be documented after repair. Venous injury to the upper extremity rarely requires repair because the collateral network is extensive. Ligation of the venous injury is typically well tolerated.

Endovascular treatment

Since 1991, an increasing variety of vascular injuries have been found to be amenable to endovascular treatment. Endovascular procedures are effective and decrease morbidity. They are attractive alternatives to standard surgical techniques, which require wide exposure and dissection, especially in proximal injuries. Transcatheter embolization with coils can be used to manage selected arterial injuries such as low-flow arteriovenous fistulas and active bleeding from noncritical arteries. Endoluminal repair of false aneurysms, large arteriovenous fistulas, intimal flaps, and focal lacerations has been performed using stent-graft technology. Castelli and colleagues reported a 100% immediate success rate in managing 9 axillosubclavian arterial injuries.[44] However, careful patient selection must be emphasized.[45] Studies monitoring the long-term patency of these stent-grafts are still needed.

Management of compartment syndrome

Although the incidence of compartment syndrome is lower in the upper extremities than in the lower extremities, fasciotomy should be considered with any arterial repair.[1] The clinical manifestation of reperfusion injury and increased fascial compartment pressure must be identified promptly and treated aggressively. Compartment syndrome is caused by increased pressure in the fascial compartment that results in muscle and nerve ischemia.[2] Early physical findings and symptoms suggestive of compartment syndrome include extreme pain that is disproportionate to the level of injury and increased pain with passive movement of the affected compartmental muscles. Other suggestive though less reliable signs and symptoms of compartment syndrome include paralysis, paresthesia, pallor, swollen compartments, and decreased sensation.

Pulselessness of the extremity is a late and unreliable sign of compartment syndrome, as pulses are commonly present during the early stages of compartment syndrome. Normal tissue pressure is generally agreed to be less than 10 mm Hg. Many authors recommend fasciotomies when the tissue pressure is 10-30 mm Hg less than the diastolic blood pressure. When borderline tissue pressure measurements exist, serial examinations should be conducted at one-hour intervals. Repeat examinations should be conducted by the same examiner in an effort to maintain consistency of the readings. If tissue pressure 10-30 mm Hg less than the diastolic pressure occurs, then fasciotomy should be performed.[46]

The upper extremity includes the compartments of the arm, forearm, and hand. The arm has 2 compartments: anterior and posterior. The forearm contains 3 compartments: the volar, dorsal, and mobile wad compartments. The hand contains 4 compartments: the central, thenar, hypothenar, and interossei compartments.

Straight lateral and medial incisions are used to decompress the anterior and posterior arm compartments, respectively. Dorsal and volar incisions are used in the forearm. The dorsal incision should be straight, whereas the volar incision should follow a lazy S-shape to avoid scar contracture. The incision may extend over the midproximal wrist to decompress the carpal tunnel at the same time. Five incisions are typically used to decompress the hand: 2 incisions placed on the dorsum of the hand over the 2nd and 4th metacarpals, 1 volar incision over the carpal tunnel, and 2 volar incisions, one each on the thenar and hypothenar eminences, respectively.

Complications

Occlusion and bleeding from thrombosis are common early complications in the postoperative period. These complications necessitate an immediate reoperation.

Muscle edema that increases compartmental pressure is another complication of vascular injury; pain is the most important symptom. Decompression of the fascial compartments (fasciotomy) is performed to treat this process (see image below).

Decompression of fascial compartments (fasciotomy) Decompression of fascial compartments (fasciotomy).

Nerve injury that causes motor or sensory deficits is another complication that may lead to limb disability. Tissue death and necrosis are complications of prolonged vascular compromise and limb ischemia (see image below).

Prolonged limb ischemia resulting in tissue necros Prolonged limb ischemia resulting in tissue necrosis.

Amputation of the necrotic part is usually the method of treatment (see image below).

Amputation of a hand because of tissue necrosis. Amputation of a hand because of tissue necrosis.

Another serious complication of vascular injury is infection, which requires immediate debridement and antibiotic treatment. Late complications of arterial injury include arteriovenous fistulas and false aneurysms. These complications are usually managed with operative repair.

Outcome and Prognosis

The prognosis of patients with upper extremity vascular injury is typically good but depends on early and aggressive diagnosis and repair of the injured vessels in a timely, tension-free manner. Vigilant monitoring for compartment syndrome with early fasciotomies can prevent long-term disability and promote full functional recovery. Long term follow-up studies in children who underwent vascular reconstructions of the upper extremity showed similar-sized limbs and blood supply.[47] However, they did have a high incidence of asymptomatic enlargement of the reconstructed arteries.[47] Lastly, many of these patients with arterial reconstruction of the upper extremity can suffer from cold intolerance long term, which can be problematic.[48]

A retrospective cohort study by Prieto et al indicated that in children aged 16 years or younger with upper or lower extremity vascular trauma, limb salvage rates tend to be higher at hospitals with American College of Surgeons (ACS) trauma center verification than in those without ACS-verified trauma centers.[49]

A study by Frech et al found that long-term patency was common, but that functional impairment was as well, in patients who underwent upper extremity arterial repair for civilian upper limb injuries. At median 5.3-year follow-up in 65 patients, 97% exhibited patency. However, the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure questionnaire, answered by 57 patients, revealed a high rate of functional impairment, predicted by neurologic injury and by ischemia at the time of injury.[50]

A retrospective study by Asensio et al indicated that in patients with brachial artery injury who do not require emergency department thoracotomy, factors associated with survival include the Glasgow Coma Scale score and Injury Severity Score, as well as estimated blood loss.[51]

In a study of the long-term results of vascular reconstruction in patients with hypothenar hammer syndrome, Endress et al found that 14 out of 18 grafts (78%) were occluded after a mean postoperative period of 118 months. The study involved 16 patients, in whom a total of 18 vein graft reconstructions of the ulnar artery were performed. Although patients with a patent reconstruction had significantly better outcomes with regard to cold intolerance and pain severity than did the other patients, patient scores associated with patent or occluded grafts did not differ statistically on the Disabilities of the Arm, Shoulder and Hand questionnaire.[52]

A study by Alves et al indicated that interpositional vein grafting via microsurgery can effectively repair pediatric brachial artery injuries. At median 1.75-year follow-up, all 10 children in the report had perfused hands with palpable radial pulses. In each patient, the injured limb at follow-up did not significantly differ from the uninjured limb with regard to motion, sensibility, and strength. Arterial patency and normal flow patterns were present in nine patients (90%), while the patient who experienced graft occlusion demonstrated collateralization around the elbow, with the distal vessels undergoing normal reconstitution.[53]

A study by Wegmann et al suggested that in cases of vascular compromise caused by supracondylar humeral fracture, patients who, after fracture reduction, have a pulseless hand with good capillary refill time may benefit from a strategy of “watchful waiting” rather than vascular surgery. The study included 14 pediatric patients who remained without peripheral pulse following fracture reduction. Although four of the patients (three of whom had prolonged peripheral capillary refill times) underwent vascular surgery, watchful waiting was used in the remaining 10 patients, with blood flow having recovered in all 10 of them by 2- to 6-year follow-up.[54, 55, 56]

Future and Controversies

Treatment of upper extremity vascular injuries has evolved over the past 200 years from mandatory amputation to complex procedures that allow the reconstruction and revascularization of the injured extremity. Functional recovery from devastating vascular injuries of the upper extremity is the norm rather than the exception today. Despite this, technological advances continue to be made that will allow modern surgeons to improve patient outcomes in regards to vascular injuries of the upper extremity. Drug-eluting stents to prevent vessel thrombosis, pharmacologic treatments to prevent ischemia-reperfusion injury and implantable continuous monitoring devices to detect flow abnormalities are a few of the technological advances under investigation and research at this time.

Perhaps, one or all of these advances will allow surgeons to treat upper extremity vascular injuries with decreased morbidity and improved functional outcome. Until then, rapid diagnosis, prompt treatment, and hypervigilant monitoring for compartment syndrome will remain the standard of care for these potentially devastating injuries.