Elsevier

Injury

Volume 45, Issue 12, December 2014, Pages 1870-1875
Injury

Salvage of upper extremities with humeral fracture and associated brachial artery injury

https://doi.org/10.1016/j.injury.2014.08.038Get rights and content

Abstract

Background

Humeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.

Methods

We conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.

Results

Thirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).

Conclusions

Salvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.

Type of study/level of evidence

Therapeutic III.

Introduction

Amputation or near amputation of the upper extremity requiring vascular repair for salvage presents a challenging situation for the patient and surgeon. Although brachial artery injuries infrequently result in amputation [1], [2], the at-risk limb presenting with arterial injury is almost universally treated with expedient revascularization, and relative consensus exists regarding this approach [1], [2], [3], [4], [5], [6], [7], [8], [9]. Although many recent reports [1], [2], [3], [4], [5], [6], [7], [8], [9], [10] of successful revascularization and limb salvage after brachial artery injury have been published, the techniques and outcomes for management of major upper-extremity trauma presenting with substantial combined bony and vascular injury have not been well studied. The purposes of this study were to show a viable option of immediate limb salvage using a treatment algorithm that consists of immediate internal fixation and determination of when emergent vascular shunting is necessary.

Variations in practice include the use of temporizing vascular shunts, multispecialty team treatment as opposed to single upper-extremity surgeon management of the injury, and external versus immediate internal fixation or even intramedullary nailing. An upper-extremity surgeon has an orthopaedic or plastic surgery background with added qualifications and training in the discipline of hand surgery. Immediate internal fixation has become the standard for treatment of open fractures in other anatomic locations, including the forearm and tibial and femoral shafts [11], [12], [13]. By contrast, many authors still advocate external fixation of open humeral fractures and for cases of arterial repair to protect the anastomosis [14], [15], [16].

We describe our approach to treating humeral fractures with associated brachial artery injury, including closed fractures, near amputations, and amputations. We also review our experience in an attempt to identify significant predictors of limb survival versus amputation. We hypothesized that we would be able to identify specific treatment variables that would be associated with a higher salvage rate, such as decreased time to revascularization by shunt use and management by an upper extremity surgeon with the ability to address all components of the injury (osteological, vascular, and neurological) at a single setting. Our secondary hypothesis was that immediate internal fixation would be safe and effective for limb salvage.

Section snippets

Study design

We studied a retrospective cohort of patients presenting with humeral fracture and associated brachial artery injury. After obtaining Institutional Review Board approval, we searched the database at our level I trauma centre to identify all adult patients (older than 18 years) with this injury. The study time period extended from 1999 through 2012. To qualify for study inclusion, patients had to be followed at least to the clinical end point of limb viability (discharged with limb intact) or

Results

Thirty-eight patients met the above criteria and were included in the study (Table 1). The median patient age was 27.5 years, with an interquartile range of 22–41 years. Median follow-up was 263 days, with an interquartile range of 97–587 days. Injuries consisted of 13 penetrating gunshot injuries and 25 blunt injuries caused by motor vehicle or motorcycle collisions. Seventeen (68%) of the 25 blunt injuries were open fractures (Table 1).

Overall, 36 upper extremities were successfully salvaged

Discussion

Our study of a retrospective cohort of humeral fractures with brachial artery injury treated at a single institution provides some insight into contemporary treatment strategies and salvage rates. Although principles of early reperfusion, aggressive debridement of devitalized soft tissues, early soft-tissue coverage, and definitive internal fixation have been common practice at some institutions, the goal of our study is to better define when immediate reperfusion is needed, using absolute

Conflict of interest statement

In the past, author T.H. received money from Smith + Nephew for giving a presentation at a Smith + Nephew-sponsored meeting. He also owns stock options in Summit Med Ventures. The authors have no other potential conflicts of interest to report.

Funding source

No outside funding was received for this work.

Acknowledgment

We thank senior editor and writer Dori Kelly, MA, for professional manuscript editing.

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