Management of upper extremity arterial penetrating vascular trauma.

Penetrating vascular injuries in the upper extremity are relatively uncommon; suboptimal treatment may result in significant morbidity including amputation. Arterial trauma accounted for 68% of amputations (24% in the upper extremity) during World War II. Although surgical techniques including microsurgical principles have matured, results vary secondary to the mechanism of injury, systemic factors, anatomic considerations and physiologic events. This annotated review article is based upon the literature and the author's 42 years of vascular trauma experience including over 1500 revascularizations and replantations. It discusses the complex interplay of associated injuries; the mechanism of injury, the location of the injury; the collateral circulation; the extent of soft tissue damage; the adequacy of debridement; the significance of pre-existing conditions; and magnitude of wound contamination. Based upon this evaluation, a guide to indications for arterial reconstruction is provided and a comprehensive management plan for vascular trauma may be derived.

Management of venomous snakebite injury to the extremities.

Pit vipers (subfamily Crotalinae) are responsible for most venomous snakebites in the United States. The mixture of proteins with cytotoxic, proteolytic, and/or neurotoxic enzymes in snake venom varies by species. Treatment in the field consists of safe identification of the species of snake and rapid transport of the patient to the nearest health care facility. Swelling, bruising, and systemic symptoms are seen following snakebite. Most patients respond to elevation of the affected extremity and observation. Some require the administration of antivenin. Crotalidae Polyvalent Immune Fab (Ovine) (CroFab, BTG International, West Conshohocken, PA) antivenin is safe and effective for the management of local and systemic effects of envenomation. Rarely, compartment syndrome may develop in the affected limb because of edema and tissue necrosis. Close monitoring of the extremity via serial physical examination and measurement of compartment pressure is a reliable method of determining whether surgical intervention is required.

Complex regional pain syndrome after hand surgery.

Complex regional pain syndrome (CRPS) after an emergent or elective upper extremity surgery may complicate recovery, delay return to work, diminish health-related quality of life, and increase the likelihood of poor outcomes and/or litigation. CRPS after hand surgery is not uncommon and may complicate postoperative care. Early diagnosis and treatment of CRPS is critical for optimal patient outcomes. This article discusses the diagnosis, physiology, and management of postsurgical CRPS that occurs after hand surgery.