Hand Surgery Source

ULNAR ARTERY LACERATION

Introduction

Upper extremity arterial injuries account for up to 50% of all peripheral vascular injuries. Ulnar artery injuries, in particular, can occur secondary to open lacerations, puncture wounds, bullet wounds, severely displaced fractures, or crush injuries. Brachial artery injuries are more common than radial and ulnar artery injuries; however, radial and/or ulnar artery lacerations are commonly associated with laceration around the volar aspect of the wrist. Lacerations that cut the ulnar artery are usually obvious, but ulnar artery injuries associated with puncture and/or bullet wounds often require a higher level of suspicion to detect and accurately diagnose. A history of profuse bleeding—particularly pulsatile bleeding—hypotension, and/or a pulsatile mass associated with a wound are indicators of a possible arterial injury. Ulnar artery lacerations are usually associated with other soft tissue injuries like tendon and nerve lacerations, or fractures. Proper management of these injuries is essential to optimize functional outcome.  The vast majority of cases require surgery with ligation, repair, or reconstruction with a vein graft. Unfortunately, surgical indications vary, and there does not appear to be a clear consensus on which approach is best.1-5

Pathophysiology

  • An ulnar artery laceration occurs when the vessel is transected anywhere along its length. Possible sources of trauma include self-inflicted wrist injuries, falls into glass, industrial and traffic accidents, grinder/saw injuries, and stabbing, gunshot, and other penetrating wounds from violent altercations. Although the majority of cases are due to penetrating trauma.4-6
  • An ulnar artery laceration can be a partial or a complete transection. Incomplete ulnar artery laceration can lead to pseudoaneurysms because the cut artery can not retract and thrombosis as easily as after a complete transection. 
  • Ulnar artery injuries can also be categorized as noncritical or critical by the potential for ischemic tissue damage secondary to the unrepaired ulnar artery laceration.
  • Noncritical ulnar artery injuries are less likely to be associated with combined neural, tendon and/or bone injuries. These ulnar artery injuries occur in the upper extremity with collateral circulation that is normal and can provide adequate blood flow without an intact ulnar artery.
  • With a healthy collateral circulation and a cut and thrombosed artery, the patient is not likely to have ischemic pain, impaired function, avoid use of the hand, or experience cold intolerance. However, isolated ulnar artery lacerations can occur in patients with inadequate collateral blood supply where an isolated ulnar artery laceration could cause symptoms secondary to ischemia.  Therefore, deciding whether an injury is noncritical is a clinical judgment that have to be made in the operating room after surgical assessment of the ulnar artery injury, the dominance of the injured ulnar artery in the specific patient, associated injuries, and the medical comorbidities of the patient.1,5
  • Critical ulnar artery injuries are associated with acute ischemia to the hand because of damaged and/or inadequate collateral circulation to the hand. For example, a laceration of the ulnar artery in a patient with a previous radial artery thrombosis and diabetes may cause critical hand ischemia.  With critical arterial injury the patient may be at risk for amputation and potentially hypovolemic shock.1,5,7

Related Anatomy

  • Related anatomical structures include:
    • Brachial artery
    • Radial artery with its deep and superficial branches
    • Ulnar artery with its deep and superficial branches
    • Collateral arteries including the superficial palmar arch and the deep palmar arch
  • In the proximal forearm, the brachial artery bifurcates at the radial tuberosity into the radial and ulnar arteries. These arteries have recurrent branches that anastomose with the upstream brachial artery branches to form a network of rich collaterals around the elbow. The ulnar artery gives off the common interosseous artery, which immediately gives rise to the anterior and posterior interosseous branches that run on either side of the forearm's interosseous membrane.
    • The ulnar artery courses superficial to the transverse carpal ligament and deep to the palmar carpal ligament at the wrist, gives off a deep palmar branch and then continues on superficial to the flexor tendons to form the superficial palmar arch. The hand has a robust collateral network comprised of the deep and superficial palmar arches, which derive their main contributions from the radial and ulnar arteries, respectively.3
  • Variation in the ulnar artery pathway or position is only seen in about 3-5% of individuals, making it much less common than radial artery pathway variation.8
  • Recent studies have shown that the vascular anatomy of the forearm and hand is very complex and true flow dominance can be difficult to assess accurately.8

Overall Incidence

  • Almost half of the diagnosed vascular injuries occur in the upper extremity.
  • The majority of the upper extremity vascular injuries will be to the brachial artery with fewer arterial injuries occurring in the radial and ulnar arteries.5
  • Blunt injuries account for 6-10% of upper extremity vascular trauma and are often associated with musculoskeletal and neural injuries.5

Related Conditions

  • Chronic vascular insufficiency
  • Ulnar artery thrombosis
  • Arterial aneurysm
  • Arthritis
  • Vasospastic disease
  • Acute compartment syndrome
  • Diabetes
  • Hyperlipidemia

Differential Diagnosis

  • Chronic vascular insufficiency
  • Ulnar artery thrombosis
  • Arterial aneurysm
  • Arthritis
  • Vasospastic disease
  • Acute compartment syndrome
  • Hypothenar hammer syndrome
ICD-10 Codes

ULNAR ARTERY LACERATION

Diagnostic Guide Name

ULNAR ARTERY LACERATION

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
ULNAR ARTERY LACERATION (FOREARM LEVEL)   S55.012_ S55.011_  
ULNAR ARTERY LACERATION (WRIST/HAND LEVEL)   S65.012_ S65.011_  

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S68
A - Initial Encounter
D - Subsequent Routine Healing
S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Pathoanatomy Photos and Related Diagrams
Upper Extremity Vascular System
  • Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
    Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
  • Upper Extremity Veins
    Upper Extremity Veins
Symptoms
History of trauma with a penetrating or non-penetrating wound, e.g. deep transverse wrist laceration
History of excessive bleeding, particularly pulsatile bleeding
Swelling at the zone of injury with or without expanding and/or pulsatile mass
Ischemic fingers
Typical History

A typical patient is a 30-year-old right-handed male contractor who injured himself on the job. The man was carrying a new window that he was preparing to install during house remodel when he failed to notice a loose screwdriver on the ground. As he slipped backwards and fell on his back, he placed his right arm up to protect him from the window, but the glass shattered and punctured the palmar-ulnar aspect of his right forearm. This trauma resulted in immediate pain and rapid, pulsatile bleeding from the wound, but a nearby coworker applied pressure with some clean rags to try to stop the bleeding. The man was then taken to the emergency room, where the injury was diagnosed as an ulnar artery laceration and surgically repaired in the operating room.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control bleeding
  • Check for signs of ischemia in the hand
  • Assure the presence of adequate blood supply to the hand and digits 
  • Minimize the risk of cold intolerance
  • Prevent hypovolemic shock
  • Prevent the need for amputations
Conservative
  • There is no nonoperative treatment for an ulnar artery laceration. With rare exceptions, ulnar artery transections must be ligated, repaired, or reconstructed with a vein graft; however, penetrating injuries leading to ulnar artery lacerations may rarely result in life-threating hemorrhage that must be arrested. Control is best achieved by simple compression over the site, while tourniquets should be avoided unless there is no other means to control bleeding.5
Operative
  • Critical ulnar artery lacerations associated with ischemia should be repaired or reconstructed. Ischemia is indicated by poor capillary refill, poor skin turgor, delayed or abnormal Allen's testing, or poor digital pressure readings (ie, a DBI of ≤0.74). In the last analysis, the decision to repair or reconstruct is always a clinical judgment call. Repair is also mandated if both the radial and ulnar arteries are injured, or if suspicion of an incomplete arch exists.1-3. Approximately 20% of individuals have an incomplete palmar arch. These cases also require surgical repair to avoid partially ischemic hand and fingers.5
  • Noncritical isolated ulnar artery lacerations usually do not require repair but cannot be appropriately treated by surgical ligation of both ends of the transected ulnar artery. Some surgeons have argued that repairing noncritical lacerations should be done to improve the overall healing and nerve regeneration while preventing cold intolerance. Despite these arguments, other surgeons have argued that isolated ulnar artery laceration repairs frequently thrombose and primary ligation is indicated. However, modern microsurgical techniques can produce patency rates after ulnar artery laceration repair of ≥80%.1,2,9
  • Other authors have recommended simple ligation in cases of a well-perfused hand without ischemia or significant brachial or palmar arterial trauma, as long as there is one remaining patent artery and the palmar arch circulation is intact. Ligation is best oerformed in the operating room with adequate exposure, lighting, equipment and anesthesia.3,4
  • Immediate surgical exploration is not mandatory if bleeding can be stopped with conservative compressive maneuvers and a complete physical examination of the hand is performed. The appropriateness and safety of an outpatient strategy is validated with evidence-based literature.3
  • The operative repair options for ulnar artery lacerations include:1,2
    • Ulnar artery ligation for true noncritical ulnar artery lacerations
    • End-to-end microsurgical ulnar artery repair
    • Vein grafting for ulnar artery lacerations that have resulted in a significant gap in the ulnar artery 
    • Arterial grafting may be rarely indicated for young patients with a significant ulnar artery gap
  • Postoperative management should include anticoagulants such as Dextrin 40, heparin, or factor Xa-inhibitors during hospitalization and aspirin for 2-3 months after discharge.
  • Patient should not be allowed to smoke. The wrist is usually splinted for 2-3 weeks and heavier hand use avoided for 6 weeks.1
Treatment Photos and Diagrams
Ulnar Artery Laceration Repair
  • Ulnar artery laceration (arrow) secondary to a cut on a broken window.
    Ulnar artery laceration (arrow) secondary to a cut on a broken window.
  • Ulnar artery laceration with brisk antegrade bleeding when tourniquet deflated.
    Ulnar artery laceration with brisk antegrade bleeding when tourniquet deflated.
CPT Codes for Treatment Options

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Common Procedure Name
Ulnar artery repair
CPT Description
Repair blood vessel, upper extremity
CPT Code Number
35206
Common Procedure Name
Artery ligation
CPT Description
Ligation, major artery, extremity
CPT Code Number
37618
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • Bleeding
  • Infection
  • Ulnar artery thrombosis after microsurgical repair
  • Distal embolization from proximal thrombosis
  • Pseudoaneurysm
  • Cold intolerance
  • Ischemia and tissue necrosis (myonecrosis) 1,2,8-11
  • Compartment syndrome
  • Amputation
  • Paresthesia
  • Hypovolemic shock (rare) with isolated ulnar artery civilian injuries
Outcomes
  • In noncritical ulnar artery lacerations, ligation is considered a safe and cost-effective intervention that produces excellent outcomes in most patients.3,4
  • One study found that ligation of the ulnar artery after trauma is not associated with any significant long-term ischemic sequelae so long as the clinical examination confirms the adequacy of circulation through the other wrist vessel.11
  • Another study that involved similar microsurgical repair techniques and an average follow-up of 10 months found an overall arterial patency rate of 84%, with these rates being higher for repairs without vein grafts (92%) and highest specifically for single-vessel repairs without vein grafts (100%).9
  • After ulnar artery repair, early studies reported a very high incidence of arterial thrombosis at the repair site. These findings initially caused surgeons to question the wisdom of ulnar artery repair. However, more recent studies—where repairs were done with modern microsurgical techniques—have shown excellent patency rate as high as 94–100% for a single vessel repair without a vein graft.9
Key Educational Points
  • Remember the presence or absence of a palpable pulse is not a reliable predictor of the presence of an ulnar artery laceration. An ulnar pulse can be present when the artery is completely transected because of retrograde flow from the collateral vessels.
  • Current practice trend show increasing efforts to reestablish normal anatomy (ie, ulnar artery repair or reconstruction).8,9
  • There is no conclusive data to support the concept that an ulnar artery repair facilitates nerve recovery after simultaneous neuropathy.2
  • For noncritical ulnar artery lacerations, there does not appear to be a clear consensus regarding whether ligation alone or end-to-end repair is the best therapeutic option.1,2,9
  • Strong pulsatile “backflow” suggests the presence of adequate collateral circulation.1,2
  • Vasospasm can make adequate collateral circulation appear to be inadequate.1,2
  • Ulnar artery lacerations can be properly managed without arteriography.1,2
  • Ulnar artery lacerations should be repaired without excessive tension at the repair site.1,2
  • Intraoperative and postoperative anticoagulation medications are indicated after ulnar artery laceration repairs.1,2
  • Emergency tourniquets can cause irreversible ischemia after ulnar artery lacerations and is a potential cause for amputation in some cases.5
  • It is well established in the literature that nerve injury rather than arterial injury determines the long-term functional disability of the hand.3
  • Doppler ultrasonography
  • Angiogram (arteriography)
    • May be particularly helpful for patients with multiple sites of potential injury.5
  • Digital plethysmography [determines brachial artery index (DBI) where a numerical finding of greater than 0.7 indicates adequate perfusion]1,7
References

New and Cited Articles

  1. Koman LA, Smith BP, Smith TL, Ruch DS, Li Z. Vascular Disorders.  In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery, 6thedition, Philadelphia: Elsevier Churchill Livingstone, 2011, 2797-2240.
  2. Gelberman, RH, Blasingame, JP, Fronek, A, et al. Forearm arterial injuries. J Hand Surg Am 1979;4(5):401-8. PMID: 501048
  3. Thai, JN, Pacheco, JA, Margolis, DS, et al. Evidence-based Comprehensive Approach to Forearm Arterial Laceration. West J Emerg Med 2015;16(7):1127-34. PMID: 26759666
  4. Johnson, M, Ford, M and Johansen, K. Radial or ulnar artery laceration. Repair or ligate? Arch Surg 1993;128(9):971-4. PMID: 8368933
  5. Hunt, CA and Kingsley, JR. Vascular injuries of the upper extremity. South Med J 2000;93(5):466-8. PMID: 10832942
  6. Lee, CH, Cha, SM and Shin, HD. Injury patterns and the role of tendons in protecting neurovascular structures in wrist injuries. Injury2016;47(6):1264-9. PMID: 26971085
  7. Ashbell, TS, Kleinert, HE and Kutz, JE. Vascular injuries about the elbow. Clin Orthop Relat Res 1967;50:107-27. PMID: 6029009
  8. Higgins, JP and McClinton, MA. Vascular insufficiency of the upper extremity. J Hand Surg Am 2010;35(9):1545-53. PMID: 20807633
  9. Rothkopf, DM, Chu, B, Gonzalez, F, et al. Radial and ulnar artery repairs: assessing patency rates with color Doppler ultrasonographic imaging. J Hand Surg Am 1993;18(4):626-8. PMID: 8349969
  10. Ruch, DS, Aldridge, M, Holden, M, et al. Arterial reconstruction for radial artery occlusion. J Hand Surg Am 2000;25(2):282-90.PMID: 10722820
  11. Aftabuddin, M, Islam, N, Jafar, MA, et al. Management of isolated radial or ulnar arteries at the forearm. J Trauma 1995;38(1):149-51.PMID: 7745646

Classics

  1. Gelberman, RH, Blasingame, JP, Fronek, A, et al. Forearm arterial injuries. J Hand Surg Am 1979;4(5):401-8. PMID: 501048
  2. Cameron, JD. Cases of severe vascular injury to the hand. Hand1970;2(1):74-5. PMID: 5520129