COMPLICATIONS OF INJURY
Complications of vascular injuries
Missed vascular hand injuries
Ring avulsion injuries range from trivial skin lacerations to arterial or venous disruption to combined injuries in continuity to complete amputation. The zone of injury is usually greater than would be suspected from casual inspection, and combined vascular and skeletal disruption injuries are often not salvageable despite the external appearance of a simple laceration (ringavul.htm). When the ring is completely pulled off the finger in association with a circumferential finger wound, the distal soft tissue envelope is usually severely injured, effectively turning the soft tissue sleeve inside out and irreparably damaging the distal part. For all but the most minor injuries, successful salvage with vein grafts and flaps is unlikely, and even when successful, often results in a stiff, insensate digit.Iatrogenic vascular surgery related hand complications
Partial vascular laceration is the most likely mechanism for persistent uncontrolled hemorrhage, and substantial bleeding may follow a partial venous laceration. As elsewhere, persistent bleeding is better controlled by local pressure than blind clamping, which may result in iatrogenic nerve injuries (clamp.htm). Late effects include pseudoaneurysm, delayed hemorrhage and delayed thrombosis.
Graft harvest: Radial artery harvest for coronary artery bypass may result in hand ischemia or superficial radial nerve injury (AG, BR). The incidence of hand ischemia following radial artery harvest may be reduced by the use of preoperative color duplex scanning in addition to care for physical examination.General complications of upper extremity vascular injuries: Ischemic gangrene, chronic ischemia, intrinsic contractures, traumatic aneurysms, arteriovenous fistula, thrombosis and embolism may occur in the hand as elsewhere following vascular injury. Supracondylar fractures of the humerus may result in brachial artery compression or disruption, and post ischemic reperfusion compartment syndrome of the forearm can follow restoration of arterial flow following either closed reduction or vascular repair. Fasciotomy should be considered if ischemic time exceeds two hours, and should be performed if compartment pressures are elevated.
Dialysis access: Severe hand ischemia occurs in nearly 2 percent of patients undergoing new angio access surgery (AK). This problem is more common in diabetic patients who have had multiple angio access procedures (AI) or who have diabetic neuropathy (BA) . Prompt recognition and treatment is critical to avoid tissue loss and permanent nerve injury. This problem should be suspected when finger pain, numbness or nerve symptoms arise immediately after angio access surgery. Optimum treatment options include ligation of the fistula, intraoperative duplex scanning guided banding (AJ), or distal revascularization-interval ligation. Neurologic symptoms may arise even if critical ischemia cannot be demonstrated, and recovery of nerve function is unpredictable (BA). Direct nerve compression may result from adjacent access materials (vascular.htm) or hematoma around the side of a vascular suture line (BL).
Bypass surgery: Upper extremity ischemia has been reported as a steal phenomena following axillofemoral bypass graft, and due to emboli after thrombosis of an axillofemoral bypass graft (BF, BQ).
Complications of treatment of vascular injuries
Inappropriate use of techniques to control bleeding in the emergency room can add significant injury. Nearly all bleeding in the upper extremity can be controlled by elevation and direct pressure. Tourniquet use in the emergency room should be limited to a few minutes at most, and ideally only by the surgeon who is going to provide the definitive surgical care. Inflating a tourniquet and then waiting for the hand surgeon to arrive in the emergency room is inappropriate, dangerous and limits future treatment options. Similarly, use of local destructive intervention with clamps, ligature or cautery (clamp.htm) by anyone other than the surgical specialist assuming final care of the patient should be strongly discouraged.
Inappropriate primary call to the vascular surgeon for upper extremity hemorrhage is a common problem. Upper extremity hemorrhage is usually best managed by an upper extremity surgeon. Time permitting, the ideal order of repair of the severely injured upper extremity is debridement, skeletal stabilization, musculotendinous repairs, nerve repairs, and then vascular repairs (flow.htm), all under tourniquet control. Such an approach minimizes hemorrhage and allows the most precise primary repairs. Unfortunately, a common scenario is that the bleeding arm is first managed by a vascular surgeon who does not provide definitive care of adjacent nerve and musculoskeletal injuries. In this situation, the vascular injury is repaired, often with a graft, and then the extremity surgeon called in to complete the work. When the adjacent nerve and muscles are then repaired, the vascular "gap" requiring a graft disappears, and the graft may need to be removed to avoid kinking from redundancy. Similarly, performing only vascular repair, closing the wound and referring to patient for secondary repair of adjacent structure may sacrifice the best opportunity to do a precise primary repair of all structures in the most safe and efficient manner.
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