Significant Vascular Injury Research Articles

Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

Percutaneous transventricular and fetoscopic umbilical catheterization have been applied to animal and human fetuses. These methods have a high rate of failure and complications. Here, we propose an alternative route for anterograde echocardiography-guided cardiac catheterization through a transhepatic approach of the intra-abdominal vessels in the fetal lamb. After exteriorization of the uterus in 12 pregnant ewes between 118 to 122 days' gestation, a 4F sheath mounted over a 1.2-mm needle was placed into the intra-abdominal portion of the umbilical vein (n=2) and into the subdiaphragmatic portion of the inferior vena cava via a transhepatic approach (n=10) under ultrasound guidance. In the first 2 animals using a transumbilical approach, it was impossible to reach the heart through the ductus venosus. In the next 10 animals, using a conventional technique, echocardiography-guided catheterization of the 4 chambers was performed in the all fetuses, atrial or ventricular pacing in 6 fetuses, and ballooning of the pulmonary valve in 9 of 10 fetuses. Among the 10 fetuses catheterized through the transhepatic approach, 2 were euthanized immediately after the procedure to evaluate intraperitoneal bleeding (23 and 29 mL, respectively), and 3 died after the procedure (1 of major bleeding and 2 deaths related to balloon catheter manipulation). Finally, 5 were delivered vaginally after an uneventful pregnancy, and autopsy at day 5 did not show significant liver, vascular, or cardiac injury. Echocardiography-guided fetal cardiac catheterization through a transhepatic approach is feasible and provides an interesting alternative approach for human fetal cardiac interventions.

Circulating Endothelial Progenitor Cells (EPCs): Variability between Normal Individuals as Measured by a New Standardized, Functional 5-Day In Vitro Colony Assay.

Endothelial cells derived from pre-existing blood vessels are believed to be responsible for minor repairs to the peripheral vasculature; however, a more primitive circulating EPC is thought to contribute to the maintenance and repair of heart tissue and may be useful in treating more significant vascular injuries as well as myocardial infarcts. While numerous attempts to identify the antigen expression of endothelial precursors have been made, to date no conclusive in vitro functional assays have correlated with the proposed phenotypes. Although the exact phenotype of the precursor cell remains elusive, a recently described colony assay for EPCs showed an inverse correlation between the number of circulating colony-forming cells (CFCs) and the risk of cardiovascular disease (Hill et al., NEJM 348(7):2003). This suggests that the precursor cells that read out in this colony assay may play a role in cardiac tissue maintenance and repair. For this assay to be useful in research and clinical studies, the variability in the frequency of circulating EPCs in the general population needs to be determined. We evaluated the EPC number in peripheral blood (PB) of volunteer male (n = 18) and female (n = 13) donors from the general population (age range 23–54, median age 34 years). PB white blood cell counts (WBC) were determined and mononuclear cell fractions were obtained by Ficoll® gradient density centrifugation. Following cell washing, 5 x 106 cells per well were plated in EndoCult™ medium in a 6-well fibronectin coated (FN) plate and incubated for 48 hours. Non-adherent cells were then harvested and replicate cultures were initiated with 1 x 106 cells per well in a 24-well FN plate. EPC derived colonies, consisting of a central core of round cells and more elongated cells at the periphery, were enumerated following an additional 3 days in culture. The frequency of EPCs in PB varied between individuals with a range of 0 to 99 and a mean ± SD of 25 ± 23 per ml of blood. The frequency of EPCs did not correlate with either WBC (r = 0.199) or age (r = −0.083) for either gender. In a subset of individuals studied (n = 5), fluctuations in the frequency of EPCs were determined at multiple time points over an 8-month period. Two of 5 donors consistently had less than 10 EPCs per ml of blood, whereas the other 3 donors never had less than 20 EPCs per ml of blood. These results show that, while there is a relatively large variation in the frequency of EPCs between individuals in the general population, an individual's colony content is quite consistent over time. In conclusion, the lack of temporal variability in the frequency of circulating EPCs within an individual supports the use of this standardized 5-day EPC assay for the measurement of differences in endothelial progenitor content between individual patients. As these endothelial progenitors may have a clinical association with cardiovascular health, this standardized functional assay could be useful for further comparative clinical trials across multiple centers.

Treatment of vascular injuries in themultiple-ligament-injured knee

Popliteal vascular injury associated with the multiple-ligament-injured knee, including knee dislocation, continues to be an uncommon but morbid injury. The tethering of the popliteal vessels to the femur at Hunter's canal and to the tibia by the soleus muscle allows for significant vascular injury when the supporting ligamentous structure is disrupted. The majority of injuries are related to motor vehicle accidents, including driver and passenger injuries, motor vehicle versus pedestrian injuries (bumper injuries), and motorcycle accidents. The mechanisms of vascular injury, both artery and vein, include stretching that results in intimal injury, contusion, laceration, transection, or avulsion. A high index of suspicion must be maintained in the evaluation of these injuries. Modes of evaluation include physical examination, ankle brachial indices, duplex examination, magnetic resonance imaging, and angiography. Given the potentially devastating consequence of a missed popliteal artery injury, routine arteriography or serial physical examination with duplex examination is recommended for patients with a multiple-ligament-injured knee. Vascular repair to include primary repair, patch angioplasty, or interposition grafting is performed from either a medial or posterior approach. Adjunctive measures include 4-compartment fasciotomy, mannitol administration, and vasodilator therapy. Several controllable factors have been found to improve limb salvage, such as decreased ischemia time, systemic anticoagulation, and 4-compartment fasciotomy. Prompt recognition of vascular injury, prompt restoration of flow, and use of proven adjuncts provides the optimal possibility of limb salvage with popliteal artery injuries associated with the multiple-ligament-injured knee.

Electrolytic ablation as an adjunct to liver resection: experimental studies of predictability and safety.

Combined liver resection and local ablation may offer the only chance of cure to patients with liver metastases who are presently deemed unresectable because of a single awkwardly placed metastasis. By definition, such a metastasis is often close to a major vein. An ablative technique is needed that is both predictable and safe in such a circumstance. Electrolytic liver lesions were created in 21 pigs using platinum electrodes, connected to a direct current generator. Both electrolytic 'dose' and electrode separation were varied to produce different sized lesions. The 'dose' was correlated with the volume of necrosis and any vascular damage was determined histologically. There was a significant (P < 0.001) correlation between the electrolytic 'dose' and the volume of liver necrosis. For a given 'dose' the volume of necrosis was less when the electrodes were together, rather than separated. Liver enzymes were only transiently deranged. There were no significant vascular injuries. Predictable and reproducible necrosis is produced by electrolysis in the pig liver. The treatment appears to cause little or no damage to immediately adjacent liver or major vascular structures and, when combined with resection, may offer the chance of a cure to many patients who are currently unresectable.

Evaluation of Vascular Injury in Penetrating Extremity Trauma: Angiographers Stay Home

The debate over the use of diagnostic angiography (DA) to exclude arterial injury in penetrating extremity trauma (PET) continues. This review evaluates our current protocol for PET and identifies indications for DA. Patients presenting to our urban Level I trauma center between January 1997 and September 2000 with PET were included. Demographic data, emergency department (ED) course, and patient follow-up were reviewed. ED evaluation directed by physical examination (PE) included Doppler pressure indices (DPI) and DA if indicated. A total of 538 patients had PET injuries. Twenty (4%) patients with hard signs of vascular injury were taken to the operating room. Ninety-one (17%) patients without vascular compromise underwent operative procedures or were admitted for other injuries. One hundred twenty-three (23%) patients with nonproximity wounds were discharged. Four DAs were performed for abnormal DPI with no change in management. Three hundred patients with a negative PE and normal DPI were discharged from the ED. Follow-up was available on 51 per cent of these patients (range 1-49 months) with no missed injuries identified. We conclude that PE with DPI is an appropriate way to identify significant vascular injuries from PET. Patients with normal PE and DPI can be safely discharged. DA is only indicated for asymptomatic patients with abnormal DPI.

Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.

Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Total laparoscopic tube hysterectomy: a safer option?

Objective To compare outcomes in women undergoing total laparoscopic hysterectomy performed with the assistance of a colpotomizing tube (TLTH), with those in women in whom a laparoscopically assisted hysterectomy (LAH) procedure was performed. Design A retrospective review of consecutive patients. Setting State health service patients were treated at Flinders Medical Centre, Adelaide, South Australia, and private patients were treated by the same surgeons in three private hospitals in metropolitan Adelaide. Subjects A total of 227 women who underwent operation between January 1996 and August 1999. Interventions The women involved in the first two years of this study exclusively underwent an LAH, whilst those in the latter 18 months underwent a TLTH. Main outcome measures These included intraoperative complications, including significant haemorrhage, ureteric, bladder, vascular and bowel injury; postoperative complication rates for vault infection, late bowel and ureteric injury, and miscellaneous febrile morbidity. Also documented were the operating time, nonautologous blood transfusion, operation–discharge interval, and readmission with a complication. Results The women having the TLTH procedure had significantly fewer intraoperative complications (χ2 = 8.07, P = 0.004) in comparison with the LAH group; postoperative complications were not statistically different. The mean operating times and readmission rates with surgical complications were equivalent for the two groups. The hospital stay was shorter by 1.5 days for the women having a TLTH (t = 8.39, P &lt; 0.001), and the estimated blood loss was less than half of that for the LAH patients (t = 8.94, P &lt; 0.001); nonautologous blood transfusion was not needed in either group. Conclusion Total laparoscopic hysterectomy utilizing the nondisposable colpotomizing tube and uterine manipulator has both fewer intraoperative complications and reduced blood loss when compared with laparovaginal hysterectomy, and is a safe alternative to LAH.

The Role of Angiography in Periclavicular Penetrating Trauma

Our objective was to evaluate whether physical examination in conjunction with chest X-ray can accurately diagnose the presence of significant vascular injury in penetrating periclavicular trauma. Results from a management protocol for penetrating periclavicular trauma were reviewed for the period January 1992 through December 1996 at an urban Level I trauma center. All patients requiring angiography for periclavicular penetrating trauma with trajectory of the injury falling between the lateral border of the manubrium and the anterior axillary line were entered into the management protocol. All patients underwent anterior-posterior chest radiography on arrival to the trauma center and 6 hours after admission. Tube thoracostomy was placed if clinically indicated on presentation or for X-ray findings. Clinical assessment was performed on all patients, with emphasis placed on the presence of "hard" signs for vascular injury. In addition to accepted hard signs for vascular injury, significant chest tube output (>1000 cc) and chest X-ray findings consistent with significant hemorrhage were also considered hard signs for vascular injury. Assuming hemodynamic stability, all patients with suspected subclavian/axillary arterial injury based on wound trajectory or clinical findings consistent with vascular injury underwent angiography. Forty-six patients were entered into the protocol with 30 left-sided injuries and 16 right sided injuries. The majority of injuries were secondary to gunshot wounds (31), with 14 stab wounds and 1 shotgun injury. Emergency room chest X-ray results revealed 32 negative chest X-rays, 7 pneumothoraces, 2 hemopneumothoraces, 2 hemothoraces, and 3 chest tubes placed before initial chest X-ray. A total of 7 injuries were diagnosed, with 1 missed injury, resulting in a sensitivity of 86 per cent for clinical assessment. The missed injury was a pseudoaneurysm of an axillary artery secondary to a self-inflicted shotgun wound. One mortality occurred in this series, which was a death in the operating room secondary to blood loss from an axillary artery injury. We conclude that clinical assessment can adequately diagnose the presence of surgically significant vascular injury in periclavicular penetrating injuries with trajectories lateral to the manubrium.

Radioactive beta-emitting solution-filled balloon treatment prevents porcine coronary restenosis

Purpose. Intracoronary gamma or beta radiation from centrally located sources at the time of overstretch balloon injury inhibits neointimal proliferation. In an effort to deliver homogeneous, centered radiation fields in a technically straightforward fashion, we studied the effects of a beta-emitting solution used as a balloon inflation fluid to deliver radiation at the time of coronary injury. Methods. Twenty-one coronary arteries in 13 juvenile swine underwent irradiation (control and 11 or 25 Gy media dose). Radiation was delivered using a perfusion balloon inflated with an Re-188 solution. Subsequently, overdilatation percutaneous transluminal coronary angioplasty was performed at the pretreated segment. Histopathologic and histomorphometric analysis was performed at 30 days after injury on the entire irradiated artery. Results. Balloon overdilation was associated with significant vascular injury and marked neointimal proliferation in control and low-dose (11 Gy)-treated arteries. High-dose radiation (25 Gy) significantly inhibited neointima formation compared with controls (neointimal area: 0.49 ± 0.29 mm 2 vs. 1.51 ± 0.22 mm 2, respectively; p = 0.02) and low-dose radiation (neointimal area 1.75 ± 0.54 mm 2, p > 0.1 compared with controls). Conclusions. Liquid Re-188 is an effective beta-emitting vehicle to deliver intracoronary radiation and prevent restenosis in this model. Intracoronary radiation treatment using aqueous radioisotope sources is technically straightforward and provides the optimally achievable radiation dose distribution.

Emergent transcatheter embolization of massive hepatic hemorrhage

Seven cases of blunt trauma to the abdomen are reported with significant hepatic vascular injury, hemoperitoneum, and hypotensive shock. Six patients were involved in motor vehicle accidents, and one patient was assaulted. By computed tomographic imaging, the liver injuries were all grade 3–4, according to the Mirvis classification system (Mirvis SE, et al. Radiology 1989;171:27–32). All seven patients underwent angiography with the identification of an active bleeding site(s). Embolization was performed with Gelfoam pledgets, steel coils, polyvinyl alcohol particles, or a combination of materials. In all seven cases, technical success was achieved, with control of hemorrhage and stabilization of the patient’s shock. One patient later succumbed to multiorgan failure. One patient required a second embolization for hemorrhage at a second site. Transcatheter embolization is an effective method for the control of life-threatening hepatic hemorrhage secondary to blunt abdominal trauma.

The Role of Microvascular Permeability in the Mechanism for Stunned Myocardium in Rats

The microvascular permeability of stunned myocardium in ratsin vivowas studied with FITC-labeled albumin (FITC–BSA). It was found that 15 and 20 min of myocardial ischemia followed by 1 hr of reperfusion resulted in myocardial stunning. The concentrations of FITC–BSA in myocardial tissue were 240.6 ± 7.8 (IS15) and 267.4 ± 7.9 (IS20) μg/g myocardium in ischemic groups, respectively, which were significantly higher than those in the control group (166.0 ± 7.9 μg/g myocardium;P< 0.01). In stunned groups, the concentrations were 224.8 ± 11.8 (MS15) and 241.7 ± 6.0 (MS20) μg/g myocardium, decreased from those in ischemic groups but still higher than those in control group by 35.4 and 45.6%, respectively. The more significant the concentration of FITC–BSA, the more serious the myocardial stunning. Electron microscopy revealed no significant vascular injury. The results suggest that the increase in microvascular permeability resulting from transient ischemia is functional and is involved in the pathogenesis of stunned myocardium.

Ultrastructural demonstration of spirochetal antigens in synovial fluid and synovial membrane in chronic lyme disease: Possible factors contributing to persistence of organisms

To perform the first systematic electronmicroscopic (EM) and immunoelectron microscopy (IEM) study of the pathological changes and the evidence of spirochete presence in synovial membranes and synovial fluid (SF) cells of patients with chronic Lyme arthritis. EM examination was performed on four synovial membrane and eight SF cell samples from eight patients with chronic Lyme disease. Spirochetal antigens in the samples were sought by IEM using monoclonal antibody to Borrelia burgdorferi outer surface protein A (OspA) as the immunoprobe. Prominent ultrastructural findings were surface fibrinlike material, thickened synovial lining cell layer and signs of vascular injury. Borrelia-like structures were identified in all four synovial membranes and in two of eight SF cell samples. The presence of spirochetal antigens was confirmed by IEM in all four samples studied (one synovial membrane and three SF cell samples). OspA labelling was in perivascular areas, deep synovial stroma among collagen bundles, and in vacuoles of fibroblasts in synovial membranes; and in cytophagosomes of mononuclear cells in SF cell samples. Electron microscopy adds further evidence for persistence of spirochetal antigens in the joint in chronic Lyme disease. Locations of spirochetes or spirochetal antigens both intracellulary and extracellulary in deep synovial connective tissue as reported here suggest sites at which spirochaetes may elude host immune response and antibiotic treatment.

Late Lateral Displacement of the Humeral Head after Closed Reduction of Glenohumeral Dislocation

WAXMAN, DAVID L. M.D.†; FRANCE, MATTHEW P. M.D.†; HARRYMAN, DOUGLAS T. II M.D.†, SEATTLE, WASHINGTON Author Information

Vascular Injuries and Their Sequelae in Pediatric Supracondylar Humeral Fractures: Toward a Goal of Prevention

Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first 24-36 h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children.

Advances in the Diagnosis and Treatment of Extremity Vascular Trauma

Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The still evolving trend in management of these injuries is toward more rapid, less costly, and less invasive diagnostic modalities, an improved understanding of the therapeutic implications of the clinical presentation, prompt repair of significant vascular injuries, and a liberal use of adjunctive techniques such as fasciotomy. Many issues remain to be resolved by further experience and investigation, in order to achieve optimal limb salvage in this setting.

Renal ablation acutely transforms 'benign' hypertension to 'malignant' nephrosclerosis in hypertensive rats.

The present studies examine the consequences of the hemodynamic changes associated with approximately 5/6 renal ablation in the spontaneously hypertensive rat (SHR), a strain that normally does not exhibit evidence of vascular and/or glomerular injury until late in life despite significant hypertension. Control SHR with intact renal mass demonstrated normal renal autoregulation and an absence of vascular or glomerular injury. Renal mass reduction resulted in an initial expected decrease in renal blood flow to the remnant kidney at 5 days (2.8 +/- 0.3 mL/min) compared with control SHR (8.1 +/- 0.7 mL/min) at a mean arterial pressure of approximately 160 mm Hg (P < .01). By 10 to 14 days after renal ablation, marked renal vasodilation was observed (renal blood flow 8.3 +/- 0.8 mL/min at mean arterial pressure of approximately 160 mm Hg) along with severe impairment of autoregulatory ability. Striking and florid vascular injury to interlobular arteries and afferent arterioles had also developed by 10 to 14 days after approximately 5/6 renal ablation in a pattern similar to that observed in "malignant" hypertension, despite systolic blood pressures that were not significantly different from those in control SHR (168.2 +/- 6.4 versus 165.6 +/- 4.7 mm Hg). An additional group of SHR that were made normotensive with a triple-therapy antihypertensive regimen before and after approximately 5/6 renal ablation also exhibited hemodynamic changes similar to those in the untreated rats at 10 to 14 days but did not develop significant vascular or glomerular injury.(ABSTRACT TRUNCATED AT 250 WORDS)

The Success of Duplex Ultrasonographic Scanning in the Diagnosis of Extremity Vascular Proximity Trauma

I read with great interest the article by Fry et al 1 in the December 1993 issue of theArchives.The report concerns a cohort of 200 patients with 225 extremity injuries, only 50 of whom underwent confirmatory operative exploration or arteriography. The authors detail remarkably good results with duplex scanning for the diagnosis of significant vascular injury: 100% sensitivity, 97.3% specificity, and an overall accuracy of 98.5%. Although I wholeheartedly agree that duplex scanning may potentially have an invaluable role in the diagnosis of vascular injuries, a few cautionary provisos are in order. In a small pilot study recently published, Schwartz et al 2 found that duplex ultrasonography was capable of diagnosing an arterial injury in 58% of the cases and that it was very technically dependent. This provides a note of caution with regard to the widespread application of duplex scanning. The technical expertise required to adequately examine an

The role of arteriography in assessing vascular injuries associated with dislocations of the knee.

All patients with a diagnosis of knee dislocation during a 7 1/2-year period (1984-1991) were reviewed retrospectively. There were 37 knee dislocations (KDs) in 35 patients. The mechanism of injury was predominantly motor vehicle or pedestrian crashes. Popliteal artery injury was present in 6 of 37 (16%). There was no significant vascular injury in 31 of 37 knee dislocations as evidenced by normal arteriograms or absence of vascular complications on follow-up. Of those with no significant vascular injury, 3 of 31 had limb ischemia that improved with reduction of the KD, had normal arteriograms, and had no further vascular treatment. All patients with popliteal artery injury had a pulse deficit (five of six) or a documented history of ischemia (six of six). In the absence of these findings, no patient was found to have an arterial injury. Arterial injuries were treated with interposition (five of six) or bypass graft (one of six) and fasciotomies (six of six). Amputation was required in one of six of the vascular injury group and none of 31 of the remainder of the patients with no vascular injury. We recommend the selective use of arteriography in patients with KDs based on a history or clinical findings of ischemia and do not recommend routine arteriography for all patients with KD.

Reassessing the role of arteriograms in the management of posterior knee dislocations.

Vascular injury has been reported in up to one third of patients with posterior knee dislocations, which has led to the routine use of arteriograms in the management of these injuries. Recent studies have shown physical examination (PE) is reliable in detecting significant vascular injuries requiring surgery from other mechanisms. We hypothesized that PE would be similarly sufficient to assess popliteal injury in patients with posterior knee dislocations. To test this, we reviewed the records of all 37 patients with 38 such injuries at our institution over the past 5 years. The average age was 29.5 years, and 31 patients (81.5%) had other associated injuries. All dislocations were the result of blunt trauma. Two patients (5.3%) had hard signs (distal ischemia and no pulses) that clearly indicated vascular injury. Total occlusions of the popliteal artery were seen on arteriograms in both cases and these were successfully treated surgically with reversed saphenous vein bypass grafts. The remaining 36 dislocations manifested no hard signs of vascular injury (absent pulses, distal ischemia, active bleeding, bruit/thrill). Nineteen patients (50.0%) had normal vascular examination results, did not receive arteriograms, and had no adverse sequelae, with a mean follow-up of 9.3 months (range 1 day-43 months). Sixteen patients with 17 dislocations (44.7%) underwent arteriography and the findings appeared normal in ten extremities; nine of these extremities had normal pulses and one had a diminished but palpable pulse. A minimal injury (intimal defect, 3; narrowing, 4) was demonstrated in seven extremities, five with normal pulses and two with diminished pulses.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of major penetrating glass injuries to the upper extremities in children and adolescents.

Penetrating glass injuries are a common cause of severe neurovascular damage, both in adults and in children. Frequently, an innocent skin wound disguises the extensive nature of the injuries beneath. Nineteen children and adolescents (ages 3-16 years) with a mean age of 9 years who sustained upper extremity penetrating glass wounds were evaluated retrospectively in order (1) to determine the incidence of unappreciated significant neurologic, musculotendonous, or vascular injury; (2) to provide indications for intraoperative evaluation under anesthesia; and (3) to further define the role of microneurorrhaphy in this population. Twelve patients sustained injuries above the elbow and seven patients injuries distal to the elbow. Above the elbow, the structures injured in order of frequency were the median nerve (75%), the brachial artery (58%), the ulnar nerve (50%), the musculocutaneous nerve (33%), sensory nerves of the arm and forearm and venae commitantes (42% each), the radial nerve (25%), and the chords of the brachial plexus (8%). Distal to the elbow, the ulnar nerve was the most frequently involved (71%), followed by the ulnar artery (57%), the flexor carpi ulnaris (57%), the superficialis and profundus flexor tendons (43%), the median nerve (43%), and the palmaris longus and flexor carpi radialis (14% each). Early exploration is critical to successful management. Vascular repairs and or microneurorrhaphy were necessary in all cases. A detailed follow-up evaluation to assess the results of these repairs was carried out from 4 to 9 years postsurgery. There were no clinical problems related to the vascular reconstructions. The results of the nerve repairs in this small series of children and adolescents were remarkably good.(ABSTRACT TRUNCATED AT 250 WORDS)