Artery and Vein (blood vessel) injuries
What are blood vessels?
Blood vessels are the tubes that take blood under high pressure from the heart to the body (arteries) and return blood under low pressure back to the heart via the lungs (veins). In the arm and especially the hand there are enough blood vessels with links between them that cutting of one main artery does not usually give a major problem. If both main arteries to the hand or fingers/thumbs are cut then the hand or finger/thumb may die within 4-6 hours. This becomes a very urgent surgical emergency.
Why does it occur?
Injuries usually occur due to a cut with a sharp object such as a knife or broken glass. Heavy machinery can cause amputation of a whole finger or even part or all of the hand.
What happens if nothing is done?
(This is referred to as the natural history i.e. what happens if Nature runs its own course.)
If just one artery is cut there will be a lot of bleeding initially but then the body is usually able to seal the bleeding artery. Veins are under lower pressure and will seal more easily, although in elderly patients there may be considerable bleeding initially. The bleeding stops more easily if the hand/arm is elevated i.e. held up to reduce the blood pressure in the hand and if local pressure is applied (this is common sense first aid that most people use). If a blood vessel has been cut in part (especially an artery) this may make it harder for the body to seal off and sometimes surgery is the only way to stop the bleeding. If both arteries to a finger or thumb have been cut then at least one needs repairing within 6 hours to avoid death of the finger/thumb (see below).
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking in particular at the area of injury. The diagnosis of a significant injury is usually clear. As well as damage to an artery/vein there may be damage to other important structures such as nerves and tendons. These need to be addressed on their own merits (see relevant information sheets). Often damage just to a single artery with no evidence of damage to other local structures can be left as the risks of surgery will outweigh any likely benefits. But if there is doubt about the extent of deep injury then surgical exploration will almost certainly be needed.
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
The diagnosis is usually obvious after listening to and examining a patient. An X-ray may be taken to look for possible bone or joint injury or to look for any foreign material that might have been left in the wound such as a shard of glass.
In exceptional circumstances a special X-ray or scan will be taken following an injection of a special dye into an artery. This is called an arteriogram. It helps to show the extent of the injury before going to surgery.
Treatment:
What are the non-operative treatments?
Treatment should start with non-operative options. The first step is stopping bleeding by applying pressure and raising the hand/arm. Then the wound can be assessed and other injuries looked for such as to nerves or tendons. If the wound is reasonably clean, the blood supply to the hand/finger/thumb is good and there appear to be no other injuries then the wound can be cleaned and either left to heal on its own if small e.g. < 2cm long (under 1 inch), or sewn up under local anaesthetic. If the blood supply is good but there is doubt about injury to other important structures then the wound can be explored under local anaesthetic in the Accident and Emergency (A&E) department. If there is no deep injury then again the wound can be left open or sewn up after cleaning. If there is doubt after exploration of the wound or clearly other significant injuries then the patient should be referred to a specialist for planned surgery. This does not usually need to be performed immediately but can be done over the next few days or even a week or so. In the mean time the wound can either have been sewn up or left open and covered whilst awaiting definitive surgery. If the blood supply to the hand/finger/thumb is not adequate this is a surgical emergency and the patient needs to be prepared for and taken to the operating theatre within hours. Arteries and veins even tiny ones in the fingers can be repaired saving the hand/finger/thumb. This is not always successful. Repeat surgery may be needed and sometimes the repair fails and the hand/finger/thumb dies. Amputation surgery is then needed with possible late reconstructive surgery. The total time in hospital varies. Simple repairs in the finger can often be performed as a daycase i.e. with no overnight stay. Complex repairs around the wrist may result in 2 – 3 nights in hospital.
What happens in the next few weeks?
The care of the hand/arm in the post-injury/post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation.
Comfort and elevation: These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine) if the hand/wrist/elbow has been operated upon. The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
Dressings: Blood vessel injuries on their own tend not to need much protection beyond a supportive dressing for 5-7 days. If there have been other injuries such an nerve or tendon injuries requiring repair then these may need protection in a plaster or splint for 4-6 weeks. The treating Hand specialist will organise appropriate change of dressings/splints.
Movement: Most joint movement should be regained gained following injury just to one artery or vein. If there are other injuries recovery is more complex and less reliable. Most movement should be achieved early i.e in the first month or so from injury. In particular in the fingers the joints can quickly become stiff. Early movement is important. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people manage to stretch 5-6 times a day. Elevation and icing the elbow also help reduce swelling and thus pain and improve movement.
Wound massage: The wound(s) should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks, or after 4-6 weeks if protected in plaster). This is called desensitisation. Massage reduces the scar sensitivity which can be a nuisance. If this is marked hand therapy may be organised to help reduce the scar tenderness. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful. Examples of activities to avoid are using the palm to grip/twist a heavy or tight object or use the palm to help get out of a chair.
Return to daily activities: Many patients can return to light work e.g. office work in a few days – 2 weeks. With combined artery and other injuries this may be much longer. Return to heavy manual work may take up to 6 weeks even for relatively simple injuries. The treating team should advise about this.
What are the results of treatment?
This is mainly dependent upon the severity of the injury. If there is only injury to one artery or a few veins then an excellent recovery should occur although there will often be some aching in cold and wet weather. This typically improves for up to 3-4 years from injury but usually does not resolve fully.