Evidence-based Comprehensive Approach to Forearm Arterial Laceration

Abstract

IntroductionPenetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge.DiscussionThe optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury.ConclusionManagement in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.

Endovascular Radial Artery Sacrifice in an Unsalvageable Transradial Access Site Bleeding due to Cutting Balloon Angioplasty

“…Surgical repair of distal radial laceration is known to have limited long term patency of around 50–77% and has the potential risk of associated iatrogenic nerve injury during repair. 5) To this end, simple artery ligation (radial artery sacrifice) is preferred in the presence of adequate palmar collateral circulation. This formed the basis of using coil embolization as an alternative to surgical ligation and has the advantage of being a percutaneous approach.…”

Peripheral Vascular Trauma in Pediatrics: A Case Report and Literature Review

“…For this purpose, direct digital pressure is considered a safe and effective method if applied for a minimum of five minutes without interruption. The use of pneumatic tourniquets at the brachial or antebrachial level is also effective, being applied in children with a pressure between 100 and 200 mmHg, and the technique can also be used with the help of a blood pressure cuff [8]. It should be pointed out that many children with vascular lesions may not show any signs of hemodynamic instability, even after significant blood loss [9].…”

“…It should be pointed out that many children with vascular lesions may not show any signs of hemodynamic instability, even after significant blood loss [9]. Immediate surgical exploration is not necessary in cases where the bleeding is controlled by compression maneuvers and a thorough examination of the limb is performed [8].…”

“…The diagnosis of peripheral vascular injuries is obtained by a systematic and judicious physical examination. At the forearm level, it may be more evident due to the superficial location of the arteries and the presence of hard signs, such as the absence of a distal pulse, auscultation of a murmur or palpating a thrill, as well as paleness and coldness of the limb (Figure 1) [7,8]. In those cases, Doppler ultrasonography and arteriography are indicated, since these signs are related to a high suspicion of vascular injury.…”

“…The radial artery is one of two major blood vessels that supply blood to the forearm and the hand [8]. …”