JBJS | Pseudoaneurysm of the Superficial Palmar Arch. A Case Report*

The Journal of Bone & Joint Surgery, Volume 78, Issue 7

Articles | July 01, 1996

Pseudoaneurysm of the Superficial Palmar Arch. A Case Report*

WILLIAM I. STERETT, M.D.†, SACRAMENTO, CALIFORNIA

Investigation performed at the Division of Hand Surgery, Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento

The Journal of Bone & Joint Surgery. 1996; 78:1089-91

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Figures

References

text A A A

Introduction

Introduction | Case Report | Discussion | References

Pseudoaneurysms involving the upper extremity are uncommon but, when they do occur, they invariably follow a penetrating injury. Although the palm is a common site of laceration, I am aware of only one case in the literature of a pseudoaneurysm involving the superficial palmar arch following a penetrating injury⁹. The present report describes the case of an additional patient who had a pseudoaneurysm of the superficial palmar arch. The lesion presented with an episode of massive hemorrhage.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Steadman Hawkins Clinic, 181 West Meadow Drive, Suite 400, Vail, Colorado 81657.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Steadman Hawkins Clinic, 181 West Meadow Drive, Suite 400, Vail, Colorado 81657.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1 Operative photograph of a pseudoaneurysm (solid arrow) of the superficial palmar arch (asterisk) in the right hand. The intervening segment between the third and fourth common digital arteries (open arrows) was involved.

Case Report

Introduction | Case Report | Discussion | References

A thirty-seven-year-old man, who was unemployed, sustained a puncture wound to the ulnar aspect of the palm of the right, non-dominant hand while cleaning a glass-faced clock. Active arterial bleeding persisted despite direct pressure on the wound, a compressive dressing, and local exploration by the emergency-room physician performed under tourniquet control. The patient was therefore taken to the operating room. The preoperative hematocrit was 0.39. After the induction of general endotracheal anesthesia, the bleeding abated. This was believed to be the result of hypotension secondary to the anesthesia. Local exploration by the on-call surgeon, without operative extension of the wound, did not disrupt the clot sufficiently to stimulate bleeding. Formal exploration and repair was not performed. The wound was irrigated and closed primarily.

The patient was seen in the emergency room three weeks later because of a tender mass in the palm. Removal of the sutures resulted in pulsatile arterial bleeding from the wound. The bleeding continued despite direct manual compression on the wound, a compression dressing with elevation of the limb, and a ten-minute cycle of tourniquet control. Manual compression of the ulnar and radial arteries individually at the wrist crease also did not stop the bleeding. It ceased only with manual occlusion of both arteries. An emergent arteriogram was performed to determine the extent of arterial involvement and to confirm the diagnosis. The patient was brought to the operating room.

The wound was explored under loupe magnification with the patient under general endotracheal anesthesia, the arm exsanguinated, and a tourniquet inflated to 250 millimeters of mercury (33.33 kilopascals). A three-by-four-centimeter pseudoaneurysm was found emanating from the superficial palmar arch between the common digital arteries to the ring and little fingers. The mass occupied the entire space between the two arteries, with fibrosis extending into both of them (Fig. 1). At the site of origin of the pseudoaneurysm, approximately a one-centimeter segment of the superficial arch appeared thin-walled and fibrotic. Proximal and distal control of the vessel was obtained with a vascular loop around the superficial arch at the base of the common digital arteries. After resection of the pseudoaneurysm, the free ends of the arch were brought together easily. A primary anastomosis in this position would have formed an intersection with the superficial palmar arch and the third and fourth common digital arteries. However, it was concluded that the tension that would have been produced by such an anastomosis would have probably led to occlusion.

A timed Allen test⁶ was then performed. The cut ends of the superficial palmar arch were closed with microvascular clamps. Vessel loops provided occlusion of the arch on both sides proximal to the common digital arteries. Normal color and turgor were noted with brisk capillary refill in the ring and little fingers within three seconds after release of either the ulnar or the radial side of the superficial palmar arch. Since the arteriogram had shown digital flow and the Allen test had demonstrated sufficient flow at rest, it was elected not to perform a vein graft and the superficial palmar arch was ligated. A timed Allen test was again performed, with occlusion of the radial and ulnar arteries at the wrist crease. Brisk capillary refill was again noted within three seconds after sequential release of the occlusion of the arch. Because a large amount of blood had been lost in the emergency room, the hematocrit was now 0.22.

The patient was re-evaluated two years after treatment. He had no intolerance to cold, claudication with exercise, or changes in the color or temperature of the involved hand. A timed Allen test revealed normal perfusion to all of the digits on release of the occlusion of the radial artery and on subsequent release of the ulnar artery at the wrist.

Discussion

Introduction | Case Report | Discussion | References

Green⁹, in 1973, reported on a pseudoaneurysm of the superficial palmar arch, which was treated with excision and ligation. Suzuki et al.²⁸ reported on a pseudoaneurysm of the common digital artery to the thumb and index finger that had been noted eleven weeks after a stab injury; this was also treated with excision and ligation. Other pseudoaneurysms in the hand have been treated with a primary anastomosis^14,27.

In previous reports of traumatic pseudoaneurysms in the upper extremity, the clinical presentation was two to three years after the initial injury^5,7,19. All of the patients in these reports were seen with progressive pain and swelling. Although there have been some reports of a pseudoaneurysm in the upper extremity following medical procedures^7,19,22, the lower extremity has more often been the site of iatrogenic formation of pseudoaneurysm^{2-4,8,16,18,20,23-25,30,31}. Complications that are associated with pseudoaneurysms include infection²⁶, compartment syndrome¹⁷, osseous erosion¹¹, and nerve compression^{1,7,10,12,14,21}. Rupture has been an unusual presentation of pseudoaneurysm³¹.

A painful mass in the palm after a penetrating injury should elicit a high clinical suspicion of a pseudoaneurysm. The mass may be tender and erythematous and it may resemble an abscess¹⁹.

The bleeding in the patient in the present report continued despite direct compression, application of a tourniquet, and local exploration by the emergency-room physician. Persistent bleeding, despite adequate non-operative measures, may be due to direct injury to deep structures such as the superficial palmar arch; a ruptured true aneurysm; a pseudoaneurysm; an arteriovenous fistula; or, less likely, a persistent cutaneous arteriole remaining open, with elevated blood pressure preventing occlusion by a local thrombus.

Arteriography is an excellent means of defining the arterial anatomy. In the present report, the clinical suspicion of pseudoaneurysm was confirmed; flow within the digital arteries was demonstrated; and a complete superficial palmar arch, with arteries to all five digits, was seen on arteriography. In addition to the timed Allen test, arteriographic evidence of a complete arch suggested that operative reconstruction with grafting was not necessary^13,15,29.

The adequacy of arterial flow was also assessed at the time of the operative procedure. Brisk capillary refill with reappearance of normal color and turgor occurred within three seconds after the occlusion of either the ulnar or the radial side of the superficial arch was released. This represented a clinical impression of acceptable arterial inflow in the resting condition. Although the potential for intolerance to cold or for other manifestations of ischemia cannot be excluded, Gelberman et al.⁷ suggested that patients who sustain an isolated arterial injury to the forearm and in whom another artery is intact will have few symptoms of pain or intolerance to cold. In addition, they demonstrated that the velocity of the flow in the intact artery increases⁷.

A traumatic pseudoaneurysm begins as a sac-like outpouching of the arterial wall. This often starts as an extra-arterial hematoma that undergoes organization. Typically, there is a thinner intimal layer, with fibrosis and decreased vasculature within the medium. This weakened artery is more susceptible to rupture than is the native vessel. Acute exploration of a penetrating injury prevents the formation of a pseudoaneurysm by obliterating the site of penetration.

References

Introduction | Case Report | Discussion | References

Axe, M. J., and |and |McClain, E. J.: Complete involvement of the ulnar nerve secondary to an ulnar artery aneurysm. A case report. Am. J. Sports Med.,14: 178-180, 1986.14178 1986 [PubMed][CrossRef]

Bassett, F. H., III, and |and |Houck, W. S., Jr.: False aneurysm of the profunda femoris artery after subtrochanteric osteotomy and nail-plate fixation. J. Bone and Joint Surg.,46-A: 583-585, April 1964.46-A583 1964

Beck, D. E.; Robinson, J. G.; and |and |Hallett, J. W., Jr.: Popliteal artery pseudoaneurysm following arthroscopy. J. Trauma,26: 87-89, 1986.2687 1986 [PubMed][CrossRef]

Catinella, F. P.; De Laria, G. A.; and |and |De Wald, R. L.: False aneurysm of the superior gluteal artery. A complication of iliac crest bone grafting. Spine,15: 1360-1362, 1990.151360 1990 [PubMed][CrossRef]

Duchateau, J., and |and |Moermans, J.-P.: False aneurysm of the radial artery. J. Hand Surg.,10A: 140-141, 1985.10A140 1985

Gelberman, R. H., and |and |Blasingame, J. P.: The timed Allen test. J. Trauma,21: 477-479, 1981.21477 1981 [PubMed]

Gelberman, R. H.; Blasingame, J. P.; Fronek, A.; and |and |Dimick, M. P.: Forearm arterial injuries. J. Hand Surg.,4: 401-408, 1979.4401 1979

Giacchetto, J., and |and |Gallagher, J. J.: False aneurysm of the common femoral artery secondary to migration of a threaded acetabular component. A case report and review of the literature. Clin. Orthop.,231: 91-96, 1988.23191 1988 [PubMed]

Green, D. P.: True and false traumatic aneurysms in the hand. Report of two cases and review of the literature. J. Bone and Joint Surg.,55-A: 120-128, Jan. 1973.55-A120 1973

Groh, G. I.: Pseudoaneurysm of the axillary artery with median-nerve deficit after axillary block anesthesia. A case report. J. Bone and Joint Surg.,72-A: 1407-1408, Oct. 1990.72-A1407 1990

Hall, R. F., Jr., and |and |Watt, D. H.: Osseous changes due to a false aneurysm of the proper digital artery: a case report. J. Hand Surg.,11A: 440-442, 1986.11A440 1986

Ho, P. K.; Weiland, A. J.; McClinton, M. A.; and |and |Wilgis, E. F.: Aneurysms of the upper extremity. J. Hand Surg.,12A: 39-46, 1987.12A39 1987

Jones, N. F.: Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J. Hand Surg.,16A: 1074-1083, 1991.16A1074 1991

Kalisman, M.; Laborde, K.; and |and |Wolff, T. W.: Ulnar nerve compression secondary to ulnar artery false aneurysm at the Guyon's canal. J. Hand Surg.,7: 137-139, 1982.7137 1982

Koman, L. A., and |and |Urbaniak, J. R.: Ulnar artery insufficiency: a guide to treatment. J. Hand Surg.,6: 16-24, 1981.616 1981

Korovesis, P.; Siablis, D.; Salonikidis, P.; and |and |Sdougos, G.: Abdominal-hip joint fistula. Complicated revision of total hip arthroplasty for false aneurysm of external iliac artery. A case report. Clin. Orthop.,231: 71-75, 1988.23171 1988 [PubMed]

Langen, R. P.: Acute compartment syndrome in the thigh complicated by a pseudoaneurysm. A case report. J. Bone and Joint Surg.,71-A: 762-763, June 1989.71-A762 1989

Lieberman, J. R.; Goldstock, L. E.; and |and |Jacobs, R. L.: Pseudoaneurysm of the dorsalis pedis artery after Lisfranc amputation. Foot and Ankle,12: 123-124, 1991.12123 1991 [PubMed]

Louis, D. S., and |and |Simon, M. A.: Traumatic false aneurysms of the upper extremity. A diagnostic problem. J. Bone and Joint Surg.,56-A: 176-179, Jan. 1974.56-A176 1974

Manning, M. P., and |and |Marshall, J. H.: Aneurysm after arthroscopy. J. Bone and Joint Surg.,69-B(1): 151, 1987.69-B(1)151 1987

May, J. W., Jr.; Grossman, J. A. I.; and |and |Costas, B.: Cyanotic painful index and long fingers associated with an asymptomatic ulnar artery aneurysm: case report. J. Hand Surg.,7: 622-625, 1982.7622 1982

Narsete, E. M.: Traumatic aneurysm of the radial artery. A report of three cases. Am. J. Surg.,108: 424-427, 1964.108424 1964 [PubMed][CrossRef]

Nielsen, B. F.; Rordam, P.; and |and |Christoffersen, J. K.: Popliteal aneurysm after plate osteosynthesis. A case report. Acta Orthop. Scandinavica,58: 426-428, 1987.58426 1987 [CrossRef]

Perdue, G. D., and |and |Smith, R. B., III: Postangiographic false aneurysms of the femoral artery. J. Am. Med. Assn.,223: 1511, 1973.2231511 1973 [CrossRef]

Rians, C. B.; Bishop, A. F.; Montgomery, C. E.; and |and |Cahill, B. R.: False aneurysm of the perforating peroneal artery: a complication of lateral ankle sprain. A case report. J. Bone and Joint Surg.,72-A: 773-775, June 1990.72-A773 1990

Sadove, R. C.: Traumatic infected pseudoaneurysm of the hand. J. Hand Surg.,15A: 906-909, 1990.15A906 1990

Sanchez, A.; Archer, S.; Levine, N. S.; and |and |Buchanan, R. T.: Traumatic aneurysm of a common digital artery—a case report. J. Hand Surg.,7: 619-621, 1982.7619 1982

Suzuki, K.; Takahashi, S.; and |and |Nakagawa, T.: False aneurysm in a digital artery. J. Hand Surg.,5: 402-403, 1980.5402 1980

Upton, J.; Mulliken, J. B.; and |and |Murray, J. E.: Classification and rationale for management of vascular anomalies in the upper extremity. J. Hand Surg.,10A: 970-975, 1985.10A970 1985

Vincent, G. M., and |and |Stanish, W. D.: False aneurysm after arthroscopic meniscectomy. A report of two cases. J. Bone and Joint Surg.,72-A: 770-772, June 1990.72-A770 1990

Wand, J. S.; Zuckerman, J. N.; and |and |Higginson, D. W.: Delayed rupture of false aneurysm following a femoral fracture. J. Bone and Joint Surg.,71-B(4): 700, 1989.71-B(4)700 1989

Topics