Management of Traumatic Radial and Ulnar Artery Injuries and Risk Factors for Amputation.

INTRODUCTION: Traumatic injuries to the radial and/or ulnar arteries represent a subset of arterial injuries. In the absence of injury to both forearm arteries, treatment was historically ligation if perfusion was maintained to the hand via the uninjured vessels or adequate collateral vessels. We sought to determine management of traumatic forearm arterial injuries in 2019 and to identify risk factors for major upper extremity amputation. METHODS: The American College of Surgeons Trauma Quality Improvement Program database was queried by International Classification of Diseases 10 code for patients with traumatic radial and/or ulnar artery injuries within the year 2019. Patient demographics, Injury Severity Score, time to operating room, type of repair, outcomes, and mortality were collected. Multivariable logistic regression was used to identify risk factors for major upper extremity amputation. RESULTS: A total of 4048 patients with traumatic radial and/or ulnar artery injuries were identified. A total of 1907 radial artery operations were performed including repair (59%), ligation (29%), and interposition bypass (12%). A total of 1637 ulnar artery operations were completed including repair (67%), ligation (21%), and interposition bypass (12%). Major upper extremity amputation occurred in 0.6%. Older age (adjusted odds ratio [AOR]: 1.014, 95% confidence interval [CI]: 1.004-1.024, P = 0.0048), blunt mechanism (AOR: 2.457, 95% CI: 1.730-3.497, P < 0.0.0001), and ipsilateral radial and ulnar artery injury (AOR: 2.148, 95% CI: 1.298-3.553, P = 0.0029) were associated with major amputation. Surgical revascularization, time to operating room, fasciotomy, and compartment syndrome were not associated with major amputation, but this may be secondary to Type II error. CONCLUSIONS: In the operating room, radial and ulnar artery injuries were managed more often with restoration of flow versus ligation. Older age, blunt mechanism, and ipsilateral radial and ulnar artery injury were associated with major amputation. Amputation rate was low at 3% overall and 0.6% for amputation of the hand or a more proximal level. Upper extremity fracture, upper extremity nerve injury, and ipsilateral radial and ulnar artery injury were associated with need for revision operation.

Prospective observational study of clinical outcomes in using posterior interosseous free flap for finger defects.

Finger injuries are common in hand and plastic surgery practice. There are various options for reconstructing finger defects. Moderate sized skin defects of the fingers which need flaps are commonly covered using various abdominal flaps. These conventional workhorse flaps are thick, need two-staged procedures and require the hand to be kept in a cumbersome position. The radial artery or the ulnar artery flap need sacrifice a major vessel. To address the above, we have used the posterior interosseous artery free flap to cover finger defects. This was a prospective observational clinical study done on 15 patients admitted to a tertiary level hospital from July 2017 to July 2021. These patients had accidental industrial injuries with a loss of soft tissue on the fingers. There were finger fractures in 6 cases. These patients underwent posterior interosseous artery free flap cover. The flap size ranged from 6 × 3 cm to 10 × 4 cm. We had to cover the donor defects with skin graft in all our cases. Fourteen out of 15 flaps survived, with loss of one flap due to venous congestion. The mean two-point discrimination was 7.8 mm, with a total active motion percentage of more than 70% in 11 out of 15 cases. The posterior interosseous artery flap is a thin and pliable one stage flap, and may not need further flap thinning either, thereby establishing itself as a single stage procedure and moreover not requiring sacrifice a major vessel.

Evaluations of Repaired Artery Patency in Forearm Wounds Using the Allen Test, Handheld Doppler and Doppler Ultrasonography / Avaliações do lúmen da artéria reparada em lesões do antebraço usando o teste de Allen, Doppler portátil e ultrassonografia com Doppler

Abstract Objective The purpose of the present study was to evaluate the rate of patency in the postoperative period of arterial injuries of the forearm secondary to penetrating trauma. The injuries were subjected to primary repair and examined with the Allen test and a handheld Doppler device, and the results were later confirmed with Doppler ultrasonography. Methods Eighteen patients were included, with a total of 19 arterial lesions, 14 ulnar lesions, and 5 radial lesions; one patient had lesions on both forearms. All patients underwent surgery and three clinical evaluations: the Allen test and assessment of arterial blood flow by a handheld Doppler device at 4 and 16 weeks after surgery and Doppler ultrasonography performed at 12 weeks after surgery. Results At the first clinical evaluation, 77% of the patients had patency based on the Allen test, and 72% had a pulsatile sound identified by the handheld Doppler device. In the second evaluation, 61% of the patients had patency based on the Allen test, and the rate of pulsatile sound by the handheld Doppler device was 72%, similar to that observed 2 months earlier. Based on the Doppler ultrasonography evaluation (~12 weeks after surgery), the success rate for arteriorrhaphy was 88%. Regarding the final patency (Doppler ultrasonography evaluation) and trauma mechanism, all patients with penetrating trauma had patent arteries. Conclusion We cde that clinical evaluation using a handheld Doppler device and the Allen test is reliable when a patent artery can be palpated. However, if a patent artery cannot be located during a clinical examination, ultrasonography may be required.

Resumo Objetivo O objetivo deste estudo foi avaliar a taxa de perviedade pós-operatória de lesões arteriais do antebraço secundárias a traumatismo penetrante. As lesões foram submetidas a reparo primário e examinadas com o teste de Allen e um dispositivo Doppler portátil; posteriormente, os resultados foram confirmados à ultrassonografia com Doppler. Métodos Dezoito pacientes foram incluídos, com um total de 19 lesões arteriais, 14 lesões ulnares e 5 lesões radiais; um paciente tinha lesões em ambos os antebraços. Todos os pacientes foram submetidos à cirurgia e três avaliações clínicas: o teste de Allen e a avaliação do fluxo sanguíneo arterial com um dispositivo portátil de Doppler na 4ª e 16ª semanas após a cirurgia e ultrassonografia com Doppler 12 semanas após o procedimento. Resultados Na primeira avaliação clínica, 77% dos pacientes apresentavam perviedade segundo o teste de Allen e 72% apresentavam som pulsátil identificado pelo Doppler portátil. Na segunda avaliação, 61% dos pacientes apresentaram perviedade com base no teste de Allen e a taxa de som pulsátil ao Doppler portátil foi de 72%, semelhante à observada 2 meses antes. À ultrassonografia com Doppler (cerca de 12 semanas após a cirurgia), a taxa de sucesso da arteriorrafia foi de 88%. Em relação à perviedade final (avaliação por ultrassonografia com Doppler) e mecanismo de trauma, todos os pacientes com traumatismo penetrante apresentavam artérias pérvias. Conclusão Concluímos que a avaliação clínica com um dispositivo Doppler portátil e o teste de Allen é confiável caso a artéria pérvia possa ser palpada. No entanto, a ultrassonografia pode ser necessária em caso de impossibilidade de localização de uma artéria pérvia durante o exame clínico.

Recognition of Laceration of an Aberrant Superficial Ulnar Artery With Intraoperative Allen Test and Primary Repair.

There are variations in anatomy that may alter the vasculature of an individual. This case report demonstrates an abnormal branching pattern of a lacerated ulnar artery and its successful surgical repair. Without proper identification, anatomical variations can negatively impact a trauma patient.

[Accident-related and workplace-related vascular disorders of the hand]. / Unfall- und arbeitsplatzbezogene Erkrankungen der Hand mit gefäßmedizinischem Hintergrund.

BACKGROUND: Limited hand function as the result of occupational exposure or accidental injury could primarily be of vascular origin. Since it is quite rarely seen in the course of routine traumatology, special awareness of this is needed. AIM OF THE PAPER: The occupational diseases hypothenar/thenar hammer syndrome (occupational disease 2114) and vibration-induced vasospastic syndrome (occupational disease 2104) are presented on the basis of their etiological and pathogenetic characteristics, taking aspects of occupational medicine and expert opinion into consideration. DISCUSSION: Blunt force trauma to vascular structures of the hand can damage the tunica intima of the affected thenar or hypothenar arteries. Chronic exposure of the arms, hands and fingers to vibration can lead to the injury of nerve and vascular structures. Thermometry and pallesthesiometry are used in the diagnostics alongside methods of vascular medicine. CONCLUSION: Vascular entities can also play a role in the surgical assessment of the impact of an accident or of an occupational disease after exposure to vibration. Awareness of them can shorten the latency between the onset of symptoms and a definitive diagnosis.

Reparo de lesão vascular não letal causada por tamanduá-bandeira (Myrmecophaga tridactyla) no Brasil / Repair of non-lethal vascular injury caused by giant anteater (Myrmecophaga tridactyla) in Brazil

Resumo O tamanduá-bandeira é um mamífero encontrado na América Central e na América do Sul. Esse animal possui garras que podem chegar a 6,5 cm de comprimento, utilizadas para escavar formigueiros e obter alimento, além de servir para sua defesa. Relatamos o caso de paciente masculino de 52 anos, com histórico de epilepsia, que foi levado desacordado ao pronto-socorro, devido a lesões no seu braço direito causadas por um tamanduá. Frente à suspeita de trauma vascular, o paciente foi submetido a exploração cirúrgica, que evidenciou uma lesão combinada de vasos braquiais, submetida a reparo. Apresentou boa evolução do quadro, recebendo alta hospitalar no segundo dia de pós-operatório e, no seguimento ambulatorial, evoluiu sem sequelas neurológicas ou vasculares.

Abstract The giant anteater is a mammal found in Central and South America. These animals have claws that can reach 6.5 centimeters in length, which they use to dig anthills to obtain food and for defense. We report the case of a 52-year-old male patient with a history of epilepsy who was taken unconscious to the emergency room due to injuries to his right arm caused by an anteater. He underwent surgical exploration to investigate suspected vascular trauma, revealing a combined (arterial and venous) injury of the brachial vessels, which were repaired. He recovered well and was discharged on the second postoperative day. During outpatient follow-up he continued to improve, with no neurological or vascular sequelae.

Traumatic injury of radial and ulnar artery with perfusion of the hand through the median artery: a case report.

CASE DESCRIPTION: A young male patient with a complete section of the ulnar and radial arteries preserved the perfusion of the hand through an anatomical variant, the median artery, identified by angiotomography. CLINICAL FINDINGS: A wound in the distal third of the left forearm with present pulses and adequate hand coloration. An angiotomography of the upper left limb showed a median artery originating as a continuation of the anterior interosseous artery and ending in the palm of the hand with an incomplete superficial palmar arch. TREATMENT AND OUTCOMES: Ligation of both radial and ulnar arteries was performed. It was not possible to follow up the patient. CLINICAL RELEVANCE: Forming the superficial and deep palmar arches, the irrigation of hand comes from the ulnar and radial arteries, which can compromise the viability of the limb when injured. The median artery is present in 0.6-21.1% of the population, originates from the anterior interosseous artery (branch of the ulnar), accompanies the median nerve in its path and ends in the palm joining the superficial palmar arch. Diagnostic imaging is a key tool for assessing arterial circulation and characterizing upper limb vascular lesions. Knowledge of the anatomical variations of the arterial supply of the hand, including variability of the superficial palmar arch, is crucial for the safety and success of hand surgeries.

DESCRIPCIÓN DEL CASO: Un paciente joven de sexo masculino con sección completa de las arterias cubital y radial conservó la perfusión de la mano a través de una variante anatómica, la arteria mediana, identificada por angiotomografía. HALLAZGOS CLÍNICOS: Herida en el tercio distal del antebrazo izquierdo con pulsos presentes y coloración adecuada de la mano. Una angiotomografía del miembro superior izquierdo mostró una arteria mediana que se originaba como continuación de la arteria interósea anterior y terminaba en la palma de la mano con un arco palmar superficial incompleto. TRATAMIENTO Y RESULTADOS: Se realizó la ligadura de las arterias radial y cubital. No fue posible realizar un seguimiento del paciente. RELEVANCIA CLÍNICA: La irrigación de la mano proviene de las arterias cubital y radial, que forman los arcos palmar superficial y profundo, comprometiendo la viabilidad de la extremidad cuando se lesionan. La arteria mediana está presente en el 0.6-21.1% de la población, se origina en la arteria interósea anterior (rama del cubital), acompaña al nervio mediano en su recorrido y termina en la palma uniéndose al arco palmar superficial. El diagnóstico por imagen es una herramienta clave para evaluar la circulación arterial y caracterizar las lesiones vasculares del miembro superior. El conocimiento de las variaciones anatómicas de la irrigación arterial de la mano, incluida la variabilidad del arco palmar superficial, es de importancia crucial para la seguridad y el éxito de las cirugías de la mano.

Hypothenar hammer syndrome and repair of ulnar artery aneurysm in a patient without history of trauma.

The patient is a 50-year-old male with a history of tobacco use presented for evaluation of pulsatile right-hand mass. The patient was employed as a barber but had no known history of trauma or injury. He was diagnosed with hypothenar hammer syndrome and underwent excision of ulnar artery aneurysm with reconstruction of ulnar artery with interposition saphenous vein graft. The presented case describes an uncommon presentation of hypothenar hammer syndrome in a patient without history of repetitive blunt trauma or injury and discusses the diagnosis, pathophysiology and treatment options for symptomatic ulnar artery aneurysm.

A Clampless Technique to Facilitate Successful End-to-End Anastomosis in Small Vessels With Spasm.

End-to-end anastomosis in small arteries can be challenging, especially when the stumps are in spasm after traumatic transection. We describe a novel technique to facilitate such anastomoses under local anesthesia, presenting a 24-year old patient who suffered complete traumatic transection of the left ulnar artery. After having found and prepared the proximal and distal stumps, a soft polyurethane feeding tube (La-med Healthcare, India) and a vein cannula were inserted in the proximal and distal stump, respectively, without using vascular clamps. The manipulation of the catheters offered excellent visualization and widening of the anastomotic line, enabling simultaneous infusion of heparinized saline or vasodilating agents. The anastomosis was completed with no stenosis and pulpable pulses were restored immediately postoperatively. At 1-month follow-up, the Allen test was normal with a normal regular flow of the ulnar artery at duplex ultrasound. The described technique ensures efficient sealing avoiding clamping, casts the small lumens, provides optimal visualization of the anastomotic aspects and prevents stenosis. We believe it should have a place in the surgeon's armamentarium.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Relationship between Serum YKL-40 Level and Forearm Arterial Patency after Repair.

BACKGROUND: The study aimed to assess the effects of serum YKL-40 level on patency at the repair site in patients who underwent arterial repair at the level of the forearm. METHODS: The study included 58 subjects, including 29 patients (aged 18-50 years) who had ulnar or radial artery injury secondary to cut injury to wrist between June 2015 and November 2019 and no comorbid disease and 29 age- and sex-matched healthy controls. The vascular patency was assessed using Doppler sonography in patients who underwent arterial repair at the level of the forearm. The patients were defined as flow failure if the blood flow was ≤50%, and sufficient flow if the blood flow was >50% of those in the synonymous artery on the intact extremity. The YKL-40 level differences in the patient and control groups were compared to those in the sufficient and insufficient flow groups. RESULTS: The patients were stratified into 2 groups based on the presence of sufficient flow. The mean YKL level was 11.96 ± 8.87 in the sufficient flow groups, whereas it was 32.22 ± 15.43 in the insufficient flow groups (p= 0.038). Besides, it was found that each unit of increase in the YKL-40 level increased the likelihood of having flow failure by 1.128. CONCLUSION: Based on our results, it was observed that over-expression of the YKL-40 level has adverse effects on patency following arterial repair.

Maintained Hand Perfusion in the Setting of Radial and Ulnar Artery Transections: A Report of 2 Cases.

CASE: Two otherwise healthy male patients presented with lacerations to the volar distal forearm. Both patients had capillary refill at the fingertips and intact Doppler signals of the palmar arch. Computed tomography angiography revealed cessation of flow in the major forearm arteries at the level of the lacerations, with distal reconstitution from the anterior interosseous artery in both cases and from a branch off the ulnar artery in 1 case. The patients underwent operative exploration, where complete transections of the radial and ulnar arteries were found and repaired. CONCLUSIONS: In patients without arterial disease, contributions from minor forearm arteries can be sufficient for hand perfusion in the setting of radial and ulnar artery transection.

Prospective assessment of function and cold-intolerance following revascularization for hypothenar hammer syndrome.

Ulnar artery revascularization in hypothenar hammer syndrome has repeatedly been shown to reduce ischaemic symptoms, however with varying graft patency percentages. This study prospectively assesses the effect of revascularization surgery with a vein graft using validated questionnaires in seven patients. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Cold Intolerance Symptom Severity (CISS) questionnaires have been used to compare the preoperative and postoperative functionality and cold intolerance. All patients showed improvement in either functionality, or cold intolerance, or both from disabled to nearly normalized levels and resumed their occupation at final follow-up (mean of 28 months). Strikingly this was also the case in a patient with graft stenosis. Patients with the highest preoperative questionnaire scores showed most postoperative improvement. In conclusion, revascularization surgery seems to improve the symptomatology irrespective of graft patency. Questionnaires can be a valuable contribution to quantify and to follow the symptomatology in hypothenar hammer syndrome.

Diagnosis of hypothenar hammer syndrome in a patient with acute ulnar artery occlusion.

A 56-year-old truck driver with a history of tobacco use presented with acute onset digital ischaemia in the ulnar distribution of his dominant hand, associated with severe pain. Occupational exposures included extensive manual labour and prolonged vibratory stimuli. Workup with Doppler and angiography confirmed the diagnosis of hypothenar hammer syndrome (HHS). After the failure of medical management, he underwent ulnar artery thrombectomy with reconstruction and arterial bypass grafting. His pain improved significantly postsurgically, and he was able to return to a normal routine. This case illustrates the classic presentation, examination, imaging findings and management options of HHS. HHS should be considered in patients with digital ischaemia and associated occupational exposures. Diagnosing the condition appropriately allows for optimal management, aiming at minimising symptoms and maximising quality of life.

Hypothenar hammer syndrome: An uncommon cause of secondary syndrome and digital ischemia.

Hypothenar hammer syndrome affects less than 1% of the population, but if the diagnosis is delayed, digital gangrene and critical ischemia can ensue. The condition is caused by injury to the ulnar artery at the level of the hook of hamate when the palm of the hand is repetitively used as a hammer. Injury includes segmental occlusion of the ulnar artery and aneurysmal formation with or without occlusion. Patients with hypothenar hammer syndrome often present with symptoms of secondary Raynaud syndrome; if Raynaud is unilateral, a vascular origin should be suspected and ruled out. Treatment options for hypothenar hammer syndrome include conservative treatment measures, fibrinolysis, or surgical resection and repair, and depend on the specific injury and timing of diagnosis.

[Hypothenar hammer syndrome: A recurrent case report after surgery]. / Syndrome du marteau hypothénarien : à propos d'un cas de récidive après traitement chirurgical.

Hypothenar hammer syndrome is a rare entity secondary to ulnar artery damage in the wrist, affecting mainly those exposed to repeated hand-palm trauma. Surgery is discussed in case of severe symptoms, resistant to medical treatment, and/or when anatomical lesions with emboligenic potential are demonstrated in the radiological exams. In this case, resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after the completion of a surgical treatment. There was an aneurysmal thrombosed vein graft with extensive thrombus extending from the ulnar artery upstream of the Guyon's canal to the superficial palmar arch. The digital revascularization was provided by the radial superficial palmar arch and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed consisting of the resection of the thrombosed zone, including the vein graft, without vascular reconstruction given the good vascularization of all the fingers, and release of the ulnar nerve to the wrist. The operative follow-up was uneventful with the disappearance of pain and sensory-motor deficits. Good digital vascularization was confirmed by imaging at 3 months postoperatively; nerve recovery by electromyogram at 6 months with normal conduction.

[Cold and White - Hypothenar Hammer Syndrome]. / Kalt und weiss ­ Hypothenar-Hammer-Syndrom.

Cold and White - Hypothenar Hammer Syndrome Abstract. Hypothenar hammer syndrome (HHS) is a condition caused by digital ischemia as a result of repeated trauma to the little finger. Routine diagnosis should include a detailed medical history and a physical examination including Allen's test. Imaging of vascular lesions can be done initially by acral plethysmography and duplex sonography, or directly in the context of angiography (gold standard). Early diagnosis enables effective therapeutic strategies and preventing permanent sequelae. The optimal treatment options are selected depending on the intensity of symptoms, ranging from conservative methods, secondary prevention, through a local thrombolysis up to operational measures.

Surgical treatment and functional outcomes of multicomponent soft tissue injuries of the wrist.

The aim of this study was to emphasize the importance of early surgical treatment of multicomponent soft tissue injuries of the wrist. A retrospective review was performed on 156 patients with multicomponent soft tissue injuries of the wrist who were treated between July 2007 and July 2015. All the patients included in the study were operated within the first 36hours of the injury and were hospitalized after the surgery based on the extent of their injury. The patients were evaluated in terms of age, gender, etiology, injured structures, total number of damaged structures, mean follow-up time, complications and reoperation. The results were evaluated based on tendon function, opposition, intrinsic muscles, deformities and sensation. According to these criteria, excellent results were obtained in 81.6% to 88.8% of the patients. Poor results were found in less than 4 percent of the patients. In conclusion, we believe that early surgical management of multicomponent soft tissue injuries of the wrist, a meticulous approach and regular physical therapy are required to achieve good functional outcomes.