This case report presents a rare instance of persistent severe vasospasm resulting from a crush injury to the hand with successful use of a periarterial sympathectomy to restore digital flow. The patient was involved in an auto rollover and suffered open fractures of the second through fifth metacarpals, with a comminuted fracture of the thumb proximal phalanx. She presented with severe swelling and ischemia in the hand and fingers. Initial operative treatment was directed at fracture treatment coupled with compartment decompression in the hand, warming of the extremity, and bathing of the vessels in warm solution, 4% lidocaine, and papaverine, without success in restoring distal flow. Therefore, exposure of the superficial vascular arch from the distal ulnar artery to the first webspace was performed to examine the vessels directly. Severe vasospasm was observed without intraluminal thrombosis or adventitial hematoma. Sympathectomy was then performed from Guyon's canal to the level of the proper digital arteries in a sequential fashion, as isolated proximal sympathectomy was unsuccessful in relieving spasm in distal segments. The fingers responded with reperfusion and the patient healed without tissue loss.
Compartment syndrome is a common sequel to severe crush injury in the hand. Severe swelling and tissue edema can easily exceed perfusion pressure in the small interosseous compartments, the thenar space, and the deep palmar space. The hand may lose perfusion, and ischemia in the intrinsic structures in the hand can result quickly as a result of very rapid swelling. Early identification and compartment release through multiple incisions are usually successful at restoring circulation. This case presents an interesting and important case of ischemia in the hand from a crush injury, which was unresponsive to early identification and treatment of compartment syndrome in the hand, presumably from extensive reactive vasospasm in the large vessels proximal to the digital arteries. The absence of any visible damage to the adventia or intima of the vessels suggests that the ischemia resulted from intense tissue damage surrounding the vessels and the action of mediators of tissue injury on sympathetic control of the arteries in the zone of injury. All appropriate measures short of sympathectomy were unsuccessful at restoring flow. Therefore, vasospasm has to be considered the ultimate cause of the ischemia. It is interesting to note that regional sympathectomy was successful only in restoring flow to the vessels in that region, and not within distal regions, unlike the experience with ischemia from systemic processes such as collagen-vascular diseases. This again suggests that the milieu of tissue injury contributes strongly to local vasospasm exclusive of other factors. This case illustrates an important surgical adjunct to the more commonly employed measures used to treat acute digital ischemia in the traumatized hand.
Related Links
Journal of Reconstructive Microsurgery