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ANEURYSM

Introduction

In the upper extremity, trauma is by far the most common cause of aneurysms. True aneurysms result from repetitive blunt trauma and weakness in an arterial wall; false (pseudo) aneurysms result from penetrating trauma and arterial perforation.  The false aneurysms are often eccentric and do not have an endothelial lining.  Usually, a small arterial puncture bleeds, a clot is formed and is eventually surrounded by fibrous tissue.  As the clot begins to lyse, the pressure in the fibrous sac increases creating new leaking and a new clot which, again, may be surrounded by a fibrous scar.  This bleed, clot, lyse and bleed again cycle can cause the aneurysm to slowly enlarge over weeks or months.  The enlarging pulsatile aneurysms can cause pain, compress nerves and be the source of distal emboli with secondary ischemia.  True aneurysms include all layers of the arterial wall with weakening of the internal elastic lamina.  Traumatic aneurysms in the hand can arise from acute causes or from chronic occupational related repetitive injury. Aside from trauma, true aneurysms can also be idiopathic, arteriosclerotic or mycotic.

Related Anatomy

  • Ulnar artery and branches
    • Guyon’s canal
    • Hamate
    • Hypothenar eminence
  • Radial artery and branches
    • Scaphoid edge of trapezium
    • First metacarpal
    • First dorsal interosseous muscle

Incidence and Related Conditions

  • In the hand, ulnar artery aneurysms are most common; 70% from blunt trauma, 20% from penetrating trauma and 10% with no history of trauma
  • Digital artery aneurysms are very rare

Differential Diagnosis

  • Ganglion cyst
  • Synovial cyst
  • Dermal cyst
  • Abscess
  • Neural tumor
  • Muscular fibroma
  • Raynaud’s disease
  • Venous aneurysm
ICD-10 Codes

  • ANEURYSM

    Diagnostic Guide Name

    ANEURYSM

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    ANEURYSM, ARTERY, UPPER EXTREMITYI72.1   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Ulnar Artery Aneurysm
    Ulnar Artery Aneurysm
  • Ulnar Artery Aneurysm
    Ulnar Artery Aneurysm
  • Ulnar Artery Aneurysm
    Ulnar Artery Aneurysm
  • Ulnar Artery Aneurysm
    Ulnar Artery Aneurysm
  • Radial artery pseudoaneurysm (arrow) after what was thought to be a superficial laceration that was closed in the emergency room.
    Radial artery pseudoaneurysm (arrow) after what was thought to be a superficial laceration that was closed in the emergency room.
Symptoms
Pain
Pulsatile mass that is gradually expanding
Mottling of fingers (ischemia)
Cold intolerance
Purple or blackish fingers
The skin over an aneurysm may be erythematous
There may be a history of recent catheterization of the artery
Typical History

A typical patient is a young male with a history of a puncture wound to the volar radial aspect of the right wrist which occurred several months earlier.  On presentation, he complains of a painful enlarging mass with a pulse.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Angiogram of right ulnar artery aneurysm
    Angiogram of right ulnar artery aneurysm
Treatment Options
Conservative
  • None
Operative
  • Resection of aneurysm and reconstruction of artery with resection and arterial repair or patch grafting of the artery or interpositional vein grafting
  • If uninvolved artery provides adequate blood supply to the area, resection and ligation is sufficient
Complications
  • Infection
  • Thrombosis
  • Nerve injury
Outcomes
  • Resection and ligation: excellent results from numerous case reports
Key Educational Points
  • False or pseudo aneurysms occur when an artery sustains a small puncture wound that bleeds intermittently after the skin wound heals.
  • False aneurysms have no endothelial lining.
  • True aneurysms have a weak internal elastic lamina with uniform dilation of all layers of the arterial wall.
  • Painful pulsatile masses require further diagnostic investigation.
  • Appropriate treatment options include resection of the aneurysm with end-to-end arterial repair or patch grafting or alternatively interpositional vein grafting.  If there is adequate collateral blood supply to the area served by the involved artery, then resection of the aneurysm and proximal and distal ligation of the artery is sufficient.
References

New Articles
 

  1. Igari K, et al. Surgical treatment of aneurysms in the upper limbs. Ann Vasc Dis 2013;6(3):637-41. PMID: 24130621
  2. Nagura I, et al. Nontraumatic true aneurysm of the superficial palmar arch: a case report. Kobe J Med Sci 2012;58(1):E29-32. PMID: 22972027

Reviews

  1. De Santis F, et al. Forearm and hand arteries’ aneurysms – a case report of bilateral true ulnar artery aneurysm in the hypothenar eminence and systematic review of the literature. Vascular 2013;21(3):169-76. PMID: 23493282
  2. McClinton MA. Reconstruction for ulnar artery aneurysm at the wrist. J Hand Surg Am 2011;36(2):328-32. PMID: 21276898

Classics

  1. Smith JW. True aneurysms of traumatic origin in the palm. Am J Surg 1962;104:7-13. PMID: 13914312
  2. Spittel JA Jr. Aneurysms of the hand and wrist. Med Clin North Am 1958;42(4):1007-10. PMID: 13564986
  3. Koman LA, Smith BP, Smith TL, Ruch DS, Li Z.  Vascular disorders.  In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH.  Green's Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier, 2011:2197-2240
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