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21 • Upper Extremity and Junctional Zone Injuries 255
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8. Endovascular repair of upper extremity vascular injury
is now possible with reasonably good early results, particularly in proximal or central injuries.
9. Liberal use of Duplex ultrasound as a means to surveille the repair is recommended.
10. Elevation of the extremity, early rehabilitation, and
antithrombotic therapy are important in the postoperative care after revascularization for upper extremity
trauma.
TEMPORARY VASCULAR SHUNTS IN UPPER
EXTREMITY VASCULAR INJURY
Traditionally, the operative strategy for extremity vascular
injury was guided by the dictum “life over limb.” In the wars
in Afghanistan and Iraq, experience with damage control
resuscitation and damage control surgery have shown that
in many instances of mangled extremity it is possible to save
both life and limb. An understanding of damage control
adjuncts such as temporary vascular shunts and a methodical evaluation of complex extremity injuries can assist in
minimizing morbidity and mortality while attempting to
maximize functional outcomes in these scenarios.
Temporary shunts can allow for rapid restoration of distal arm perfusion when immediate vascular reconstruction
is not possible (Fig. 21.2).
32–40
Delays in vascular repair may
result from a need for xation of an associated fracture,
débridement of a soft tissue wound, or even harvesting and
preparing vein conduit. Vascular injury repair may also
need to be postponed while more serious, life-threatening
injuries are managed. Finally, if there is not time or the
clinical expertise at the initial operation, delayed repair of
the injury may be necessary. In any of these cases, and as
discussed in a dedicated chapter of this textbook, placement
of a temporary vascular shunt may be indicated as a means
to restore perfusion and buy time until formal repair can be
accomplished.
MANGLED EXTREMITY SCORES IN UPPER
EXTREMITY VASCULAR TRAUMA
A mangled extremity is dened as an injury involving soft
tissue, bone, nerve, and vasculature. Determining which
patients and mangled upper extremities will benet from
aggressive attempts at limb salvage and which would be better served with primary amputation is challenging. Exhaustive efforts at limb salvage in severely injured patients may
result in misdirection of care, whereas premature extremity
amputation may preclude optimal functional outcome.
Scoring systems have been developed to take into consideration concomitant injuries, as well as the degree and nature
of the bony, soft tissue, the nerve features, and the vessel
features of extremity injury. These systems are designed to
assist in decision-making during the early phases of mangled limb management and to provide a mechanism to do
comparative retrospective studies of extremity injury.
These systems could theoretically discern between those
extremities in which salvage will be successful and those
in which up-front amputation is most appropriate. The use
of scoring systems, such as the Mangled Extremity Severity
Score (MESS) (Table 21.2), Mangled Extremity Syndrome
Index (MESI) (Table 21.3), Predictive Salvage Index (PSI),
41,42
Fig. 21.2 Brachial artery temporary vascular shunt used to maintain
distal perfusion while orthopedic fixation was performed to bring the
humerus to length.
Table 21.2 Mangled Extremity Severity Score (MESS).
Variable Injury Assessment Points
Skeletal Low energy (stab; simple fracture; civilian
Limb ischemia Pulse reduced or absent but perfusion
Shock SBP always >90 mm Hg 0
Age (years) <30 0
a
Score doubled for ischemia time >6 hours.
GSW, Gunshot wound; SBP, systolic blood pressure.
Adapted from Johansen, et al. Objective criteria accurately predict
amputation following lower extremity trauma. J Trauma. 1990;30:568–572,
discussion 72–73.
GSW)
Medium energy (open or multiple
fractures, dislocation)
High energy (close-range shotgun or
military GSW; crush injury)
Very high energy (above + gross
intact
Pulseless; paresthesias; diminished
capillary refill
Cool; paralyzed; insensate; numb 3
Transient hypotension 1
Persistent hypotension 2
30–50 1
>50 2
and Limb Salvage Index (LSI), has been evaluated and each
system’s ability to predict limb-salvage and functional outcome assessed.
mangled upper extremities, but the MESS has also been retrospectively applied to upper extremity injuries.
42–44
Only the MESI was proposed to evaluate
41,45–47
The most robust validation studies of mangled extremity scores focused on the lower extremity, and caution is
advised in applying the MESS to upper extremity inju-
42,47
ries.
However, the simplicity of determining the MESS
(evaluation of four clinical variables—skeletal/soft-tissue
1
2
3
4
a
1
a
2
a
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Table 21.3 Mangled Extremity Syndrome Index (MESI).
Variable Injury Assessment Points
Injury severity
score
Integument Guillotine 1
Nerve Contusion 1
Vascular Artery transection 1
Bone Simple fracture 1
Lag time 1 point for every hour >6 hours
Age 40–50 1
Preexisting disease 1
Shock Systolic blood pressure <90 2
0–25 1
25–50 2
>50 3
Crush/burn 2
Avulsion/degloving 3
Transection 2
Avulsion 3
Artery thrombosed 2
Artery avulsed 3
Venous injury 1
Segmental fracture 2
Segmental-comminuted fracture 3
Segmental-comminuted with bone
loss <6 cm
Segmental fracture intra-extra
articular
Segmental fracture intra-extra articu-
lar with bone loss >6 cm
Bone loss >6 cm Add 1
50–60 2
60–70 3
4
5
6
injury, limb ischemia, shock, and age) has resulted in its
use in assessing upper extremities for viability. Slauterbeck
et al. reported on 43 upper extremity injuries, and found all
9 arms with a MESS of greater than or equal to 7 were primarily amputated, whereas a score of less than 7 resulted in
successful limb salvage.46 Durham et al. also evaluated the
application of limb-salvage scores for both upper and lower
mangled extremities and concluded MESS and MESI both
decently predicted upper limb salvage (MESI Sn = 100%,
Sp = 67%, PPV = 90%, NPV = 100%; MESS Sn = 78%,
Sp = 100%, PPV = 100%, NPV = 60%).45 Interestingly,
the authors concluded that these scores did not accurately
predict functional outcome, emphasizing that limb viability
and limb function are related but not the same.
The application of MESS to combat-related upper extremity injury has been published from experiences during the
wars in Iraq and Afghanistan. In a combination of 17 upper
and 43 lower extremity injuries, Rush and colleagues suggested a MESS of 7 or greater predicted limb loss.48 In a propensity-adjusted, multivariate analysis of 64 shunted versus
61 matched, non-shunted arterial extremity injuries with
nearly 2-year follow-up, Gifford conrmed the delity of the
MESS.49 This case-control study included 35 upper extremity injuries and 90 lower extremity injuries. No difference
in amputation-free survival was seen in extremities with
MESS scores less than 4. However, graduated reductions
in amputation-free survival were observed in patients with
a MESS of 5 to 7 (relative risk [RR] 3.5; 95% condence
interval [CI] 0.97–12.4; P = .06) and a MESS of 8 to 12
(RR 16.4; 95% CI 3.79–70.98; P < .001).
Collectively, we believe that mangled extremity scores
serve as objective reminders of subjective clinical experience. They provide cues to the nuances leading to either limb
salvage, or limb loss in severely injured extremities, and provide general guidelines. However, their clear and unquestioned use as indicators of whether an upper extremity
should be primarily amputated remains to be proven, and
the expertise and opinion of the evaluating surgical team
remains most essential in the approach to management.
Surgical Management for Upper
Extremity Vascular Injury
Although hemorrhage and ischemia are the key determinants indicating the need for intervention and repair, a
deeper understanding of the presentation and diagnostic
nuances of the different upper extremity arteries is necessary. This knowledge allows one to optimize decisions,
including in situations where nonoperative management
may be appropriate. Unstable patients should be taken to
the operating room. Those with normal vital signs and no
signs of bleeding may undergo further diagnostic imaging
to better inform their treatment. Chest x-ray can reveal a
fractured rib(s) or clavicle(s) and hemopneumothoraces,
and provide information about the mediastinum. Bilateral arm pressures using continuous wave-Doppler (i.e.,
measurement of an injured extremity index) functions
as an extension of the physical examination that allows
diagnosis of arterial injury. In a hemodynamically stable
patient, CT angiography (CTA) offers the opportunity
to determine the location and nature of upper extremity injury and dene concomitant non-vascular injuries,
thereby optimizing operative planning. Duplex ultrasound
can be helpful in diagnosis beyond the subclavian artery.
Contrast arteriography is useful, particularly when catheter-based endovascular repair (e.g., stent-graft repair) is
considered.
SUBCLAVIAN ARTERY
Subclavian Artery Injuries
The relatively short extent of the subclavian vessels, along
with their surrounding bony structures and musculature,
makes injuries to these proximal upper extremity vessels rare.
Although injury to the subclavian artery is more common
in penetrating trauma, reports from military and civilian
centers show the prevalence of subclavian artery injuries to
range from 1% to 10%. Subclavian vascular injury should
be considered when the bony structures of the thoracic outlet, such as the rst rib or the clavicle are fractured. Subclavian artery injury may not present with critical ischemia
given the ample collateral circulation around the shoulder.
Absence of a distal pulse in an upper extremity, reduction in
the injured extremity index (less than 0.9), or the presence
21 • Upper Extremity and Junctional Zone Injuries 257
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of hemodynamic collapse with apparent mechanism should
be considered highly suspicious for occult subclavian artery
injury. In fact, many patients with a subclavian artery
injury will present in shock. Hemopneumothorax is common. Other signs can include supraclavicular and low cervical swelling or tracheal compression from a hematoma.
Concomitant injuries to the cervical or thoracic spine may
be present, and brachial plexus injuries along with associated venous injury will commonly be present. Meticulous
assessment for these injuries should be performed as soon
as the patient's status permits.
Anatomy of the Junctional Zone and Subclavian
Artery
The junctional zone of the upper extremity is composed
of the thoracic aperture and shoulder. The articulations
between the rst rib, the sternum, and spinal column create
the bony boundaries of the thoracic outlet. The clavicle connects to the manubrium anterior to the rst rib, and these
anatomic relationships make direct access to the vasculature, including the subclavian vessels and their branches,
challenging. The musculature surrounding the thoracic
outlet can be best visualized as an inverted cone with the
anterior and posterior scalenes attaching to the rst and
second ribs, respectively, the sternothyroid; the sternohyoid attaching to the sternum; and the sternocleidomastoid
attaching to the medial clavicle and sternum. Although the
complexity of the anatomy in this area creates a protective
cage for the underlying vessels and nerves, obtaining proximal control in rushed situations can easily result in inadvertent damage to critical structures.
The major arterial structure of the thoracic outlet is the
subclavian artery (Fig. 21.3). The right subclavian originates
from the innominate artery posterior to the costoclavicular
joint, and the left subclavian artery originates from the aortic arch at roughly the level of the 4th left interspace. The
subclavian artery is divided into three sections based on the
relationship to the anterior scalene and the branches provide
collateral pathways around the shoulder (Fig. 21.4). The r st
portion is proximal to the muscle and its branches include
the vertebral artery, the thyrocervical trunk, and the internal thoracic artery. The phrenic and vagus nerves cross anterior to the artery, and the internal jugular and subclavian
vein join anterior to the nerves. On the left, the thoracic duct
courses across the proximal subclavian artery and drains
into the junction of the left internal jugular and left subclavian vein. The mid portion of the subclavian artery is posterior to the anterior scalene, abuts the brachial plexus trunks
located posteriorly and superiorly to the artery, and gives off
the dorsalscapular branch. The third portion is located lateral to the anterior scalene and remains in close proximity to
the brachial plexus as the cords form from the trunks. These
cords are intimately associated with the third part of the subclavian artery, which does not have side branches.
Operative Management of Junctional Zone and
Subclavian Artery
The proximal portion of the right subclavian artery can be
exposed via a median sternotomy. Further exposure may
require a supraclavicular extension of the incision, with
or without resection of the clavicular head. The origin of
the left subclavian artery is in a more posterior location
on the aortic arch and must be exposed through a high,
left anterolateral thoracotomy (Fig. 21.5). The mid to
distal left subclavian artery may be controllable through
a median sternotomy with a supraclavicular or cervical
extension or via “trapdoor” thoracotomy. When the goal
is to expose the mid-portion of the artery, a combined
supraclavicular and infraclavicular (two-incision) technique has been described, but in the authors' experience
a single-incision approach with subperiosteal clavicular
resection (with or without simultaneous reconstruction of
the clavicle) seems most expeditious and exible. A distal
left subclavian and proximal axillary vessel injury can be
Brachial plexus
Subclavian vein
vian artery
A
Fig. 21.3 (A) Anterior view of the thoracic outlets. (B) Angiogram of the left subclavian artery with branches. (Adapted from Gregory RT, et al. The
mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma. 1985;25(12):1147–1150.)
Vagus nerve
Phrenic nerve
Anterior scalene
muscle
B
258 SECTION 4 • The Management of Vascular Trauma
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Right axillary artery
Level of
tourniquet
Fig. 21.4 Angiogram demonstrating collateral circulation in the shoulder. The important collateral vessels are the thoracoacromial, the lateral thoracic, the subscapular, and the anterior and posterior humeral
circumflex arteries.
exposed by a separate supraclavicular incision. Alternatively, the clavicle can be resected in a subperiosteal fashion to expose the subclavian vessels. The distal subclavian
artery and proximal axillary artery is potentially treatable
from a two-incision approach, but injury management
may require a lateral clavicular resection, again with or
without bony replacement.
Dissection in the area of the subclavian artery and vein
should be performed with care given the abundance of
adjacent nerve structures (Fig. 21.6). In addition to the
brachial plexus and vagus, the phrenic nerve sits on the
anterior scalene muscle and should be identied and preserved. The abundance of collaterals around the shoulder
and neck may allow for ligation of the subclavian artery in
emergency situations with modest upper extremity ischemia. Temporary shunting, however, may be considered
and, in the authors' opinions, provides a better alternative
to ligation. Tension-free repair of the subclavian artery cannot be overemphasized as the vessel is relatively thin, nonmuscular, and delicate. Because of this, primary repair and
patch angioplasty is challenging. If these are entertained,
Supraclavicular
incision
Infraclavicular
incision
Left anterolateral
Median
sternotomy
Fig. 21.5 Surgical exposure of the junctional zone
vessels can be obtained by supraclavicular and
infraclavicular incisions, by left anterolateral thoracotomy, and by median sternotomy.
21 • Upper Extremity and Junctional Zone Injuries 259
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A BB
Junction innominate artery bifurcation
Internal jugular
Vagus nerve
Phrenic nerve
Subclavian artery primary repair with pledgets
C
Fig. 21.6 (A) A gunshot wound sustained to the left sternoclavicular region is shown. (B) A view from the patient's head. A supraclavicular incision was
performed, and a subclavian artery and vein injury were identified. A subclavian artery greater saphenous vein (GSV) interposition graft was performed,
as well as a subclavian vein to internal jugular GSV bypass. (C) The complexity of the anatomy in the area of the subclavian artery and vein necessitates
meticulous dissection during operative exposure.
use of pledgets is recommended. Prosthetic material can
be used as an interposition graft for larger, more proximal
great vessel and upper extremity reconstructions. Autologous conduit such as saphenous vein, paneled saphenous
vein, internal jugular vein, or even femoral vein can be used
depending on size and length considerations. The choice is
dependent on patient condition and associated soft-tissue
injury. In more extensive injuries, ligation and revascularization using bypass with inow based more proximally,
such as from the ascending aorta, the innominate artery, or
the carotid systems, may be options.
Operative Technique
In order to accomplish proximal surgical control of the left
subclavian, an anterolateral thoracotomy is completed.
Position the patient supine and place shoulder roll. Create a
transverse, curvilinear incision over the left 5th rib from the
lateral border of the sternum to the anterior axillary line
(just below the breast in a female patient, along the lower
contour of the pectoralis major muscle in a male patient).
Divide the pectoralis fascia and muscle bers at the 4th
intercostal space, then the intercostal muscles. Enter the
4th intercostal space at the cranial aspect of the 5th rib and
incise the parietal pleura. At this point, place a rib spreader
retractor (i.e., Fianchetto rib retractor). Retract superiorly
below the left lung caudally and visualize the aortic arch,
then divide the mediastinal pleura overlying the arch and
descending thoracic aorta. Identify the proximal origin of
the left subclavian artery. Of note, avoid injury to the left
vagus and recurrent laryngeal nerves at this location.
Achieve proximal control of the left subclavian artery.
The supraclavicular approach to the subclavian provides exposure to the mid and distal portions of the artery.
The surgeon should consider that this approach is more
time-consuming and subjects critical nerve structures to
risk. Position the patient supine and place shoulder roll.
260 SECTION 4 • The Management of Vascular Trauma
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Create a transverse, supraclavicular incision approximately
one ngerbreadth cranial to the clavicle with the medial
extent originating at the medial aspect of the clavicular
head of the sternocleidomastoid muscle. Divide the clavicular head of the sternocleidomastoid and expose the scalene
fat pad. Identify and protect the phrenic nerve which is
located at the anterior aspect of the anterior scalene muscle. Mobilize the scalene fat pad cephalolaterally. Complete
a phrenic neurolysis to increase nerve mobility and facilitate division of the anterior scalene muscle. Divide (resect
if required) the anterior scalene muscle and identify the
underlying subclavian artery. Circumferentially, isolate the
subclavian artery and achieve proximal and/or distal control. The thyrocervical trunk can be ligated if required.
The trapdoor thoracotomy provides excellent exposure
to the left subclavian artery and is another option that surgeons should be familiar with. Perform an anterolateral
thoracotomy as previously described. Next, control the
proximal subclavian artery. Ligate the internal mammary/
thoracic vessels and perform a supraclavicular approach as
previously described. Then complete a vertical incision over
the sternum to connect the medial borders of the anterolateral thoracotomy and supraclavicular incisions. Divide the
exposed sternum via median sternotomy.
AXILLARY ARTERY
Axillary Artery Injuries
Axillary artery injuries are more common than subclavian
artery injuries because the artery is longer and outside of
the protective structures of the thoracic outlet. Similar to
subclavian vessels, penetrating trauma is the most common
form of axillary artery injury. In contrast to isolated subclavian artery injuries—in which patients often present in
shock—isolated injuries to the axillary artery rarely present with hemodynamic collapse. More common hallmarks
include absent distal pulse or reduced injured extremity
index (less than 0.9), pulsatile bleeding, and/or an expanding hematoma. The substantial collateral network often
precludes the development of critical ischemia, and an
axillary artery injury may not be readily recognized without the aid of the continuous-wave Doppler and measurement of the injured extremity index. As with other forms of
vascular trauma, arteriography is a useful diagnostic tool in
many situations, including those in which an endovascular
therapy is considered.7 However, with good physical examination, use of continuous-wave Doppler and other noninvasive imaging modalities, most axillary artery injuries can
be diagnosed without arteriography. Anterior dislocation of
the humeral head or fractures of the humerus can result in
axillary artery injury, as well as injury to the nearby nerves
of the brachial plexus and the axillary vein.
Axillary Artery Anatomy
The axillary artery is the continuation of the subclavian
artery and extends from the lateral border of the rst rib. It
becomes the brachial artery at the lateral border of the teres
major muscle. The three parts of the artery are dened by the
relationship to the anteriorly located pectoralis minor. The
rst part has only one branch, the superior thoracic artery.
The second part contains two branches, the thoracoacromial
and lateral thoracic artery. The third part contains three
branches, the subscapular branch, the anterior humeral circumex, and the posterior humeral circumex arteries. The
axillary artery is bordered medially by the axillary vein and
posteriorly by the cords of the brachial plexus. Moving distally, the cords of the brachial plexus surround the axillary
artery, and ultimately these form the named nerves of the
arm at the level of the distal axillary and proximal brachial
artery.
Operative Management of Axillary Artery Injuries
The skin of the ipsilateral neck, chest, and supraclavicular fossa should be prepared and draped into the sterile
eld in order to allow for proximal control. Generally, the
arm, hand and ngers should also be prepped as part of the
operative eld to allow thorough intraoperative assessment
of distal perfusion, and in some cases performance of fasciotomy. The authors advocate for achieving proximal control
proximal to any hematoma, which, depending on the location of axillary artery injury and the size of the hematoma,
may be at the subclavian artery which is controlled through
a supraclavicular incision.
To expose the axillary artery an infraclavicular incision is
made two ngerbreadths below and parallel to the clavicle
(see Fig. 21.7A). In the case of proximal injuries, one may
choose both supra- and infraclavicular incisions allowing
for more completed control of the subclavian and axillary
arteries. Clamps should be applied with care and precision
in these locations, given the proximity of the artery to the
axillary vein and brachial plexus (Fig. 21.7B). A primary
end-to-end repair of the axillary artery can be performed,
with ligation and division of side branches to enable mobilization of the artery and provision of a tension-free anastomosis. However, most axillary artery injuries require a more
extensive repair in the form of interposition graft reconstruction. As is the case with subclavian artery, the use of
an autologous vein as an interposition or paneled graft is a
reasonable option, particularly in the setting of a signicant
soft-tissue injury. Prosthetic grafts such as Dacron or ePTFE
are often favored because they are readily available (i.e., off
the shelf) and they come in uniform sizes that better match
the diameter of the artery. Although the collateral circulation of the upper extremity may allow for ligation of an isolated axillary artery injury with few adverse consequences,
most injuries are associated with soft-tissue trauma which
disrupts these collaterals making repair of the main artery
a must. Temporary intravascular shunting is a good alternative to ligation of the artery and allows limb perfusion,
patient stabilization, and deferred denitive repair.
Operative Technique
The patient should be positioned supine and with a small
roll placed transversely under his or her shoulders to provide gentle extension of the neck. An infraclavicular incision is created 1 to 2 cm below the clavicle, beginning at
the mid-clavicle extending laterally. The clavipectoral fascia
is next divided and the bers of the clavicular head of the
pectoralis major are completely separated or divided for the
length of the incision. The subclavian vein, often covered
by a soft fatty wad of tissue is encountered and should be
mobilized/retracted caudally. This often requires ligation
and division of branches emptying into the main axillary
21 • Upper Extremity and Junctional Zone Injuries 261
(cut)
A
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Infraclavicular
incision
C5
C6
Axillary artery
Lateral
cord
Subclavian
artery
C7
C8
T1
Brachial
plexus
Musculocutaneous
Median nerve
Anterior circumflex artery
Radial nerve
Pectoralis minor muscle
Fig. 21.7 (A) An infraclavicular incision made two fingerbreadths below and parallel to the clavicle can expose the proximal axillary artery. Surgical
anatomy of the axillary artery and six branches with the three parts defined by the relationship to the anteriorly located pectoralis minor. (B) The cords
of the brachial plexus are located posteriorly to the proximal axillary artery, but surround the distal axillary artery. This close relationship explains the
high incidence of nerve injuries with axillary artery trauma.
vein. Once the vein is mobilized, one can feel and the expose
the axillary artery. Frequently, the pectoralis minor muscle
may be lifted and retracted laterally and or medially, or it
may be divided to facilitate complete exposure of the axillary artery. The incision can be extended laterally onto the
upper, medial arm as required.
nerve
B
Most brachial artery injuries can be diagnosed with physical examination, use of the continuous-wave Doppler, and
measurement of an injured extremity index (normal index
greater than 0.90). Other ndings, such as a supracondylar
fracture or elbow dislocation, increase the likelihood of a
brachial artery injury.50 Use of the brachial artery for vascular access, either for hemodynamic monitoring or endovascular procedures, can lead to iatrogenic brachial artery
BRACHIAL ARTERY
Brachial Artery Injuries
Patients with brachial artery injury, especially those with
injuries sustained from a penetrating mechanism, will typically present with hard signs of vascular injury. In some
instances, however, critical ischemia may not develop
because of the robust collateral network around the elbow.
The degree of ischemia resulting from a brachial artery
injury will depend on whether or not the injury occurred
proximal or distal to the origin of the deep brachial artery
and the degree of muscle and soft-tissue damage associated
with the injury. The second factor relates to interruption of
the deep brachial artery (collateral) network that makes signicant ischemia more likely in cases of injury with larger
soft-tissue defects.
injury (i.e., thrombosis or pseudoaneurysm). As with the
other extremity vascular injuries, a thorough sensorimotor
examination should be performed and documented before
any operative intervention.
Brachial Artery Anatomy
The brachial artery is the continuation of the axillary artery
and extends from the inferior border of the teres major muscle to its bifurcation in the antecubital fossa (Fig. 21.8). The
brachial artery resides medial to the humerus and is in close
anatomic proximity to the median, ulnar, and radial nerves.
The radial nerve courses away via the triangular interval
with the profunda brachii artery. The ulnar nerve courses
posterior to the brachial artery, then toward the posterior
medial humeral epicondyle in the ulnar groove. As the brachial artery approaches the elbow joint, the median nerve
262 SECTION 4 • The Management of Vascular Trauma
Brachial
Ulnar artery
in
Antecubital f
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Subclavian artery
Cephalic vein
plexus
Brachiocephalic ve
Axillary artery
Subclavian vein
Brachial artery
Humerus
Teres major muscle
Basilic vein
ossa
Radial artery
Fig. 21.8 The brachial artery is the continuation of the axillary artery and extends from the inferior border of the teres major muscle to its bifurcation in
the antecubital fossa. Important anatomic relationships include three main artery branches, three associated veins, three associated nerves, and three
associated muscles.
Median cubital vein
Axillary vein
Brachial vein
Aortic arch
travels from lateral to medial by crossing anterior to the
artery. Following its exit from the axilla, the brachial artery
is fairly supercial, and is the most commonly injured vessel
in the upper extremity. The three branches of the brachial
artery are (from proximal to distal) the profunda brachii
artery, the superior ulnar collateral artery, and the inferior
ulnar collateral artery. The profunda brachii artery passes
posteriorly with the radial nerve and runs between the
medial and lateral heads of the triceps. The branches of the
profunda brachii form important collateral networks with
the axillary artery proximally and the forearm vessels distally. Distal branches form the superior radial collateral network, along with branches from the proximal radial artery.
The superior and inferior ulnar arteries accompany the
ulnar nerve medially and also provide a collateral network
around the elbow.
Operative Management of Brachial Artery Injuries
If the vessel is bleeding, proximal control should be obtained
by compression of the brachial artery against the humerus.
Bleeding may have ceased due to vessel contraction and
local thrombosis. As with other upper extremity vascular
injuries, the ipsilateral neck and chest should be widely
prepped and draped in case more proximal exposure is
required. The wrist, hand, and ngers should be prepped
into the operative eld so that they are freely accessible for
examination, including Doppler interrogation. To access
the proximal brachial artery, a longitudinal incision is made
on the medial side of the upper arm in the palpable groove
between the biceps and the triceps. With retraction of the
pectoralis muscles, exposure as high as the distal axillary
artery is possible. The close proximity of the basilic vein and
the median and ulnar nerves to the artery requires careful dissection without excessive retraction. The basilic vein
should be preserved if possible, and ligating its tributaries
will allow it to be more completely mobilized and retracted.
Distally, the bicipital aponeurosis can be retracted or divided
to expose the brachial artery (Fig. 21.9). The position of the
median nerve in relationship to the brachial artery changes
as the nerve extends peripherally. The nerve courses from a
proximal, lateral position to a distal, medial position, with
respect to the brachial artery.
Brachial artery injuries resulting from low-energy stabbing mechanisms may be repaired primarily if the artery
is not devitalized. As expected, this type of repair is rarely
used for injuries resulting from high-energy blunt or penetrating mechanisms. Instances in which the artery is more
heavily damaged or transected require use of a vein patch
or more commonly an autogenous vein interposition graft
(see Fig. 21.1). Spatulation of the ends of the anastomosis
is a good idea to avoid narrowing and, in some instances,
an interrupted suture technique can be useful given the
21 • Upper Extremity and Junctional Zone Injuries 263
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trauma. The most common mechanism, as with the more
proximal vessels of the upper extremity, is penetrating
Biceps brachii
muscle
injury. Hypothenar eminence hammer syndrome is a rare
manifestation of repeated blunt trauma to the distal ulnar
artery which results in aneurysmal dilation, thrombosis,
Brachialis muscle
and/or distal embolization. Hematoma within the forearm can expand and result in compartment syndrome and
Brachioradialis
Pronator
teres muscle
muscle
Brachial
artery
Median
nerve
ultimately what is referred to as a Volkmann exure contracture. Signs of a tense hematoma within the forearm
associated with decrements in sensory or motor function
with or without an obvious perfusion abnormality should
prompt consideration of a fasciotomy.
Radial and Ulnar Artery Anatomy
After the brachial artery crosses the antecubital fossa, it
bifurcates into the radial and ulnar arteries (Fig. 21.10).
Whereas the radial is the more direct continuation of the
brachial artery, the ulnar artery is typically the larger of
the two. The ulnar artery gives off two branches, the anterior and posterior ulnar recurrent arteries, which form the
Fig. 21.9 Surgical exposure of the brachial artery is obtained rapidly by
a longitudinal incision along the artery’s course with an extension as
an S curve either across the axilla proximally or across the antecubital
fossa distally. The median nerve and basilic vein are in close proximity
to the artery.
distal components of the collateral circulation around the
elbow. The other branch of the ulnar artery—the common interosseous artery—passes posterolateral toward the
interosseous membrane, where it bifurcates into the anterior and posterior interosseous arteries that run on opposing sides of the membrane. The supercial palmar arch is
most commonly the terminal segment of the ulnar artery.
In the forearm, the ulnar artery is positioned next to the
relatively small size of the brachial artery and its tendency
to spasm. Injuries to the brachial distal to the origin of the
profunda brachii will be associated with a variable degree
of ischemia depending on the amount of damage to the
collateral circulation. Use of a temporary vascular shunt is
recommended when reconstruction of the brachial artery
ulnar nerve. The radial artery contains only one branch in
the proximal portion, the radial recurrent artery, which is
responsible for collateral circulation around the elbow. In
the forearm, the radial artery is positioned next to the radial
nerve and most commonly forms the deep palmar arch of
the hand.
is not feasible due to the patient’s adverse physiology, or in
situations in which the surgeon is not familiar or comfortable with (or does not have the time) performing a formal
arterial reconstruction.
Operative Technique
An incision overlying the medial bicipital groove facilitates
good exposure of the brachial artery. Proximal or tourniquet control can be accomplished based on the location of
the injury. The surgeon should identify and expose the brachial artery after entering the brachial sheath while identifying and protecting the median nerve. Direct exposure of
the injured vessel is often appropriate in the arm. Ligation
of the brachial artery distal to profunda brachii may be tolerated if the collateral networks are intact and distal perfusion can be conrmed with a Doppler. Of note, the brachial
artery is relatively elastic and redundant and one should
ex and extend the arm while setting up an interposition
graft to estimate optimal length and to avoid kinking of the
conduit. High bifurcation of the brachial artery in the upper
third of the arm is a common variant to standard anatomy.
Operative Management of Radial and Ulnar Artery
Injuries
Typically, bleeding from the forearm can be controlled
with direct pressure, but a tourniquet can be used if
needed. In the operating room, the proximal portion of
the arm, the hand, and ngers should be prepped and
draped in a circumferential manner to allow for full oper-
ative exposure, assessment, and control of the radial and
ulnar arteries. An S-shaped incision over the antecubital
fossa allows for proximal extension and exposure of both
the radial and ulnar arteries. Identifying the brachial
artery as described previously and tracing it distally may
aid in identifying the ulnar and radial arteries. The radial
artery follows the medial border of the brachioradialis
muscle, and the medial groove of this muscle can be used
as a landmark to make an incision in the mid forearm
(Fig. 21.11). In the distal portion of the wrist, the radial
artery can be exposed by a longitudinal incision slightly
lateral to the artery.
The ulnar artery courses deep to the pronator teres,
slightly beyond the bifurcation and remains deep to the
RADIAL AND ULNAR ARTERIES
Radial and Ulnar Artery Injuries
Vascular injuries in the forearm artery injury are common
among the clinical series or reports on extremity vascular
exor muscles of the proximal forearm before emerging
into a more supercial position at the midpoint of the
forearm, which can make proximal exposure difcult. To
expose the ulnar artery, a longitudinal incision is made
on the medial side of the arm about four ngerbreadths
264 SECTION 4 • The Management of Vascular Trauma
AB
superficialis muscl
Posterior branch of
Deep br
ry
ry
ry
ry
ry
ry
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profunda brachii artery
Radial collateral branch
of profunda brachii artery
Radial nerve
Radial recurrent artery
. of radial nerve
Superficial br.
of radial nerve
Interosseous
recurrent artery
Volar
interosseous artery
Radial artery
Fig. 21.10 The radial and ulnar arteries have close relationships with
the radial nerve and ulnar nerve in the forearm.
Superior ulnar
collateral arte
Inferior ulnar
collateral arte
Anterior ulnar
recurrent arte
Posterior ulnar
recurrent arte
Common
interosseous arte
Dorsal
interosseous arte
Median nerve
Anterior
interosseous nerve
Ulnar nerve
Ulnar artery
distal to the medial epicondyle. The artery can be identied
between the exor carpi ulnaris and the exor digitorum
supercialis (see Fig. 21.11). In the wrist, the ulnar artery
can be exposed through a longitudinal incision on the
radial side of the exor carpi ulnaris muscle in order to
avoid the ulnar nerve, which lies lateral to the ulnar artery.
Typically, the management of forearm artery injury
is dependent on whether or not there is a satisfactory
continuous-wave Doppler signal at the wrist and/or in the
hand. Because of the redundant nature of perfusion to the
hand, if there is an arterial signal in the palmar arch with
the injured vessel occluded, then ligation of the injured
vessel is a reasonable maneuver. If the hand is completely
ischemic (i.e., no arterial Doppler signal distal to the forearm injury), then one of the two arteries (radial or ulnar)
should be repaired. Primary repair of a simple laceration
using ne, monolament suture is reasonable if the injury
has not resulted in the loss of arterial length. If an end-toend repair is attempted, the two ends of the vessel should be
spatulated to increase the area of the anastomosis (i.e., prevent narrowing). Often because of loss of arterial length, or
because of the elastic nature of the ulnar and radial arteries, an interposition vein graft is needed to restore perfusion
to the distal arm and hand. For reconstruction at the wrist
it is helpful to have a hand surgeon or someone familiar
with microvascular repair present during the operation.
Interposition repair of forearm arterial injury typically
requires a smaller portion of saphenous vein or another
type of arterial conduit.
51
Fig. 21.11 (A) The ulnar artery can be exposed through a longitudinal incision made on the medial arm about four fingerbreadths distal to the medial
epicondyle. The artery can be identified between the flexor carpi ulnaris and flexor digitorum superficialis. (B) The medial groove can be used as a landmark to expose the radial artery, which follows the medial border of the brachioradialis muscle.
Flexor digitorum
Flexor digitorum
profundus muscle
Superficial radial
Brachioradialis
Ulnar nerve
Ulnar artery
e
Flexor carpi
ulnaris muscle
Radial artery
nerve
muscle
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