Cold intolerance may be assessed by using the McCabe Cold Sensitivity Severity Scale. An arterial arch is defined as complete when it connects with a branch from another independent artery. Winston-Salem, NC: Wake Forest University Orthopaedic Press, 1997, with permission.). Changes in the latter factor are controlled by the sympathetic system (vasoconstriction, alpha-adrenergic pathways) and the nitric oxide pathways (vasodilation). Taking a meticulous and detailed history is important and should emphasize (1) the presence or absence of trauma (e.g., using the hand as a hammer); (2) environmental factors (e.g., profession, current medications, drug exposure, and smoking); and (3) congenital factors, such as personal and family history of collagen vascular disease, clotting abnormalities (or previous clotting episodes), and heart problems. A critical vascular event (or injury) results in tissue necrosis with gangrene when surgical intervention is not sufficient to restore the structural integrity of the vessels. Chronic post-traumatic thrombosis and aneurysms of the ulnar and radial arteries may affect 10% to 15% of laborers who use their hands as a hammer, and thus this condition is the source of a significant social burden. Then the radial and ulnar arteries are occluded by the examiner and released sequentially. Physical examination should address the entire upper extremity from the neck to the fingertips. 60-5 ). 60-4 ). Although myriad normal variations of the digital vessels exist, they all share the presence of three common volar digital arteries at the level of the metacarpophalangeal joint. In this case, the additional studies previously mentioned will help to evaluate both macrovascular and microvascular flow.
Control of digit blood flow is governed by complex factors that are elucidated incompletely. ICST yields reproducible data to facilitate physiologic staging and monitor the effects of management. Group II is composed of patients with occlusive disease and adequate collateral circulation, but in contrast to group I they have refractory vasospasm. Chronic low-grade trauma initially may be responsible for periadventitial thickening resulting in constriction and stenosis, which may resolve spontaneously, be treated by surgical stripping of the adventitia, or lead to subsequent intimal damage with thrombosis. Isolated cold stress testing (ICST). Both digital arteries at the base of the finger are compressed, and then the patient elevates and fully flexes the finger several times, or the finger is milked to obtain blanching. The latter has a major negative causal effect on occlusive diseases.
The potential risks and benefits of treatment must be considered for each case and tailored to the needs and expectations of the patient.
The vascular status should include an evaluation of skin color, texture, temperature, and autonomic function, and the presence of atrophy, hair loss, ulcers, and petechiae should be documented.
From Koman LA (ed): Bowman Gray School of Medicine Orthopaedic Manual. Evaluation of 800 hands in 400 controls showed that 91% of hands were considered normal when uniform refill occurred in less than 6 seconds. If the DBI is greater than or equal to 0.7, there is adequate collateral circulation, and resection may be performed. However, symptomatic, noncritical events in which the collateral circulation or control presents adequate compensation also occur. The etiologies of thrombosis and aneurysm are similar ( Fig 60-3 ).
The presence of unilateral Raynauds phenomenon represents occlusive disease, unless proven otherwise . A precise history of the frequency of attacks, digit distribution, and duration of color changes is critical. Group III patients have occlusive disease, vasospasm, and inadequate collateral circulation. The ulnar and radial arteries branch into the superficial and deep palmar arches, respectively; in 5% of extremities, a persistent median artery is present ( Fig. 
Measurement of digital brachial indexes (DBIs) also guides the treatment decision.
Cut-film arteriograms using subtraction techniques when performed with newer contrast agents and vasodilators provide optimal structural information. Repetitive, or even acute, trauma may cause intimal damage leading to thrombosis and/or aneurysmal dilatation, or peri-adventitial fibrosis, which results in vessel constriction or even total occlusion. The goal of management is to restore pulsatile digital flow. It includes inspection, palpation, range of motion, evaluation of motor power, sensibility, and status of the vascular system. Management options include (1) environmental and behavioral modifications, such as elimination of smoking; (2) oral pharmacologic intervention; (3) biofeedback; (4) cervicothoracic sympathectomy; (5) thrombolytic therapy; and (6) surgical intervention, such as resection and ligation of involved segment(s) (Leriche-type sympathectomy), peripheral sympathectomy, embolectomy, and arterial reconstruction ( Table 60-2 ). Patencies of the ulnar and radial arterial systems are evaluated by palpating the pulses and performing the timed Allen test ( Fig. In our experience, delayed refill of longer than 3 seconds warrants careful analysis. However, symptoms may not necessarily correlate with arteriographic findings. Approximately 80% of superficial arches and 97% of deep arches are complete. Regional blood flow depends on centrally generated pressure and peripheral vascular resistance. The combined use of the following modalities permits physiologic-specific and patient-oriented management: Digital plethysmography (pulse volume recording) ( Fig. 
Based on anatomic and physiologic considerations, the following three-group classification by Koman and Urbaniak is useful in the selection of appropriate treatment options. Technetium-99m three-phase bone scanning (TPBS). Symptoms and signs related to the vascular system result from failure of (1) structural components (i.e., inadequate arteries to supply the tissues), (2) functional components (i.e., vasospastic disease), or (3) both. (From Koman LA [ed]: Bowman Gray School of Medicine Orthopaedic Manual. 60-1 ). The patient should be evaluated with standardized, validated outcome instruments (questionnaires) that provide an objective and reproducible assessment of his or her current status and allow valid comparisons following the effects of intervention. Subsequently, the hand is lowered, and the examiner releases compression from one of the arteries. Pain, numbness, cold intolerance, nail bed changes, and/or the presence of a mass are the hallmarks of arterial compromise. It does not address management of patients with primary vasospastic disease. In addition, color changes (the white, blue, and red of Raynauds phenomenon), pulsating or throbbing masses, ulcers, and/or gangrene also may be accompanying phenomena. An arch is defined as complete if it is directly connected to the other arch or to a named vessel or collateral greater than 1.5 to 2 mm in diameter. Upper extremity integrity of structure and function is evaluated at rest and under the application of a stressor. Finally, a digital Allen test may be performed for assessment of occlusion of a digital artery at or distal to the metacarpophalangeal joint. In normal states, 80% to 90% of total digit blood flow is thermoregulatory (non-nutritional), whereas the remainder consists of the nutritional flow that passes through nutritional capillaries, essential for providing cells with the nutrients required for their viability ( Fig. Symptoms and signs of occlusive disease depend on the extent and location of thrombosis, presence or absence of distal emboli, adequacy of collateral circulation, and presence or absence of vasospasm. The examiner releases the compression over one of the two arteries while maintaining a pressure of 11 pounds on the other. Arteriography, the gold standard for providing structural anatomic information.
Acute or repeated trauma may cause direct intimal damage, leading to stasis and thus predisposing to thrombosis. Testing should include a complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein, factor V Leiden, abnormal protein C or S, antithrombin III, and antiphospholipid antibodies ( Table 60-1 ). If blanching disappears and color returns, the artery is patent. The timed version of the Allen test was devised by Gelberman and Blasingame in 1981. Common instruments include the visual analog pain scale (VAS), the pain portion of the Rand Corporation Short Form 36 (SF 36), the McGill Short Form Pain Questionnaire, and self-administered questionnaires designed to assess upper extremity symptoms/function. Segmental arterial pressures (SAPs). This uses LDF and cutaneous digital temperature measurements before, during, and after the application of stress (in the form of cold temperature) and is invaluable in assessing the capability of a vascular bed to respond to and recover from physiologic stress.
A restoration of flow improves symptoms, function, and health-related quality of life significantly. Group I includes patients with occlusive disease and secondary vasospasm who have existing adequate collateral circulation.
Laser Doppler fluxmetry (LDF) cutaneous perfusion measurements, Nailfold vital capillaroscopy, which is the only means of directly estimating nutritional flow. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Vascular Thrombosis and Aneurysm About the Wrist, The Management of Avascular Necrosis in the Carpus: Preisers Disease and Avascular Necrosis of the Capitate, Wrist Ligament Innervation and Sensorimotor Function, Ulnar Styloid Triquetral Impaction: Diagnosis and Treatment, Combined Dorsal and Volar Plate Fixation of Complex Fractures of the Distal Radius, Volar Angle Stable Plating for Distal Radius Fractures, Antineutrophil cytoplasmic antibodies (ANCAs), Prothrombin time and partial thromboplastin time.
They may be managed conservatively with sympatholytic medications (e.g., calcium channel blockers) to control the vasospasm, or surgically by sympathectomy performed by resection of the thrombosed segment and ligation, or by periarterial sympathectomy. The superficial palmar arch (main vessel: ulnar artery) is complete in 78.5% of patients, whereas the deep palmar arch (main vessel: radial artery) is complete in 98.5% of patients. The common denominator in all cases is the lack of adequate nutritional flow to deliver oxygen and essential metabolites to cells and the failure to recycle metabolic waste effectively. Depending on the functional stage (described in the previous text), initial management is nonoperative, operative, or a combination of both. The presence of an underlying disorder affects the natural history, management, and prognosis. Winston-Salem, NC: Wake Forest University Orthopaedic Press, 2007, with permission.
Magnetic resonance angiography (MR angiography), including the use of gadolinium contrast, and computed tomography angiography (CT angiography), are promising less invasive techniques. These patients require minimal or no treatment, and frequently the diagnosis is a fortuitous finding during physician visits for unrelated pathologies.
The Allen test is performed by asking the patient to close the hand as tightly as possible for 1 minute or until blanching of all fingers occurs. To obtain optimal function of the vascular system, restoration of pulsatile flow into nutritional channels under stressed and unstressed conditions is critical. If the DBI is less than 0.7, collateral circulation is adequate, and arterial reconstruction is warranted.
They require restoration of arterial continuity, with either surgical reconstruction or thrombolysis. 60-2 ). The return of color to the hand indicates a patent vessel. Thoracic outlet syndrome should be included in the differential diagnosis.
Laboratory Studies in the Evaluation of a Patient with Upper Extremity Vascular Disorder. The DBI is the ratio of the brachial blood pressure to the digital blood pressure. The initial laboratory evaluation should include an evaluation for a possible autoimmune disease or hypercoagulable state. This chapter discusses the etiology, evaluation, and management of post-traumatic occlusive disease about the wrist.