Arterial injuries at the elbow carry a high risk of muscle necrosis and warrant urgent revascularisation

Introduction: Revascularisation following axial arterial system injury is effective in upper limb salvage but necrosis of muscle, the tissue most sensitive to ischaemia, may still occur. We examined the frequency of necrosis, its related factors and its functional significance. Methods: The clinical findings and operative management of 13 patients with injuries at the elbow referred to 2 plastic surgical hand surgery units over a 30-month period were reviewed. Good outcome was defined as minimal impairment with return to previous occupation, intermediate outcome as moderate impairment with change in occupation and poor outcome as major functional loss preventing work. Results: Seven patients injured the brachial and six injured both the radial and ulnar arteries. Concomitant injuries were severe with nerve injuries in 11 and muscle damage in 12 patients. Functional outcome was good in four cases, intermediate in four and poor in five. Muscle necrosis developed in four brachial artery injuries. In all four cases, initial successful revascularisation failed post-operatively. Case review revealed delayed recognition in three cases where pain heralded ischaemia but distal skin circulation and pulses were adequate. Of patients with necrosis, three had a poor outcome and one had an intermediate outcome. Conclusions: The risk of muscle necrosis must be considered when managing these injuries, particularly if initial revascularisation is unsuccessful. Every effort should be made to optimise repair technique and post-operative monitoring. Limb salvage is no longer enough. Fully viable muscle is necessary to restore function and livelihoods.