Abstract
A crushed upper limb presents a rare entity seen in trauma patients, often resulting in a significant functional disability. We report a case of a 28-year-old male patient who presented with a crush injury to his upper limb after sustaining a motor vehicle accident. Computed tomography angiography showed an abrupt cutoff of the brachial artery proximal to the elbow joint with no contrast filling distally. Revascularization was successfully done using a saphenous venous graft. This case describes a successful revascularization attempt beyond the golden 6 hours.
Keywords: Brachial artery injury, Crushed limb, Mangled limb, Upper, Venous graft
Crushed upper limb presents a rare entity seen in trauma patients. Upper limb injuries are rarely life-threatening. However, it can result in significant functional disability. The management of a crushed limb is controversial and presents a challenge to any trauma surgeon. Effective management requires a multidisciplinary approach, from initial assessment to surgical intervention and rehabilitation.1, 2, 3 Herein, we present a rare case of crushed upper limb associated with brachial artery injury successfully managed with an interposition graft from the great saphenous vein beyond the golden 6 hours.
Case report
A 28-year-old male patient referred to our facility after sustaining a motor vehicle accident around 11 am. The patient arrived at our emergency department at 5 pm, drowsy but conscious with Glasgow Coma Score of 14. Upon evaluation, he was hemodynamically stable. He had a crushed injury of the left forearm with degloving of the anterior aspect of the forearm and an open distal radius fracture. There was active non-pulsating bleeding. Radial and ulnar arteries were non-palpable, with no audible signal on Doppler. His hand was cold and pale. The motor function could not be assessed properly due to his drowsy state. Laboratory investigation revealed white blood cell count of 21 × 109/L, hemoglobin 10.3 g/dL, creatinine 81 umol/L, creatinine kinase 775 IU/L, and lactic acid 3.9 mmol/L.
Computed tomography scan showed a right hemopneumothorax with multiple right-sided rib fractures, lung contusion, T12 compression fracture, and mesenteric contusion. A computed tomography angiography (CTA) of the left upper limb showed an abrupt cutoff of the brachial artery proximal to the elbow joint with no contrast filling distally, along with a displaced distal radius fracture (Fig 1).
Fig 1.
(A) Contrast tomography angiography showing an abrupt cut off the brachial artery just proximal to the elbow joint with no contrast filling distally keeping with arterial injury; (B) Preoperative x-ray showing distal radius open fracture.
The patient was shifted to the operating room. Intraoperatively, the distal part of the brachial and the proximal ulnar and radial arteries were crushed, with a lost segment involving the proximal ulnar and radial arteries. The median nerve was severely contused with a transected superficial radial nerve. Due to the complexity of the injury and tissue damage, an ipsilateral cephalic vein could not be used as a graft. The decision was taken to harvest a segment of the great saphenous vein, providing adequate length and proper diameter and avoiding further increase in ischemic time. The isolated segment was used as an autologous interposition graft between the brachial and ulnar arteries. Radius fracture was reduced and fixed with K-wire. Debridement was done for all the non-viable tissue, along with primary skin closure. Reconstruction viability was confirmed by a pulsating graft with a good outflow Doppler signal (Fig 2).
Fig 2.
Intraoperative pictures showing interposition venous graft (A) and primary skin closure (B).
Postoperatively, a triphasic signal was audible over the ulnar artery with good capillary refill and saturation of 96% over the middle finger. The third, fourth, and fifth digits had minimal active movement. However, there was no movement of the index and thumb and diminished sensation over the left hand. The patient developed skin necrosis and was managed conservatively until a clear line of demarcation was apparent. He was then taken for debridement and skin grafting (Fig 3). The patient was followed for 3 years postoperatively; he had decreased thumb movement with preserved movement of the remaining digits and no residual pain.
Fig 3.
Postoperative picture showing skin necrosis.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Discussion
A mangled extremity is an extremity with an injury to at least three types of tissue: bone, soft tissue, nerves, and vessels. It is a surgical emergency that often causes a dilemma to the surgeon whether to amputate or to do a limb-saving surgery. Upper limbs have an important role in daily life that artificial limbs cannot substitute as in lower limbs. Thus, amputation has a significant effect on the functional and psychological well-being of the patient. Multiple scoring systems were used to predict the severity of injury and guide the management. However, their role is limited due to the complexity and diversity of injuries. The decision is often individualized for each patient, considering the patient’s age, functional status, hemodynamic stability, extent of injury, and mechanism of trauma.1,4,5
The mangled extremity severity score is the most used to predict the need for amputation in traumatic lower extremity injuries. The score is given considering the patient’s age, the degree of soft tissue injury, and ischemia from arterial injury and shock. A score of 7 or higher indicates the need for amputation. Successful limb salvage of the upper limb in patients with a score of 7 or higher was seen in the literature. This is thought to result from the difference in the arterial anatomy between the upper and lower extremities and ischemic time.4,5
The brachial artery is the most injured artery in the upper extremity. The diagnosis is made clinically based on the presence of hard or soft signs. Hard signs include pulsatile bleeding, absent pulses, expanding hematoma, and palpable thrill. These signs suggest arterial injury and require immediate management without any imaging modality.6 A history of bleeding, injury near an artery, diminished pulses, and sensory or motor deficits represent soft signs that warrant further diagnostic investigation.7
Angiography is the gold standard for diagnosing any arterial injury. It is an invasive procedure with limited use as it is time-consuming, resulting in delayed intervention.2,8,9 Doppler ultrasound is noninvasive and widely available for evaluating brachial artery injuries.8 Ekim et al found that Doppler ultrasound is as sensitive and specific as angiography in identifying brachial artery injuries.2 However, Doppler signals might be present in the setting of arterial injury due to abundant collateral circulation. Therefore, it is considered inadequate in ruling out arterial injury.7,8
CTA is noninvasive and considered the best initial diagnostic modality for a trauma patient. It rapidly provides information on the exact location of the injury and anatomic relations, avoiding delay in the patient's management.8 CTA has the advantage of diagnosing injuries while the patient is scanned for other injuries in the event of major trauma. Active contrast extravasation, pseudoaneurysm, abrupt cutoff, and lack of opacification of an artery, stenosis, or arteriovenous fistula highly suggest arterial injury.6
Delayed referral and management of brachial artery injury beyond the golden 6 hours are common, and successful outcomes are reported in the literature. This supports the decision to perform salvage surgery and revascularization rather than amputation for upper extremity trauma beyond the golden hour.10,11 Various techniques can establish vascular continuity, including primary anastomosis, autogenous graft, and artificial graft. End-to-end anastomosis is preferred if feasible without tension.10 Otherwise, an interposition graft, most commonly a saphenous venous graft, is used for arterial reconstruction.3,12,13
Functional disability is highly dependent on the presence of nerve injury, which is commonly present in association with vascular injury. Primary nerve repair is recommended in patients with transected nerves due to penetrating trauma. However, this is not feasible in patients with blunt or crushed injuries and extensive contamination. Repair is delayed weeks to months after the injury, where the full extent of the injury can be identified.2,14
Conclusion
The management of upper limb crushed injuries is controversial, as no established guideline exists to guide the decision. It is desirable to attempt revascularization for major upper limb arterial injury beyond the golden hour whenever feasible, as amputation will cause major functional limitations that cannot be restored with artificial limbs.
Funding
None.
Disclosures
None.
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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