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RADIAL ARTERY LACERATION

Introduction

Radial artery injuries can be secondary to open lacerations, puncture wounds, bullet wounds, severe displaced fractures, or crush injuries. Brachial artery injuries are more common than radial and ulnar artery injuries; however, radial and/or ulnar artery lacerations are commonly associated with laceration around the volar aspect of the wrist. A laceration cutting the radial artery is usually obvious, but the radial artery injuries associated with a puncture and/or bullet wound require a higher level of suspicion to detect and accurately diagnose. A history of profuse bleeding, particularly pulsatile bleeding, hypotension, and/or a pulsatile mass associated with a wound are indicators of a possible arterial injury. Radial artery lacerations are usually associated with other soft tissue injuries or fractures. Typical associated soft tissue injuries are tendon lacerations and nerve lacerations.1,3

Pathophysiology

  • A radial artery laceration occurs when the vessel is transected anywhere along its length.
  • A radial artery laceration can be a partial or a complete transection. Incomplete radial artery laceration can lead to pseudo-aneurysms and sustained bleeding because of the failure of the cut vessel to retract and thrombose.
  • Radial artery injuries can also be categorized as noncritical or critical by the potential for ischemic tissue damage secondary to the unrepaired radial artery laceration.
  • Noncritical radial artery injuries are usually not associated with combined neural and/or bone injuries. These radial artery injuries occur in the upper extremity with collateral circulation that is normal and can provide adequate blood flow without an intact radial artery.
  • With a healthy collateral circulation, the patient will not have ischemic pain, impaired function or experienced cold intolerance. However, isolated radial artery lacerations can occur in patients with inadequate collateral blood supply. Therefore, deciding whether an injury is non critical is a clinical judgment that ideally will be made by a surgeon's assessment of the radial artery injury, the dominance of the injured radial artery in the specific patient, associated injuries, and the medical comorbidities of the patient.1, 3
  • Critical radial artery injuries are associated with acute ischemia to the hand because of damaged and/or inadequate collateral circulation to the hand. With critical arterial injury the patient is at risk for amputation and hypovolemic shock. World War II data showed a 5% forearm amputation rate with isolated radial artery lacerations.1, 2, 8

Related Anatomy

  • Related anatomical structures include: 
    • 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 the and the deep palmar arch.
    • Digital arteries of the thumb and fingers especially the index finger.
  • At the level of the anterior elbow, the radial artery originates from the brachial artery and lies superficial to the biceps tendon, pronator teres muscle and the finger flexors. At this level the radial artery is deep to the bicipital aponeurosis and the brachioradialis muscle.
  • Distally the radial artery lies radial to the brachioradialis tendon and radial to the flexor carpi radialis tendon.
  • Anatomic variations of the radial artery are common. One such variation that may occur in 2–14% of patients is a high origin of the radial artery from the brachial or axillary artery.5, 9
  • Another important aspect of the radial artery anatomy and physiology is the radial artery’s contribution to the arterial blood flow in the upper extremity. Despite the ulnar artery being anatomically larger, the radial artery is frequently provides the majority of the blood flow to the hand.
  • Kleiner et al, showed that the radial artery provided the dominant blood flow to the 3 or more of the radial digits in 57% of 120 normal subjects. The radial and ulnar arteries contribute equal flow in 21.5% of normal subjects, while the ulnar artery alone was dominant in 21.5% of these subjects.6, 7
  • More 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. 5

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 and ulnar arteries.2

Related Conditions

  • Chronic vascular insufficiency
  • Radial artery thrombosis
  • Arterial aneurysm
  • Arthritis
  • Vasospastic disease

Differential Diagnosis

  • Chronic vascular insufficiency
  • Radial artery thrombosis
  • Arterial aneurysm
  • Arthritis
  • Vasospastic disease
ICD-10 Codes

  • RADIAL ARTERY LACERATION

    Diagnostic Guide Name

    RADIAL ARTERY LACERATION

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

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    RADIAL ARTERY LACERATION (FOREARM LEVEL) S55.112_S55.111_ 
    RADIAL ARTERY LACERATION (WRIST/HAND LEVEL) S65.112_S65.111_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S55 AND S65
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    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
Radial Artery Lacerations
  • Note healed laceration and pulsatile mass (arrow) secondary to a pseudoaneurysm.
    Note healed laceration and pulsatile mass (arrow) secondary to a pseudoaneurysm.
  • Thumb and index tip necrosis after a severe open injury to the distal radial forearm in a patient with multiple injuries including a ruptured spleen. The patient had prolonged hypotension. The radial artery laceration could not be repaired acutely. The hypotension made his collateral circulation inadequate and caused necrosis.
    Thumb and index tip necrosis after a severe open injury to the distal radial forearm in a patient with multiple injuries including a ruptured spleen. The patient had prolonged hypotension. The radial artery laceration could not be repaired acutely. The hypotension made his collateral circulation inadequate and caused necrosis.
Basic Science Photos and Related Diagrams
Radial Artery Assessment
Basic Science Pics
  • Allen Test
    Allen Test
Pathoanatomy Photos and Related Diagrams
Upper Extremity Vascular System
  • Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
    Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
  • Upper Extremity Veins
    Upper Extremity Veins
Symptoms
History of trauma with a penetrating or non-penetrating wound
History of excessive bleeding particularly pulsatile bleeding
Swelling at the zone of injury with or without expanding and/or pulsatile mass
Ischemic fingers especially the thumb and index
Typical History

A typical patient is a 23-year-old right handed male who was "fooling around at a party” and started chasing a friend through the hall and out through a glass door. As the patient approached the doorway, his friend suddenly let go of the door, which sprung shut. The patient blocked the closing glass door with his hand. The glass door shattered and a shard of glass entered the palmar radial aspect of the patient's right wrist. There was immediate pain with very brisk pulsatile bleeding. A physician assistant, who was present at the party, applied a temporary pressure dressing and brought the patient to the emergency room. In the emergency room, a laceration of the radial artery was diagnosed along with a laceration of the flexor carpi radialis tendon. These structures were subsequently surgically repaired in the operating room.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control bleeding
  • Check for signs of ischemia in the hand
  • Assure the presence of adequate blood supply to the hand and digits 
  • Minimize the risk of cold intolerance
  • Prevent hypovolemic shock
  • Prevent the need for amputations
Conservative

There is no nonoperative treatment for a radial artery laceration. With rare exceptions, radial artery that transections must be either ligated, repaired, or reconstructed with a vein graft.

Operative
  • Critical radial artery laceration that are associated with ischemia which is indicated by poor capillary refill, poor skin turgor, delayed or abnormal Allen's testing or poor digital pressure readings, i.e. have a digital brachial index (DBI) of ≤0.74, should be repaired or reconstructed. In the last analysis, the decision to repair or reconstruction is always a clinical judgment call which should be made by a surgeon.1, 3
  • Noncritical isolated radial artery lacerations usually do not require repair but cannot be appropriately treated by surgical ligation of both ends of the transected radial artery. Some surgeons have argued that repairing noncritical lacerations should be done to improve the overall healing and nerve regeneration while preventing cold intolerance. Despite these arguments other surgeons have argued that isolated radial artery laceration repairs frequently thrombose and primary ligation is indicated. However, modern microsurgical techniques prove produce patency rates after radial artery laceration repair of 80% or greater.1, 3, 4
  • The operative repair options for a radial artery laceration include:1, 3
    • Radial artery ligation for true non-critical radial artery lacerations
    • End -to-End microsurgical radial artery.
    • Vein grafting for radial artery lacerations that have resulted in a significant gap in the radial artery 
    • Arterial grafting maybe rarely indicated for young patients with a significant radial artery gap
  • Postoperative management should include anticoagulants such as Dextrin 40, heparin, or factor Xa inhibitors during hospitalization and aspirin for 2-3 months after discharge.
  • Patient should not be allowed to smoke. The wrist is usually splinted for 2-3 weeks and heavier hand use avoided for 6 weeks.1
CPT Codes for Treatment Options

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Common Procedure Name
Radial artery repair
CPT Description
Repair blood vessel, upper extremity
CPT Code Number
35206
Common Procedure Name
Artery ligation
CPT Description
Ligation, major artery, extremity
CPT Code Number
37618
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy
  • Hand therapy is usually directed at the associated bone, tendons, and nerve injuries.
  • After an isolated radial artery laceration repair, early active finger range of motion should be encouraged. Splinting of the wrist is appropriate for 2-3 weeks.1, 3
Complications
  • Bleeding
  • Infection
  • Radial artery thrombosis after microsurgical repair
  • Distal embolization from proximal thrombosis
  • Pseudoaneurysm
  • Cold intolerance
  • Ischemia and tissue necrosis
  • Compartment syndrome
  • Amputation
  • Hypovolemic shock (rare) with isolated radial artery civilian injuries1,3,4,5,7
Outcomes
  • In noncritical radial artery lacerations, ligation produces an excellent outcome in most patients.
  • After radial artery repair, early studies reported a very high incidence of radial artery thrombosis at the repair site. These findings initially caused surgeons to question the wisdom of radial artery repair. However, more recent studies – where repairs were done with modern microsurgical techniques – have shown excellent patency rate as high as 94–100% for a single vessel repair without a vein graft. 4
Key Educational Points
  • Remember the presence or absence of a palpable pulse is not a reliable predictor of the presence of a radial artery laceration. A radial pulse can be present when the artery is completely transected.
  • Current practice trend show increasing efforts to reestablish normal anatomy, i.e. radial artery repair or reconstruction.4,5
  • There is no conclusive data to support the concept that a radial artery repair facilitate nerve recovery after simultaneous neuropathy.3
  • For noncritical radial artery laceration there does not appear to be a clear consensus regarding whether ligation alone or end to end repair is the best therapeutic option.1,3,4
  • Strong pulsatile "backflow” suggests the presence of adequate collateral circulation.1,3
  • Vasospasm can make adequate collateral circulation appear to be inadequate.1,3 Warming the hand and/or applying lidocaine to the exposed portions of the artery may decrease vasospasm
  • Radial artery lacerations can be properly managed without arteriography.1,3
  • Radial artery lacerations should be repaired without excessive tension at the repair site.1,3
  • Intraoperative and postoperative anticoagulation medications are indicated after radial artery laceration repairs.1,3
  • ultrasound and color duplex Doppler
  • Angiogram (rarely needed for evaluating isolated radial artery lacerations)
  • Digital plethysmography (determines brachial artery index (DBI) where a numerical finding of greater than 0.7 indicates adequate perfusion.1,7
References
  1. 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, 6thedition, Philadelphia: Elsevier Churchill Livingstone, 2011, 2797-2240.
  2. Hunt CA, Kingsley JR.  Vascular injuries of the upper extremity.  The Southern Medical Journal, 2000; 93:466-468.
  3. Gelberman RH, Blasingame JP, Fronek A, Dimick MP. Forearm arterial injuries.  J Hand Surg Am, 1979: 4(5):401-408.
  4. Rothkopf DM, Bhu B, Gonzalez F, Borah G, Ashmead D, Dunn R. Radial and ulnar artery repairs: Assessing patency rates with color Doppler ultrasonographic imaging.  J Hand Surg Am, 1993; 18(4):626-628.
  5. Higgins JP, McClinton MA.  Vascular insufficiency of the upper extremity.  J Hand Surg Am, 2010; 35A:1545-1553.
  6. Kleinert JM, Fleming SG, Abel CS, Firelli J.  Radial and ulnar dominance in normal digits.  J Hand Surg Am, 1989; 14A:504-508.
  7. Ruch DS, Aldridge M, Holden M, Smith TL, Koman A, Paterson Smith B.  Arterial reconstruction for radial artery occlusion.  J Hand Surg Am, 2000; 25A:282-290.
  8. Ashbell TS, Kleinert HE, Klutz JE.  Vascular injuries about the elbow.  Clin Orthop Relat Res, 1967; 50:107-127.
  9. Brzezinski M, Lursetti T, London MJ.  Radial artery cannulation: A comprehensive review of recent anatomic and physiologic investigations.  Anesth Analg, 2009; 109:1763-1781.
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