1
|
Ghouri SI, Asim M, El-Menyar A, Afifi I, Abdulrahman Y, Jogol H, Al-Thani H, Rizoli S. Presentations and management of hospitalized patients with upper extremity fractures at a level 1 trauma center: a 5-year observational study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04017-2. [PMID: 38884800 DOI: 10.1007/s00590-024-04017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/31/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Upper extremity injuries (UEIs) are common in the emergency departments, yet they are under-reported in developing countries. This study examined the frequency, injury characteristics, and treatment approaches of upper extremity fractures (UEFs) among hospitalized trauma patients in a nationally representative population. METHODS We conducted a retrospective, observational study including all the hospitalized patients with UEFs in the only level 1 trauma center in Qatar between July 2015 and August 2020. Comparative analyses were performed according to injury mechanisms, severity, and management approach. RESULTS A total of 2,023 patients sustained UEIs with an average age of 34.4 ± 12.9 years, and 92% were males. Motor vehicle crashes (MVCs; 42.3%) were the primary cause of shoulder girdle injuries in 48.3% of cases. Fractures of the radius, ulna, and hands occurred in 30.8, 16.5 and 14.5%, respectively. Young adults were more involved in MVCs and motorcycle crashes (MCCs), while pedestrians who were typically older had a higher rate of humerus fractures. Patients with MCCs had a higher rate of clavicle and ulna fractures. Pedestrians were at risk of serious injuries, with a higher mean injury severity score and lower Glasgow Coma Scale. CONCLUSION Most UEFs patients were young males and mainly affected by MVCs. Shoulder girdle, particularly clavicle and scapula/glenoid fractures, emerged as common injury sites. The study highlighted the potential risk of pedestrian injuries, as reflected in higher injury severity, concomitant injuries, and higher mortality. Future studies are needed to optimize preventive measures by incorporating insights into specific injury mechanisms and patterns of UEIs.
Collapse
Affiliation(s)
- Syed Imran Ghouri
- Department of Surgery, Orthopedic Surgery, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar.
- Department of Clinical Medicine, Weill Cornell Medical College, P.O. Box 24144, Doha, Qatar.
| | - Ibrahim Afifi
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Yassir Abdulrahman
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hisham Jogol
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| |
Collapse
|
2
|
Stefanou N, Mylonas T, Angelis FA, Arnaoutoglou C, Varitimidis SE, Dailiana ZH. Upper extremity vascular injuries: Etiology, management and outcome. World J Crit Care Med 2024; 13:91558. [PMID: 38855274 PMCID: PMC11155511 DOI: 10.5492/wjccm.v13.i2.91558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population. They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations. Their management is challenging since they can lead to disabilities with major socioeconomic effects. AIM To analyze data about the mechanism of injury, the management algorithm and functional outcomes of vascular injuries of the upper extremity. METHODS One hundred and fifteen patients (96 males and 19 females) with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted. Mean patients' age was 33.7 years and the mean follow up time was 7.4 years. Patients with Mangled Extremity Severity Score ≥ 7 and Injury Severity Score ≥ 20, previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded, from the study. RESULTS A penetrating trauma was the most common cause of injury. The radial artery was the artery injured in most of the cases (37.4%) followed by the ulnar (29.5%), the brachial (12.1%) and the axillary (6%). A simultaneous injury of both of the forearm's arteries was in 15.6% of the cases. In 93% of the cases there were other concomitant musculoskeletal injuries of the extremity. Tendon lacerations were the most common, followed by nerve injuries. The postoperative functional scores (full Disabilities of the Arm, Shoulder, and Hand and VAS) had very satisfactory values. CONCLUSION Although vascular injuries of the upper extremity are rare, they may occur in the context of major combined musculoskeletal trauma. Although a multidisciplinary approach is essential to optimize outcome, the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma, excluding isolated vascular injuries, ensures shorter operative times and better functional outcomes.
Collapse
Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
| | - Theodoros Mylonas
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
| | - Fragkiskos A Angelis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
| | - Christina Arnaoutoglou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
| | - Sokratis E Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
| | - Zoe H Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa 41500, Greece
- Department of Hand, Upper Extremity and Microsurgery, IASO Thessalias, Larissa 41500, Greece
| |
Collapse
|
3
|
Yahn C, Haqqani MH, Alonso A, Kobzeva-Herzog A, Cheng TW, King EG, Farber A, Siracuse JJ. Long-term functional outcomes of upper extremity civilian vascular trauma. J Vasc Surg 2024; 79:526-531. [PMID: 37992948 DOI: 10.1016/j.jvs.2023.11.028] [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] [Received: 09/25/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences. METHODS A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed. RESULTS There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months. CONCLUSIONS UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.
Collapse
Affiliation(s)
- Colten Yahn
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Maha H Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Anna Kobzeva-Herzog
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston.
| |
Collapse
|
4
|
Priyadarshini P, Kaur S, Gupta K, Kumar A, Alam J, Bagaria D, Choudhary N, Gupta A, Sagar S, Mishra B, Kumar S. Protocolized approach saves the limb in peripheral arterial injury: A decade experience. Chin J Traumatol 2022:S1008-1275(22)00140-7. [PMID: 36641321 DOI: 10.1016/j.cjtee.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/30/2022] [Accepted: 11/12/2022] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. METHODS This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). RESULTS Out of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. CONCLUSION Over all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.
Collapse
Affiliation(s)
- Pratyusha Priyadarshini
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Supreet Kaur
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Komal Gupta
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Junaid Alam
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Narender Choudhary
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
5
|
Martínez-Quesada JI, Anaya-Ayala JE, Mier y Terán-Ellis S, Miranda-Ramírez M, Arzola LH, Ruben-Castillo C, Aramburo JC, de los Ríos JM, Hinojosa CA. Subclavian-Brachial Bypass for Chronic Limb Threatening Ischemia Associated with an Old Motorcycle Accident. Vasc Specialist Int 2022; 38:14. [PMID: 35712875 PMCID: PMC9204331 DOI: 10.5758/vsi.220012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/15/2022] [Accepted: 05/08/2022] [Indexed: 12/04/2022] Open
Abstract
Chronic limb-threatening ischemia is rarely associated with previous traumatic injury. We present a case of a 28-year-old male with progressive digit ulcers, a weak pulse, cyanosis, and a cold limb. Eight months prior, he had a motorcycle accident resulting in a right clavicle fracture and brachial plexus injury. Computed tomography angiography revealed occlusion of the right subclavian artery near a surgically implanted reduction plate. The patient underwent an open subclavian-brachial bypass with a reversed saphenous vein graft. His postoperative recovery was uneventful. After 3 months, he had a euthermic right hand with a palpable pulse and his ulcers had completely healed. This case reinforces the need for patients with a neurological deficit in the upper extremity caused by blunt trauma to undergo thorough vascular examination to identify potential arterial injury and compromised perfusion.
Collapse
Affiliation(s)
- Jose I. Martínez-Quesada
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Javier E. Anaya-Ayala
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Santiago Mier y Terán-Ellis
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Montserrat Miranda-Ramírez
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Luis H. Arzola
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Christopher Ruben-Castillo
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Juan C. Aramburo
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Jesus M. de los Ríos
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| | - Carlos A. Hinojosa
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubirán, México City, México
| |
Collapse
|
6
|
Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
Collapse
Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
| |
Collapse
|
7
|
American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
Collapse
|
8
|
Abubakar A, Okpechi S. Bilateral vascular repair in a patient with multiple upper extremity injury presenting at a teaching hospital—Case report and literature review. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2020; 10:30-35. [PMID: 35814970 PMCID: PMC9267045 DOI: 10.4103/jwas.jwas_7_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 03/24/2022] [Indexed: 11/18/2022]
Abstract
Penetrating trauma to the upper extremity will usually result in vascular injuries, which mostly also involves nerves and tendons. Morbidity related to upper extremity vascular injuries usually occurs due to the associated injuries of the nerves, tendons, and bone. Early presentation to a trauma centre and prompt intervention will reduce morbidity associated with upper extremity vascular injuries.
Collapse
|
9
|
Allemann F, Heining S, Zelle B, Probst C, Pape HC. Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries. Patient Saf Surg 2019; 13:7. [PMID: 30740144 PMCID: PMC6360674 DOI: 10.1186/s13037-019-0187-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded. Methods We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]). Results A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003).When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion. Conclusions In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities.In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.
Collapse
Affiliation(s)
- Florin Allemann
- 1Department of Trauma, Universitaetsspital, University of Zurich, Raemistr.100, 8091 Zurich, Switzerland
| | - Sandro Heining
- 1Department of Trauma, Universitaetsspital, University of Zurich, Raemistr.100, 8091 Zurich, Switzerland
| | - Boris Zelle
- 2University of Texas Science Center at San Antonio, Floyd Curl Dr., 7703, San Antonio, TX 78229 USA
| | - Christian Probst
- Department of Trauma, Cologne-Merheim Med. Center, Ostmerheimerstr. 200, 51109 Koln, Germany
| | - Hans-Christoph Pape
- 1Department of Trauma, Universitaetsspital, University of Zurich, Raemistr.100, 8091 Zurich, Switzerland
| |
Collapse
|
10
|
Stacy MR, Dearth CL. Multimodality Imaging Approaches for Evaluating Traumatic Extremity Injuries: Implications for Military Medicine. Adv Wound Care (New Rochelle) 2017; 6:241-251. [PMID: 28736684 DOI: 10.1089/wound.2016.0716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 01/08/2023] Open
Abstract
Significance: Military service members are susceptible to traumatic extremity injuries that often result in limb loss. Tremendous efforts have been made to improve medical treatment that supports residual limb function and health. Despite recent improvements in treatment and novel prosthetic devices, many patients experience a wide range of clinical problems within residual limbs that can negatively impact the progress of rehabilitation programs while also impairing functional capacity and overall quality of life. Recent Advances: In addition to existing standard imaging modalities that are used for clinical evaluation of patients suffering from traumatic extremity injury, novel noninvasive imaging techniques are in development that may facilitate rapid and sensitive assessment of various aspects of traumatic extremity injuries and residual limb health. Critical Issues: Despite recent advances, there remains a clinical need for noninvasive quantitative imaging techniques that are capable of providing rapid objective assessments of residual limb health at the time of initial presentation as well as after various forms of medical treatment. Future Directions: Ongoing development of imaging techniques that allow for assessment of anatomical and physiological characteristics of extremities exposed to traumatic injury should greatly enhance the quality of patient care and assist in optimizing clinical outcomes.
Collapse
Affiliation(s)
- Mitchel R. Stacy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher L. Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
- Regenerative Biosciences Laboratory, Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
11
|
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]
|
12
|
Breeze J, Fryer R, Lewis EA, Clasper J. Defining the minimum anatomical coverage required to protect the axilla and arm against penetrating ballistic projectiles. J ROY ARMY MED CORPS 2015; 162:270-5. [DOI: 10.1136/jramc-2015-000453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/02/2015] [Indexed: 11/03/2022]
|
13
|
Paryavi E, Pensy RA, Higgins TF, Chia B, Eglseder WA. Salvage of upper extremities with humeral fracture and associated brachial artery injury. Injury 2014; 45:1870-5. [PMID: 25249243 DOI: 10.1016/j.injury.2014.08.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/14/2014] [Accepted: 08/24/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Humeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate. METHODS We conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation. RESULTS Thirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02). CONCLUSIONS Salvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
Collapse
|
14
|
Park MJ, Gans I, Lin I, Levin LS, Bozentka D, Steinberg D. Timing of forearm arterial repair in the well-perfused limb. Orthopedics 2014; 37:e582-6. [PMID: 24972441 DOI: 10.3928/01477447-20140528-60] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the difference in the outcomes of patients with a well-perfused hand who were taken to the operating room (OR) within 6 hours of forearm arterial injury vs patients who were treated in a semiurgent fashion. A review of 201 consecutive patients who were taken to the OR with forearm-level radial or ulnar arterial injury identified 26 patients who had a well-perfused hand at presentation in whom hemostasis was achieved within 15 minutes with manual pressure and no signs of hemodynamic instability. Outcomes of interest included short-version Disabilities of the Arm, Shoulder and Hand (quickDASH) scores and patient-reported cold intolerance. Of the 26 patients, group 1 included 17 patients who were taken to the OR within 6 hours and group 2 included 9 patients who were taken to the OR in a delayed fashion. Minimum follow-up in both groups was 13 months. Average quickDASH score was 24.5 and 14.1 for groups 1 and 2, respectively. Average time spent in the OR was significantly less in group 2 compared with group 1 (1.7 vs 2.8 hours). In the setting of forearm arterial injury with a well-perfused distal limb, there was no difference in functional outcome in patients taken to the OR emergently compared with those who underwent surgery in a delayed manner. With careful evaluation and monitoring, semiurgent operative repair is feasible and may improve certain aspects of patient care and hospital resource use. Outcome measures in this study support semiurgent treatment of these injuries.
Collapse
|
15
|
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]
|
16
|
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.
Collapse
Affiliation(s)
- Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Tan TW, Joglar FL, Hamburg NM, Eberhardt RT, Shaw PM, Rybin D, Doros G, Farber A. Limb Outcome and Mortality in Lower and Upper Extremity Arterial Injury. Vasc Endovascular Surg 2011; 45:592-7. [DOI: 10.1177/1538574411415125] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Tze-Woei Tan
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Fernando L. Joglar
- Section of Vascular Surgery, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Naomi M. Hamburg
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Robert T. Eberhardt
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Palma M. Shaw
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Alik Farber
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| |
Collapse
|
18
|
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]
|
19
|
Upper extremity arterial injuries: factors influencing treatment outcome. Injury 2009; 40:815-9. [PMID: 19523624 DOI: 10.1016/j.injury.2008.08.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 08/20/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries. METHODS This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed. RESULTS The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p<0.01). CONCLUSION Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability.
Collapse
|
20
|
Franz RW, Goodwin RB, Hartman JF, Wright ML. Management of Upper Extremity Arterial Injuries at an Urban Level I Trauma Center. Ann Vasc Surg 2009; 23:8-16. [DOI: 10.1016/j.avsg.2008.04.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 04/04/2008] [Accepted: 04/28/2008] [Indexed: 10/21/2022]
|