Adult Trauma Life Support (ATLS) is the gold standard for managing trauma-related injuries. Arterial and nerve injuries of the upper limb can have significant associated mortality and morbidity. Knowledge of the basic principles, presentation, and initial management is paramount to reduce short and long-term consequences. These injuries usually require escalation to seniors and referral to relevant specialities.

Epidemiology

The incidence of nerve injury to the upper limb in England is 106 per million per year (1). There is no data on the incidence of arterial injury in the UK, however studies in the USA and Australia have shown between 1-2% of trauma patients have associated arterial injury, not specific to upper limbs (2). Trauma is a leading cause, including road traffic accidents, falls, and industrial accidents. Iatrogenic injuries, mainly due to medical procedures such as catheterisations and surgeries, also occur.

Aetiology

Understanding the aetiology of arterial and nerve injury can aid your examination and patient management. Consider the following causes:

• Trauma
  • Penetrating injuries (e.g. stab wounds, dog bites) can directly damage arteries and nerves.
  • Upper limb fractures and dislocations can lead to associated arterial and nerve damage.
• Iatrogenic causes (4)
  • Medical procedures involving arteries or performed near arteries and nerves can lead to injury. Examples include arterial line insertion, surgery and venepuncture.
  • Nerve injuries can occur during surgical interventions due to improper positioning or traction.
• Medical conditions
  • Conditions such as thoracic outlet syndrome, vasculitis, and aneurysms can lead to secondary arterial and nerve damage. Other specialties commonly manage these conditions.

History

Questions to ask regarding presenting complaint:

• When did it happen?
  • Vascular injuries are time-sensitive injuries.
• Where did it happen?
  • Locations that increase the risk of infection include farmland and marine areas.
• What happened?
  • Events of the injury which include:
    • Mechanism (crush, sharp, penetrating, fall) gives an idea of the energy involved, the extent of injury, trapped foreign bodies and potential collateral injury to surrounding structures.
    • First aid such as irrigation, tourniquet use, reduction and splinting of fractures/dislocations.
    • Pre-hospital management including intubation, IV fluids, cardiac monitoring, analgesia etc.

Past medical and drug history

• Comorbidities
  • Helps stratify the risk of infection and impaired wound and bone healing. Common contributing conditions include diabetes and immunocompromise (5,6)
• Regular medications:
  • Evaluate factors affecting suitability for surgery and wound healing including:
    • Anticoagulants
    • Immunosuppressants
  • Tetanus status
    • Puncture injuries and ‘dirty’ mechanisms are tetanus-prone wounds. (7)
  • Allergies

Social History

• Hand dominance
• Profession and hobbies
  • Could influence the operation performed in cases where the restoration of hand function is vitally important e.g. in musicians; or where speed of recovery and need to return to work take precedence. (8,9)
• Smoking status
  • Smoking has a significant detrimental impact on wound healing. (10,11)

Systemic symptoms

• In the unlikely case that there is a delay to presentation ensure to assess for systemic signs of infection e.g. fevers, rigours, tachycardia (pain, anxiety and hypovolaemia may drive tachycardia)

Clinical Examination

A systematic approach is essential as the patient may have distracting injuries. Always compare both upper limbs during the examination to identify the patient’s “normal” e.g. some people naturally have cold hands and are not ischaemic.

Inspection

• Look for signs of trauma, deformity, swelling, and discolouration. Note any open wounds, hematomas, or obvious deformities.

Palpation

• Feel the skin temperature
• Pulses: Radial, ulnar, and brachial and Allen’s test.
• Capillary refill time
• Assess for signs of compartment syndrome (pain is the most reliable indicator, pallor, pulselessness, paraesthesia, and paralysis).
• Sensation (12)
  • Median nerve: Assess sensation over the palmar aspect of the index finger.
  • Ulnar nerve: Assess sensation over the volar(palmar) aspect of the little finger.
  • Radial nerve: Assess sensation over the dorsal aspect of the hand.

Move

• Median nerve: Assess thumb opposition
• Ulnar nerve: Assess finger abduction/adduction
• Radial nerve: Assess wrist and finger extension

Investigation

Imaging (13)

• X-rays: A minimum of 2 views are required, useful for detecting fractures and dislocations. Look for signs of bone injury that may be associated with arterial and nerve damage.
• Doppler Ultrasound: Non-invasive assessment of blood flow.
• CT Angiography: Detailed imaging of arterial injuries. Provides a clear picture of the vascular anatomy and the extent of injury. It is particularly useful in preoperative planning.
• MRI: Can be used to assess soft tissue injuries, including nerve damage, especially when clinical findings are unclear.

Laboratory Test (14)

• Full Blood Count (FBC): Assess for anaemia or infection.
• Coagulation Profile: Important before surgical intervention, especially if the patient is on anticoagulants or has a coagulopathy.
• Arterial Blood Gas (ABG): May be needed in severe ischemic cases to assess the metabolic status and severity of ischemia.

Management (15, 16)

All patients should be assessed according to ATLS trauma protocol using an ABCDE approach. Early escalation to seniors may be required depending on the injury.

Haemostasis: Control bleeding with direct pressure or tourniquet application if severe. Ensure the tourniquet is applied correctly to avoid further damage and note the time of application. Suturing any actively bleeding vessels should only be done by an experienced surgeon to prevent further damage to the vessels.

Analgesia: Provide adequate pain relief using appropriate analgesics. Nerve blocks may be considered and should be performed by experienced clinicians.

Fracture reduction and immobilisation: Fracture and/or dislocation reduction can restore alignment and vascular supply as well as reduce pain.

Antibiotics: Follow local guidelines for indication, antibiotic choice and duration.

Tetanus Prophylaxis: Follow national guidelines (NICE guidelines in the UK).

When to escalate (17, 18)

Majority of suspected vascular and/or nerve injuries should be reviewed by a senior. Below are a list of signs and symptoms which may warrant prompt involvement of senior clinicians.

• Absence of distal pulses or signs of ischemia.
• Any motor or sensory deficits.
• Complex injuries including associated fractures or dislocations.
• Deteriorating clinical status despite initial management.
• Suspected compartment syndrome requires immediate senior review and potential fasciotomy.

Conclusion

Upper limb arterial and nerve injuries require a thorough understanding of anatomy, prompt clinical assessment, and timely intervention to prevent long-term disability. Mastering the basics of immediate management and recognising when to seek senior help is key to optimising patient outcomes.

References:

1. Murphy, R. N. A., de Schoulepnikoff, C., Chen, J. H. C., Columb, M. O., Bedford, J., Wong, J. K., & Reid, A. J. (2023). The incidence and management of peripheral nerve injury in England (2005-2020). Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 80, 75–85.
2. Perkins, Z. B., De’Ath, H. D., Aylwin, C., Brohi, K., Walsh, M., & Tai, N. R. (2012). Epidemiology and outcome of vascular trauma at a British Major Trauma Centre. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 44(2), 203–209.
3. Mahajan RK, Srinivasan K, Jain A, Bhamre A, Narayan U, Sharma M. Management of Complex Upper Extremity Trauma with Associated Vascular Injury. Indian J Plast Surg. 2022;55(3):224-33. doi: 10.1055/s-0042-1744453.
4. Sorock GS, Lombardi DA, Courtney TK, et al. Epidemiology of occupational acute traumatic hand injuries: A literature review. Safety Sci. 2001;38:241-56.
5. Okonkwo, U. A. 2017. Diabetes and wound angiogenesis. International journal of molecular sciences. 18. 1419.
6. Dryden, M. et al. 2015. Pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: focus on skin and soft-tissue infections. Clinical microbiology and infection: the official publication of the European society of clinical microbiology and infectious diseases. 21. S27-S32.
7. UK Health Security Agency. (2024). Guidance on the management of suspected tetanus cases and the assessment and management of tetanus-prone wounds. [Online]. Gov.uk. Last Updated: 15 March 2024. Available at: https://www.gov.uk/government/publications/tetanus-advice-for-health-professionals/guidance-on-the-m [Accessed 9 September 2024]
8. Chu, d. Y.et al. 2023. Management of common conditions of the musician: A Narrative Review for Plastic Surgeons. Journal of plastic Surgery and Hand Surgery. 58. 89.
9. Tiffanie Turnbull. (2024). Australian hockey star amputates finger to play at olympics. [Online]. BBC News. Last Updated: 26 July 2024. Available at: https://www.bbc.co.uk/news/articles/ckmg7ngkgjeo [Accessed 9 September 2024].
10. Sorensen, L. T. 2012. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Annals of surgery. 255. 1069-1079.
11. Kean, J. 2010. The effects of smoking on the wound healing process. Journal of wound care. 19. 5-8.  
12. Asensio JA, Kessler JJ 2nd, Miljkovic SS, et al. Brachial Artery Injuries Operative Management and Predictors of Outcome. Ann Vasc Surg. 2020;69:146-57. doi: 10.1016/j.avsg.2020.05.049.
13. Boll JM, Dennis AJ, Gwinn E. Vascular Trauma to the Extremity: Diagnosis and Management. In: Dieter R, Dieter R Jr, Dieter R III, Nanjundappa A, editors. Critical Limb Ischemia. Cham: Springer; 2017. p. 377-84. doi: 10.1007/978-3-319-31991-9_21.
14. Huisstede BM, Bierma-Zeinstra SM, Koes BW, et al. Incidence and prevalence of upper-extremity musculoskeletal disorders. BMC Musculoskelet Disord. 2006;7:7. doi: 10.1186/1471-2474-7-7.
15. Koman AL. Management of upper extremity arterial penetrating vascular trauma. Injury. 2021;52(12):3573-9. doi: 10.1016/j.injury.2021.10.001.
16. Durand WM, Goodman AD, Giglio P, Etzel C, Owens BD. Epidemiology of Upper Extremity Soccer Injuries Among High School– and College-Aged Players in the United States. Sports Health. 2018;10(6):552-7. doi: 10.1177/1941738118795483.
17. Kim YH, Choi JH, Chung YK, et al. Epidemiologic study of hand and upper extremity injuries by power tools. Arch Plast Surg. 2019;46(1):63-8. doi: 10.5999/aps.2018.00815.
18. Betteridge N, Taylor A, Hartley R. Clinical anatomy of the nerve supply to the upper limb. (“Clinical anatomy of the nerve supply to the upper limb – PubMed”) BJA Educ. 2021;21(12):462-71. doi: 10.1016/j.bjae.2021.07.007

Written by Mr. Mohamed Elsafti (Senior Clinical Fellow in Plastic Surgery) and reviewed by Mr. Jonathan Van (Senior Clinical Fellow in Plastic Surgery)