Periarterial Sympathectomy Salvage of the Acutely Ischemic Hand

ABSTRACT

A 40-year-old woman involved in a motor vehicle accident presented to the emergency room with signs and symptoms of acute left hand ischemia. The mechanism of injury consisted of a severe crushing component limited to a linear zone across the left hand metacarpals. After patient management, and compartment decompressions and stabilization of fractures, an ischemic state persisted that failed to improve after extensive vessel exploration and bathing in vasodilating solutions. Only after extensive peripheral sympathectomy was appropriate flow re-established to the hand. The need to employ periarterial sympathectomy in the acute trauma setting will occur infrequently, but is a valuable tool to have in mind when flow is not re-established after appropriate less invasive measures have failed.

KEYWORD

Acutely ischemic hand - salvage - periarterial sympathectomy

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This article is an interesting case report of crushing injury of the hand associated with vessel problems; it is well written, and has adequate references.

The authors stressed that this case represented the classic features of a pure crushing mechanism, resulting in open metacarpal fractures of four digits. The fractures were treated with intramedullary fixation, and decompression of the intrametacarpal compartments. Despite irrigation of the superficial palmar arch with 4 percent Xylocaine and papaverine, vessel spasm persisted, and ultimately required circumferential sympathectomy from Guyon's canal proximally extending to the level of bifurcation of the common digital arteries, to restore circulation.

The problems of crushing injury were emphasized, in which there is trauma to the vessel, leading to potential spasm or thrombosis from intimal injury. The difficulties in assessing vessel pathology were highlighted, as well as distinguishing between thrombosis and vessel spasm by inspection, or even with the use of the operating microscope. Probably, the ultimate differentiation in distinguishing true spasm or intimal tear, is to resect the vessel after the failure of extensive sympathectomy.

Vessel spasm in acute vessel injury is relatively rare, as the authors pointed out. Very often it is related to small intimal tears and thrombus formation. We should remember that there is no pure crushing injury. Invariably, there are accompanying avulsion and rotational forces (with the exception of sharp and clean amputations). Therefore, the zone of pathology often extends proximally, to involve ``intact'' tissue that is in continuity (vessels, nerves, and tendons). The vessels are often edematous and stiff. Restoration of skeletal continuity and length often stretches the injured vessels and may lead to spasm or thrombosis (note that intramedullary fixation often produces lengthening).

In this case, it was noted that the spasm extended from Guyon's tunnel to the common digital bifurcation. The ulnar artery is relatively fixed at this level. Another factor is that the shape and contour of the wrist are relatively immobile, and the wrist undergoing crushing injury may encounter maximum force.

The authors have presented a very important aspect of a clinical problem (vessel spasm) which is probably more common than clinicians have noted. In addition to vessel trauma, hypothermia, hypovolemia, pain, light anesthesia, vessel tension, hematoma, tissue edema, and compartmental compression are potential and important contributing factors to vessel spasm.