Paryavi Ebrahim, Pensy Raymond A, Higgins Thomas F, Chia Benjamin, Eglseder W Andrew
Injury. 2014 Dec;45(12):1870-5. doi: 10.1016/j.injury.2014.08.038.
Humeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.
We conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.
Thirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).
Salvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
伴有肱动脉损伤的肱骨骨折给外科医生的治疗带来了挑战。治疗方法各不相同，包括使用血管分流术、多专业团队与上肢外科医生的治疗方式，以及临时外固定。我们的目的是描述我们的治疗方法，定义“绝对缺血”，确定是否使用血管分流术，并识别可提高肢体挽救率的变量。
我们对1999年至2012年在一级创伤中心的38例肱骨骨折合并肱动脉损伤患者进行了回顾性研究。比较了钝性伤和穿透伤之间以及多专业团队治疗和上肢外科医生治疗之间的人口统计学和治疗特征。我们研究了其他感兴趣的变量，包括即刻内固定、分流术的使用、肱动脉修复时间和皮瓣覆盖。本研究关注的是即刻肢体挽救，而非肢体的最终功能结果或患者对该肢体的满意度。主要结局指标是挽救与截肢。
36例上肢成功挽救，2例最终截肢。即刻内固定（38例患者中的33例）对肢体成功挽救率没有不利影响（p>.05）。使用分流术和由上肢外科医生治疗与提高挽救率无关（p>.05）。皮瓣覆盖的需求与肢体挽救失败显著相关（p = .02）。
伴有肱动脉损伤的肱骨骨折的上肢挽救不依赖于肱动脉修复时间、分流术的使用或治疗外科医生的专业。即刻内固定可以进行，而不会对成功挽救的可能性产生不利影响。皮瓣覆盖是软组织损伤严重程度的一个指标，与这些严重损伤中的截肢相关。
研究类型/证据水平：治疗性III级。
