Upper extremity arterial injuries account for up to 50% of all peripheral vascular injuries. Of these, brachial artery lacerations are the most common, followed by those of the ulnar and radial arteries, while digital artery lacerations are seen the least frequently. Digital artery lacerations usually occur secondary to open puncture wounds to the hand, but these injuries may also result from severely displaced fractures or crush injuries. Lacerations that transect the digital artery are obvious in most cases, but digital artery injuries associated with puncture and/or bullet wounds often require a higher level of suspicion to detect and accurately diagnose. A history of profuse bleeding, particularly pulsatile bleeding, associated with a finger laceration suggests a digital artery injury. Each finger has two digital arteries and one intact digital artery will usually provide adequate profusion for the finger. Thus, the necessity for repair of a single isolated digital artery laceration remains controversial. When both digital arteries are cut then the finger will likely show signs of ischemia and repair of at least one digital artery is mandatory.1-5
Options for a single isolated digital artery laceration include cauterization, ligation, repair or very rarely reconstruction with a vein graft. However, single complete isolated digital artery lacerations often stop bleeding spontaneously or after the application of a simple pressure dressing and require no further treatment.1-5
Pathophysiology
- A digital artery laceration occurs when the vessel is transected anywhere along its length. Possible sources of trauma include falls into glass, cuts secondary to a kitchen knife, industrial and traffic accidents, grinder/saw injuries, and stabbing, gunshot, and other penetrating wounds from violent altercations. Most lacerations involve penetrating or blunt trauma, but rarely iatrogenic causes and closed injuries may also be responsible.3,5-8
- Several studies have shown that glass is the material most commonly responsible for penetrating digital artery injuries.4
- Although closed simultaneous digital artery injuries are rare, lacerations of both digital arteries can result in significant functional insult to the hand if left untreated, which is why hand surgeons must be suspicious when treating an injured digits.8
- A digital artery laceration can be a partial or a complete transection. Incomplete digital artery laceration can but rarely lead to pseudoaneurysms. Incomplete digital artery lacerations also have a tendency to not stopped bleeding spontaneously because the digital artery ends cannot retract and thrombose normally.
- Digital artery injuries can also be categorized as noncritical or critical by the potential for ischemic tissue damage secondary to the unrepaired digital artery laceration. Patients with pre existing peripheral vascular disease may have digit perfusion jeopardized by a single digital artery laceration but usually both arteries must be cut before digit viability is in question.
- Isolated digital artery lacerations can occur in patients with inadequatel blood supply from the remaining digital artery. Therefore, deciding whether an injury is noncritical is a clinical judgment that ideally will be made in the operating room after surgical assessment of the digital artery injury. The dominance of the injured digital artery in the specific patient, associated injuries, and the medical comorbidities of the patient sould be considered.1,3
- Critical digital artery injuries are associated with acute ischemia in the digit because of damaged and/or inadequate circulation in the remaining digital artery. With critical arterial injury the patient is at risk for amputation and hypovolemic shock.1,3,9
Related Anatomy
- Related anatomical structures include:
- Thumb radial, ulnar and dorsal digital arteries
- Index finger radial and ulnar digital arteries
- Long finger radial and ulnar digital arteries
- Ring finger radial and ulnar digital arteries
- Little finger radial and ulnar digital arteries
- Brachial artery
- Radial artery with its deep and superficial branches
- Ulnar artery with its deep and superficial branches
- Collateral arteries including the superficial palmar arch and the deep palmar arch
- In the proximal forearm, the brachial artery bifurcates at the radial tuberosity into the radial and ulnar arteries. The ulnar artery serves as the source vessel for the superficial palmar arch, while the radial artery serves as the source vessel for the deep palmar arch, and there are myriad anastomotic interconnections between these 2 systems.
- The superficial palmar arch is a source of 3 or 4 common digital arteries, which in turn branch into the proper digital arteries to supply the fingers, while the deep palmar arch gives rise to 3-4 palmar metacarpal arteries. The dorsal arch, likewise, is the source vessel for the anatomically diverse dorsal metacarpal artery system. These 3 systems communicate at the level of the arches themselves, as well as along the pathway of the longitudinally oriented palmar and dorsal metacarpal arteries and common digital arteries.
- Each finger has two proper digital arteries that run on either side along its length. If one vessel is injured, one proper digital arteries usually maintain the blood supply to the entire finger.
- The ulnar digital artery is dominant in the index finger, while the radial digital artery is dominant in the little finger. In the long and ring fingers, the ulnar and radial digital arteries are dominant respectively, but dominance is less obvious.10,11
- Recent studies have shown that the vascular anatomy of the forearm and hand is very complex and true flow dominance can be difficult to assess accurately.11
- Studies of the anatomic variability of the vascular network of the hand demonstrate that the superficial palmar arch is complete in more than 80% of patients, while the deep palmar arch is complete in more than 90% of patients.11
Overall Incidence
- Almost half of the diagnosed vascular injuries occur in the upper extremity.
- The majority of the upper extremity vascular injuries will be to the brachial artery with fewer arterial injuries occurring in the radial, ulnar, and digital arteries.3
- Blunt injuries account for 6-10% of upper extremity vascular trauma and are often associated with musculoskeletal and neural injuries.3
Related Conditions
- Chronic vascular insufficiency
- Digital artery thrombosis
- Arterial aneurysm
- Arthritis
- Vasospastic disease
Differential Diagnosis
- Chronic vascular insufficiency
- Digital artery thrombosis
- Arterial aneurysm
- Arthritis
- Vasospastic disease
