Clinical ResearchClinical Outcome and Quality of Life after Upper Extremity Arterial Trauma
Introduction
In Europe, traumatic vascular injuries, especially of the extremities, are rare.1, 2 Thus, surgical procedures for vascular injuries make up only 0.3-4% of all reconstructive arterial and venous operations.3, 4 For the patient, arterial injuries are always threatening. On the one hand, major blood loss can occur in a very short period of time. On the other hand, there is the imminent danger of limb loss by prolonged ischemia. Diagnostic and therapeutic strategies have been improved continuously to decrease the time to obtain the correct diagnosis, to control bleeding, and to restore arterial blood flow to the affected extremity.5, 6, 7
Not only the kind of arterial injury and the length of ischemia time but also the extent of the concomitant injuries influence the long-term outcome.8, 9, 10, 11 For injuries of the upper extremitiy, the Disabilities of Arm, Shoulder and Hand (DASH) score is a validated instrument to assess the clinical long-term outcome.12 Clinical experience shows that many patients suffer from long-term functional and social limitations. The traditional outcome measure focuses mostly on objective clinical data. Recently, more attention has been paid to patient-related data to measure the “health-related quality of life” (HRQoL) as a synonym for “medical outcome.” The purpose of these instruments, mostly questionnaires like the Short Form-36 Health Survey (SF-36), is to identify all trauma-related changes in the patient's everyday life. Because of the comprehensive design of the SF-36, it can always be used if a sustained impairment of the HRQoL can be expected as a sequel of diseases or injuries.13, 14, 15 Bullinger and coworkers16 developed and validated a German version of the SF-36. Since then, the German version of the SF-36 has been used for the measurement of HRQoL in many studies.17, 18, 19, 20 Clinical experience with patients suffering arterial injuries at the upper extremity has shown that limitations in different fields of daily life have to be expected. Therefore, the SF-36 questionnaire seems to be an excellent instrument for outcome measurement. To our knowledge, this is the first study analyzing HRQoL after vascular injuries at the upper extremity. SF-36 scores of 33 patients were compared with functional outcome assessment and mean DASH score and correlated with SF-36 scores of a representative healthy German population.21
In this retrospective study, the long-term outcome of patients with arterial injuries of the upper extremity was assessed by the DASH score and the SF-36 questionnaire. The results were correlated with the evaluation of clinical outcome by vascular surgeons.
Section snippets
Patients and Methods
Between January 1, 1996, and September 30, 2004, 54 patients with arterial injuries at the upper extremity were operated at the Regensburg University Medical Center. Patients with iatrogenic injuries or isolated injuries to hand or finger arteries were excluded. The charts of all patients were reviewed. Three patients had died since the operation, and 10 patients could not be contacted because there was no current address or telephone number. Three patients were excluded because they met
Results
Thirty-three of 54 patients with arterial injuries at the upper extremity completed the follow-up of this study. Their data were used for statistical analysis. According to age, gender, mechanism, localization, and characteristics of the injury, there were no statistically significant differences from the group of patients who did not complete follow-up.
Twenty-four patients had arterial injuries at the forearm (radial artery, ulnar artery) and nine at the upper arm (brachial artery, axillary
Discussion
The incidence of upper extremity arterial trauma is low.2, 10, 24, 25, 26, 27 During the study period of 93 months, 54 patients with vascular injuries at the upper extremity were treated at our center. Three patients died, one from severe concomitant injuries during the initial hospital stay and two for non-trauma-associated reasons during follow-up. One patient had to be amputated, and he was excluded from the analysis. Thirty-three patients (63%) could be contacted for follow-up (Fig. 1).
Conclusion
Upper extremity vascular trauma is almost always associated with severe concomitant orthopedic and/or neural injuries. Therefore, an interdisciplinary approach is essential for treatment. Obviously, the involvement of the brachial plexus and the peripheral nerves of the upper extremity is a predictor of worse long-term functional outcome. Blunt trauma and the need for immediate fasciotomy are further markers for deficient functional recovery. The DASH and SF-36 are helpful instruments to
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