Clinical Outcome and Quality of Life after Upper Extremity Arterial Trauma

Contemporary management and time to revascularization in upper extremity arterial injury

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.

Approach to mutilating hand injuries

Mutilating hand injuries are a challenge to manage due to the complex nature of the injury and the variety of structures that are damaged. Good results can only be achieved by careful planning and management. The ultimate desired outcome is achievement of a normal function of the hand and upper limb. Mutilating hand injuries occur in a variety of settings and the extent of injury and the prognosis varies according to the aetiology of the injury. The management approach focuses on the attention to the repair and reconstruction of individual parts of the hand including the bones, vessels, nerves, tendons and skin cover. Consistent results can be achieved by early aggressive management of damaged structures followed by regular physiotherapy which are the keystones for restoration of form and function of the mutilated hand.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Patency of arterial repairs from wartime extremity vascular injuries

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.

Approach to mutilating hand injuries

Mutilating hand injuries are a challenge to manage due to the complex nature of the injury and the variety of structures that are damaged. Good results can only be achieved by careful planning and meticulous management. The ultimate desired outcome is achievement of a normal function of the hand and upper limb. Mutilating hand injuries occur in a variety of settings and the extent of injury and the prognosis varies according to the aetiology of the injury. The management approach focuses on the attention to the repair and reconstruction of individual parts of the hand including the bones, vessels, nerves, tendons and skin cover. Consistent results can be achieved by early aggressive management of damaged structures followed by regular physiotherapy which are the keystones for restoration of form and function of the mutilated hand.

Outcomes of digital artery revascularization in pediatric trauma

BACKGROUND

Digit amputation is rare in pediatric trauma but can lead to functional morbidity. The true incidence of digital arterial injury is lacking in the literature, and revascularization techniques are not well-described.

METHODS

Retrospective review of a pediatric trauma registry identified patients with a digital artery injury between July 2008 and December 2013. Isolated vein injuries and arterial injuries proximal to the digits were excluded. Descriptive statistics were used.

RESULTS

Twenty-five subjects met inclusion. Most were male (n=16; 64%) and the median age was 6.8 (IQR: 2.8, 11.1) years. The most common blunt (n=12) trauma was struck/crushed by object (n=4; 33%) and the most common penetrating (n=13) trauma was because of glass (n=9; 69%). All subjects were managed operatively. Initial operations for arterial repair were primary arterial repair (15; 20%), vein graft (7; 28%), thrombectomy (1; 4%), and amputation (1; 4%). Twelve patients (48%) had reported complications at initial follow-up, but only two (8%) had long-term (>24weeks) sequelae.

CONCLUSION

Digital artery injury is rare among pediatric traumas. Functional outcomes after digital artery revascularization are favorable. Primary repair can successfully manage these injuries and vein grafting appears to be a suitable alternative when primary repair is not feasible.

Long-term Patency of Primary Arterial Repair and the Modified Cold Intolerance Symptom Severity Questionnaire

BACKGROUND

The goal of this study was to assess the long-term arterial patency of repaired arteries in the upper extremity and any morbidity resulting from the subsequent occlusion of these vessels. Concurrently, a new questionnaire, the modified Cold Intolerance Symptom Severity (mod CISS) questionnaire, was developed to allow for better assessment of cold intolerance.

METHODS

Thirteen patients who had undergone repair of the radial (4 patients), ulnar (6 patients), brachial (1 patient), digital (1), and an undefined lower arm artery (1) were examined using questionnaires, physical examination, and high-resolution ultrasound.

RESULTS

Outcome measures that were statistically significantly worse in the group of patients who presented with nerve injuries included cold intolerance symptoms, Disabilities of the Arm, Shoulder, and Hand score, Michigan Hand Questionnaire, and grip strength (middle setting on dynamometer). The results from the mod CISS correlated with high statistical significance with the results of the CISS score for the injured hand. Of note, wrist extension was significantly better with patent arteries.

CONCLUSIONS

Sixty-seven percent of arterial repairs remained patent at 6 years (mean) follow-up. The presence of nerve injury has a higher impact on the outcome metrics assessed in this study than arterial patency. Our modification of the CISS score enhances its utility as a survey of cold intolerance.

Disability following combat-sustained nerve injury of the upper limb

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Cite this article: Bone Joint J 2014;96-B:254–8.

Limb Outcome and Mortality in Lower and Upper Extremity Arterial Injury

Objective: To examine the outcomes of lower extremity (LE) and upper extremity (UE) arterial trauma. Methods: Retrospective review of 2008 version of National Trauma Databank. Adult patient with LE and UE arterial trauma was identified and outcomes were compared. Results: There were 8311 cases of extremity arterial trauma and 37% involved the LE. The LE cohort had higher blunt injury (56.2% vs 37.4%; P < .0001). The LE cohort was more likely to require fasciotomy (23.6% vs 6.7%; P < .0001) and amputation (7.8% vs 1.3%; P < .0001). Complication (18.8% vs 5.1%; P < .0001) and mortality rate (7.7% vs 2.2%, P < .0001) were higher in the LE cohort. Regardless of extremity, blunt trauma was associated with higher mortality (4.8% vs 3.8%; P = .03) and amputation (6.7% vs 1.3%; P < .0001). In multivariable analysis, LE arterial trauma was associated with increased mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9; P < .0001) and amputation (OR 4.3, 95% CI 3.2-5.8; P < .0001). Conclusions: Lower and upper extremity arterial injuries have different modes of presentation and outcomes. Lower extremity arterial trauma is more commonly caused by blunt injury and associated with worse outcomes despite more intensive intervention.

Biomedical and psychosocial factors associated with disability after peripheral nerve injury

BACKGROUND

The purpose of this study was to evaluate the biomedical and psychosocial factors associated with disability at a minimum of six months following upper-extremity nerve injury.

METHODS

This cross-sectional study included patients who were assessed between six months and fifteen years following an upper-extremity nerve injury. Assessment measures included patient self-report questionnaires (the Disabilities of the Arm, Shoulder and Hand Questionnaire [DASH]; pain questionnaires; and general health and mental health questionnaires). DASH scores were compared by using unpaired t tests (sex, Workers' Compensation/litigation, affected limb, marital status, education, and geographic location), analysis of variance (nerve injured, work status, and income), or correlations (age and time since injury). Multivariable linear regression analysis was used to evaluate the predictors of the DASH scores.

RESULTS

The sample included 158 patients with a mean age (and standard deviation) of 41 ± 16 years. The median time from injury was fourteen months (range, six to 167 months). The DASH scores were significantly higher for patients receiving Workers' Compensation or involved in litigation (p = 0.02), had a brachial plexus injury (p = 0.001), or were unemployed (p < 0.001). There was a significant positive correlation between the DASH scores and pain intensity (r = 0.51, p < 0.001). In the multivariable regression analysis of the predictors of the DASH scores, the following predictors explained 52.7% of the variance in the final model: pain intensity (Beta = 0.230, p = 0.006), brachial plexus injury (Beta = -0.220, p = 0.000), time since injury (Beta = -0.198, p = 0.002), pain catastrophizing score (Beta = 0.192, p = 0.025), age (Beta = 0.187, p = 0.002), work status (Beta = 0.179, p = 0.008), cold sensitivity (Beta = 0.171, p = 0.015), depression score (Beta = 0.133, p = 0.066), Workers' Compensation/litigation (Beta = 0.116, p = 0.049), and female sex (Beta = -0.104, p = 0.090).

CONCLUSIONS

Patients with a peripheral nerve injury report substantial disability, pain, and cold sensitivity. Disability as measured with the DASH was predicted by brachial plexus injury, older age, pain intensity, work status, time since injury, cold sensitivity, and pain catastrophizing.

Neuropathic pain in patients with upper-extremity nerve injury

PURPOSE

The purpose of this review was to present an analysis of the literature of the outcome studies reported in patients following traumatic upper-extremity (UE) nerve injuries (excluding amputation), to assess the presence of an association between neuropathic pain and outcome in patients following traumatic UE nerve injuries, and to provide recommendations for inclusion of more comprehensive outcome measures by clinicians who treat these patients.

SUMMARY OF KEY POINTS

A Medline and CINAHL literature search retrieved 48 articles. This review identified very few studies of patients with peripheral nerve injury that reported neuropathic pain. When pain was reported, visual analogue or numeric rating scales were most frequently used; standardized questionnaires measuring pain or psychosocial function were rarely administered. Recent evidence shows substantial long-term disability and pain in patients following peripheral nerve injury.

RECOMMENDATION

To better understand neuropathic pain in patients following peripheral nerve injury, future outcome studies should include valid, reliable measures of physical impairment, pain, disability, health-related quality of life, and psychosocial functioning.