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Original Article Article original

LONG -TERM OUTCOMES AFTER UPPER LIMB ARTERIAL

Corry K. van der Sluis, MD;† Daryl S. Kucey, MD, MSc, MPH;* Frederick D. Brenneman, MD;* Gordon A. Hunter, MB BS;* Robert Maggisano MD, FACS;* Henk J. ten Duis, MD, PhD†

OBJECTIVE : To assess long-term outcomes in multisystem trauma victims who have arterial injuries to up - per limbs. DESIGN : A retrospective case series. SETTING : Tertiary care regional trauma centre in a university hospital. PATIENTS : All consecutive severely injured patients ( Severity Score greater than 15) with an upper limb arterial injury treated between January 1986 and January 1995. Demographic data and the nature and management of the arterial and associated injuries were determined from the trauma registry and the hospital records. OUTCOME MEASURES : Death rate, discharge disposition, residual disabilities and functional outcomes as measured by the Glasgow Outcome Scale. RESULTS : Twenty-five (0.6%) of 4538 trauma patients assessed during the study period suffered upper ex - tremity arterial injuries. Nineteen of them were victims of . The death rate was 24%. There were 10 primary and no secondary amputations. An autogenous vein interposition graft was placed in 10 patients. Concomitant fractures or nerve injuries in the upper limb were present in 80% and 86% of the pa - tients, respectively. Long-term follow-up data (mean 2 years) were obtained in 16 of the 19 who survived to hospital discharge. The residual disability rate was high. It included upper limb joint , pain and persistent neural deficits (69%). Associated injuries in other body areas also contributed to overall dis - ability. Only 21% of the patients recovered completely or had only minor disabilities.

CONCLUSIONS : Associated injuries, rather than the vascular injury, cause long-term disability in the multi - system trauma victim who has upper extremity involvement. Persistent neural deficits, joint contractures and pain are the principal reasons for long-term impairment of function.

OBJECTIF : Évaluer les résultats de longue durée chez les victimes de traumatismes multisystémiques at - teints de traumatismes artériels d’un membre supérieur. CONCEPTION : Série de cas rétrospective. CONTEXTE : Centre régional de traumatologie et de soins tertiaires d’un hôpital universitaire. PATIENTS : Tous les patients consécutifs victimes de blessures graves (indice de gravité des traumatismes supérieur à 15) et atteints d’un traumatisme artériel d’un membre supérieur qui ont été traités entre janvier 1986 et janvier 1995. Les données démographiques et la nature et le traitement des traumatismes artériels et connexes ont été déterminées à partir du registre des traumatismes et des archives de l’hôpital. MESURES DES RÉSULTATS : Taux de décès, type de congé, incapacités résiduelles et résultats fonctionnels mesurés selon l’échelle de Glasgow.

From the *Department of Surgery and the Trauma Program, Sunnybrook Health Science Centre, Toronto, Ont. and the †Department of Rehabilitation and Department of Surgery, University Hospital Groningen, Groningen, The Netherlands Presented at the Trauma Association of Canada meeting, Halifax, NS, Sept. 26, 1996 Accepted for publication Oct. 30, 1996 Correspondence and reprint requests to: Dr. Daryl S. Kucey, Department of Surgery, Suite H-185, Sunnybrook Health Science Centre, 2075 Bayview Ave., North York ON M4N 3M5; fax (416) 480-5815 © 1997 Canadian Medical Association (text and abstract/résumé)

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RÉSULTATS : Vingt-cinq (0,6 %) des 4538 patients traumatisés évalués au cours de la période d’étude ont été victimes d’un traumatisme artériel d’un membre supérieur. Dix-neuf d’entre eux ont été victimes d’un traumatisme contondant. Le taux de mortalité a été de 24 %. Il y a eu 10 amputations primaires et aucune amputation secondaire. Dix patients ont reçu une greffe veineuse autogène par interposition. On a con - staté des fractures concomitantes ou des traumatismes nerveux du membre supérieur chez 80 % et 86 % des patients respectivement. On a obtenu des données de suivi de longue durée (moyenne de deux ans) sur 16 des 19 personnes qui ont survécu au congé de l’hôpital. Le taux d’incapacité résiduelle était élevé. Ces in - capacités comportaient des contractures articulaires du membre supérieur, la douleur et des déficits neu - rologiques persistants (69 %). Les traumatismes connexes à d’autres parties du corps ont contribué aussi à l’incapacité globale. Seulement 21 % des patients se sont rétablis complètement ou n’avaient que des inca - pacités mineures. CONCLUSIONS : Les traumatismes connexes plutôt que le traumatisme vasculaire sont une cause d’inca - pacité de longue durée chez la victime de traumatismes multisystémiques atteintes aux membres supérieurs. Les déficits neurologiques persistants, les contractures articulaires et la douleur sont les principales raisons du déficit fonctionnel de longue durée.

he operative management of and one or more upper extremity arte - requires help with daily living activi - extremity vascular injuries has rial injuries. Patients with isolated ve - ties, 4 moderate disability in which the T evolved from ligation to re - nous injuries, iatrogenic arterial in - patient is independent but disabled construction largely based on the ex - juries, arterial injuries of the digits or and 5 mild or no disability). 7 This scale perience of DeBakey and Simeone. 1 crush injuries without obvious arterial was originally designed to be used in As a result, the immediate limb salvage damage were excluded. research. However, it has rate in such injuries currently ap - The ISS is an anatomic measure of since been used to assess physical and proaches 95%. 2 Consequently, al - injury severity and is computed utiliz - mental disabilities in convalescing pa - though death and amputation rates ing the Abbreviated Injury Scale tients. 8,9 For the purposes of this study, were the original benchmarks of suc - (AIS), which categorizes each injury residual disability was assessed at the cess in this disease process, they are no by body area. 4,5 The severity of injury time of the last recorded outpatient longer adequate parameters to assess is graded from 0 (no injury) to 6 (fa - visit for follow-up of either the dam - the outcomes of treatment for these tal injury), and the ISS is calculated by aged limb or associated injuries. injuries. To measure successful treat - adding the squares of the highest AIS ment, ultimate function of the injured value in each of the three most se - RESULTS extremity is more germane. verely injured body areas. The maxi - Upper extremity arterial injuries mum ISS of 75 represents injuries Demographics represent about 30% of all cases of ar - nearly always incompatible with life terial trauma. 3 In this disease process, and an ISS of 16 or more defines a vic - Twenty-five out of 4538 multisys - it is clear that functional outcomes are tim of . 6 tem trauma patients (0.6%) met the determined not only by vascular dam - Demographic data were obtained criteria for inclusion in the study. age but also by associated injuries. from the SHSC trauma registry and Their mean age was 36 years (range The purpose of our study was to doc - hospital medical records. The mecha - from 18 to 70 years); 21 (84%) were ument and analyse the respective roles nism of injury and the location and male. Nineteen patients (76%) were of arterial damage and associated in - management of the arterial injuries referred from other hospitals. An av - juries on long-term functional out - were recorded. Associated injuries and erage of 4.3 hours (range from 0.4 to comes after upper extremity arterial injury severity were quantified and 20.6 hours) elapsed between the in - trauma. measured by the AIS and the ISS. jury and admission to the SHSC Re - Outcome measures included death gional Trauma Unit. METHODS rate, duration of hospitalization, dis - Nineteen patients (76%) sustained charge destination and the nature and blunt injuries: 16 in motor vehicle ac - The trauma registry at Sunnybrook severity of residual disabilities in long- cidents and 3 in industrial accidents. Health Science Centre (SHSC) was term follow-up. Functional outcome The 6 penetrating injuries were caused used to identify all multisystem trauma at follow-up was quantified using the by a gunshot (1), a stabbing (1), a patients admitted between January Glasgow Outcome Scale (GOS) (1 propeller (2) and machinery (2). The 1986 and January 1995 with an injury death, 2 persistent vegetative state, 3 inhospital death rate was 24% (6 pa - severity score (ISS) of 16 or greater severe disability in which the patient tients). Five patients died in the first

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24 hours after admission (3 as a result Eight patients (67% of those un - and 13 of them had concomitant of exsanguination from injuries other dergoing revascularization) under - nerve injuries. There were 16 nerve in - than the upper extremity injury and 2 went a fasciotomy because a compart - juries in these 13 patients (Table II). because of head injuries in combina - ment syndrome was suspected. To The site of nerve injury was related to tion with severe bleeding). The re - evaluate the nature and location of the the site of arterial injury in every case. maining patient died 11 days after ad - arterial damage, angiography was per - In 1 patient, a brachial plexus injury mission because of multiple organ formed before or during the operation was suspected, but this could not be failure. in only 5 patients (42% of those un - confirmed because of the patient’s dergoing revascularization). In 1 pa - early death. Arterial injuries and treatment tient the initial revascularization pro - Nearly all nerve deficits resulted cedure failed. However, revision was from blunt trauma. Only 2 of the In 10 patients, the arterial injuries successful. brachial plexus injuries were caused were part of such extensive muscu - by penetrating injury. Ten (63%) of loskeletal and soft-tissue trauma that Associated injuries the 16 nerve injuries were found to amputation of the mangled extremity be severe (no function or minimal had either occurred at the scene or was In the 25 study patients, the mean nerve function). The remaining nerve performed directly on admission to the ISS was 35 (range from 17 to 66). injuries showed only moderate func - hospital. Since 1 patient suffered bilat - Those suffering from blunt trauma tion (4 injuries) or could not be as - eral amputation, this resulted in 11 had a mean ISS of 34, which was sessed because of early death (2 in - upper extremity amputations in 10 slightly lower than that for patients juries). patients (3 shoulder disarticulations, who sustained penetrating injuries One patient underwent primary re - 3 above-elbow amputations, 4 below- (mean ISS 38). Associated injuries pair of a damaged radial nerve. An - elbow amputations and 1 wrist disar - were predominantly in the head and other 3 patients underwent secondary ticulation). In 1 patient, the forearm neck area (21 patients) and the chest repair at a later date. Two ulnar nerves, was replanted. Ultimately, this limb area (21 patients), whereas a minority 1 radial nerve and 1 median nerve became nonviable, resulting in an had associated injuries of the face (5 were repaired. above-elbow amputation. patients) and abdomen (4 patients). Excluding the arterial injuries re - Twenty-three (92%) patients had ex - Follow-up sulting in immediate amputation, ternal injuries (skin abrasions or lacer - there were 16 patients who sustained ations), but these were of minor sever - The 19 survivors stayed a mean of injuries to 16 arteries (1 patient with ity (AIS 1 or 2). All patients had 48 days in hospital (range from 10 to an above-elbow amputation also had severe injuries of the extremities (AIS 191 days); they were discharged home an ipsilateral injury of the subclavian of 3 or more). Twelve of the 16 pa - (5 patients [26%]), to a rehabilitation artery) (Table I). tients who were treated without early centre (10 patients [53%]), to an acute The most common method of sur - amputation suffered serious upper care hospital (2 patients [11%]), to a gical management was an autogenous limb fractures or joint dislocations, chronic care institution (1 patient vein interposition graft, placed in 10 patients (63%). Only 1 primary end- Table I Table II to-end anastomosis and 1 polytetra - fluoroethylene graft were placed Upper Extremity Arterial Injuries Concomitant Upper Extremity (13%). Four patients (25%) did not in 16 Patients Nerve Injuries have vascular surgery; 1 of these pa - No. (%) of No. (%) of tients sustained an injury to a deep Artery involved patients Nerve involved patients branch of the brachial artery, and 1 Subclavian 2 (12) Brachial plexus 4 (25) patient suffered an injury to the radial Axillary 3 (19) Median 3 (19) artery as a result of compression by as - Brachial 7 (44) Ulnar 4 (25) sociated fractures. These 2 patients Ulnar 1 (6) Radial 4 (25) were successfully treated nonopera - tively. The remaining 2 patients died Radial 3 (19) Unidentified 1 (6) soon after arrival at the trauma centre. Total 16 (100) Total 16 (100)

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[5%]) or detained in police custody (1 in 4 patients (2 with brachial plexus DISCUSSION patient [5%]). injuries, 1 with a median nerve injury Three of the 19 survivors were lost and 1 with median and radial nerve Vascular injuries occur in approxi - to follow-up. All were severely dis - injuries), and severe in 1 patient (ul - mately 3% of all patients with major abled at the time of discharge due to nar nerve injury). None of those who civilian trauma. 10,11 One-third of these prolonged coma in 1 patient and underwent a nerve repair, either pri - cases involve the upper limb. 3 Since shoulder disarticulation in 2 patients. mary or secondary, experienced com - vascular injuries are potentially life- The 16 patients who were available for plete recovery of the injured nerve. and limb-threatening, the operative long-term follow-up were assessed for In 1 patient, the nerve repair was un - treatment of such injuries has gar - an average of 2 years (range from 3 to successful and ultimately a tendon nered substantial attention. 12–15 This 78 months) in the outpatient clinic. transfer was performed. Since there has led to awareness of the urgency of Fourteen of them had residual func - were no secondary amputations in arterial repair and to improvements in tional disabilities (Table III). this series, the amputation rate was the technical ability to revascularize None of these 16 patients had any not influenced by residual nerve injured extremities, resulting in the residual vascular compromise from deficits. In the remaining patients, as - low limb-loss rate currently associated the arterial injury, and there were no sociated injuries in other body areas with attempted vascular repairs of secondary amputations. Residual dis - were the principal reason for residual these injuries. As a result, the major ability in the upper limb predomi - disabilities. criterion for a positive outcome is no nantly resulted from joint contrac - As measured by the GOS, this longer simply a successful arterial re - tures, pain and persistent nerve group of 16 patients had a high dis - pair. Rather, the ultimate function of deficits (11 patients [69%]). Only 2 ability rate, even at long-term follow- the injured limb with respect to pain, patients had complete recovery of the up (Table IV). Only 4 patients recov - sensation, dexterity and practical func - injured nerves. The residual deficits ered completely or had minor tion are now the outcomes that need were minor in 3 patients (1 ulnar disabilities (GOS 5). Seven patients to be assessed in the management of nerve injury and 2 with both ulnar were moderately disabled (GOS 4) this disease. and 5 had severe disabilities (GOS 3). Presently there is little documenta - Three patients with a GOS of 3 were tion regarding the extent and severity Table III disabled because of associated injuries of associated injuries in the multisys - (Table IV): leg amputation and a tem trauma victim who suffers a vas - Residual Disabilities in 16 Patients nerve deficit in the remaining leg in 1 cular injury. Further, it is unclear to Location and type of No. (%) of patient, residual cognitive dysfunction what degree associated injuries influ - disability patients in another and cerebrovascular acci - ence the functional outcome in these Upper limb dent in the third. One patient was dis - patients. This study is a retrospective Joint contractures 10 (63) abled (GOS 4) as a result of incom - review of all consecutive patients who Nerve deficits 8 (50) plete paraplegia. presented to a regional trauma centre Pain 4 (25) Amputation 4 (25) Lower limb Table IV Joint contractures 2 (13) Glasgow Outcome Scale (GOS) at Long-Term Follow-up in 16 Patients Nerve deficits 1 (6) No. (%) of patients No. (%) of patients Pain 1 (6) No. (%) of with disability due with disability due to Amputation 2 (13) GOS patients to extremity trauma associated injuries Other 1 0 0 0 Paraplegia (partial) 1 (6) 2 0 0 0 Cognitive dysfunction 1 (6) 3 5 (31) 2 (13) 3 (19) Pulmonary dysfunction 1 (6) 4 7 (44) 6 (38) 1 (6) Cerebrovascular accident 1 (6) 5 4 (25) 4 (25) 0 Post-traumatic seizures 1 (6) Total 16 (100) 12 (75) 4 (25) and radial nerve injuries), moderate 268 JCC, Vol. 40, N o 4, août 1997 14846 August/97 CJS /Page 269

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with an ISS of 16 or more and an ar - nizant of these injuries in the initial as - since our study patients were severely terial injury to the upper limb during sessment of the patient. This is partic - injured, and those patients whose up - a 9-year period (1986 to 1995). The ularly true when one realizes that at per limb amputations occurred at the location and management of the ar - least 10% of all patients with arterial scene of the injury were included in terial injuries and the nature and injuries of the upper extremities will the analysis. The 24% death rate in our severity of concomitant nerve in - have palpable distal pulses due to ex - severely injured patients is consistent juries were determined. Long-term tensive collateral vascular beds. 21 In - with those in other studies with a high follow-up over an average of 2 years deed, some authors suggest that 40% mean ISS. 9,25 was obtained to assess the overall de - of patients with proximal arterial in - From a technical standpoint, all ar - gree of disability in the survivors. juries will have palpable distal pulses terial repairs were carried out success - The 25 study patients comprised due to substantial collaterals in the ax - fully, although one revision procedure only 0.6% of all severely injured pa - illa. 18,22 In this scenario, however, it is was required. Secondary amputations tients treated at our institution during unlikely that these patients will have were not necessary, and none of the the study period. This suggests that al - an immediate limb-threatening vascu - patients had symptoms related to ar - though this injury has dire long-term lar injury. terial insufficiency. Unfortunately, consequences, it is uncommon in a In this case series, all arterial in - those who sustained injuries to the trauma centre that mainly treats vic - juries were identified without delay. brachial plexus or peripheral nerves tims of blunt trauma. Seventy-six per - Primary repair (end-to-end anastomo - did not fare as well. The majority of cent of the patients in the study suf - sis or lateral suture) was initially con - these injured nerves were associated fered blunt trauma, a proportion that sidered. However, if the injured with impaired long-term function, is consistent with reported European segment was too extensive, an inter - whether they were treated operatively series (73% to 95%) of vascular position graft was used. In a patient or not. There was no clear advantage trauma. 12,16,17 However, many large ur - with blunt trauma, the possibility of to early or late nerve repair in this ban trauma centres in the United primary repair is less likely than with study. States evaluate a higher percentage of , and this is re - In general, injuries to nervous tis - penetrating trauma and report blunt flected in the high proportion of vein sue account for approximately 40% to trauma in only 2% to 16% of patients grafts utilized in our patients. 50% of the associated injuries in vas - with vascular injuries. 15,18 Upper ex - Once the arterial deficit had been cular trauma 22 and are twice as likely tremity vascular trauma is far more repaired, the vascular injuries were rel - to occur in the upper limb as the common in these centres than in our atively unimportant in determining lower limb. 10,26 Previous studies have experience. However, the extent of short and long-term outcomes. Nei - shown that nerve injuries account for significant associated injuries in this ther the high amputation rate (40%) the majority of the 27% to 49% of pa - study is higher than that reported by nor the high death rate (24%) in this tients who continue to experience high-volume penetrating trauma cen - study could be attributed to the arter - long-term disability from upper limb tres in the US. 19,20 This may be a reflec - ial injury alone. Extensive muscu - vascular trauma. 10,11,15,18,19,27 In the pre - tion of our study inclusion criteria, loskeletal and soft-tissue damage to sent study, permanent nerve deficits, which allowed only trauma victims the upper limb and severe head in - joint contractures and chronic upper with an ISS of 16 or more entrance juries contributed largely to the over - limb pain (causalgia) incurred sub - into the study. all morbidity and mortality. stantial long-term functional impair - The high proportion of associated Amputation rates related to upper ment. The latter findings may have injuries in victims of blunt trauma extremity vascular trauma recorded in been underreported in previous stud - combined with the relative infre - the recent literature vary from 9% to ies. 26,27 In addition, associated injuries quency of upper limb vascular trauma 40%. 12,16,17,19,23,24 However, these figures in other body areas were important may lead to a concern-causing delay may not be comparable to ours be - contributors to overall disability. This in the diagnosis of arterial injuries. cause of differences in the proportions reinforces the degree of severity of the Early recognition and treatment of of blunt versus penetrating trauma in initial injuries in our series. these injuries are mandatory to the various studies and the differences These patients incurred a high achieve satisfactory outcomes. There - in the severity of the sustained injuries long-term disability rate, since only 4 fore, physicians dealing with multisys - (minor versus major trauma). Our of the 16 long-term survivors (25%) tem trauma victims need to be cog - high amputation rate is not surprising, recovered completely or had minor

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disabilities. On average, 70% of multi - 4. Baker SP, O’Neill B, Haddon W Jr, Rohr N. Arterial injuries of the upper system trauma patients show complete Long WB. The : extremities. Acta Chir Scand 1983; recovery or have only minor disabili - a method for describing patients with 149: 473-7. multiple injuries and evaluating 8,9 17. Shaw AD, Milne AA, Christie J, Jenk - ties. This serves to further emphasize emergency care. J Trauma 1974;14: ins AM, Murie JA, Ruckley CV. Vas - the suggestion that severe injuries to 187-96. the upper extremities lead to long- cular trauma of the upper limb and term disability due to persistent nerve 5. Committee on Injury Scaling, Asso - associated nerve injuries. Injury ciation for the Advancement of Au - 1995; 26:515-8. deficits, joint contractures and pain in tomotive Medicine. The Abbreviated 18. Orcutt MB, Levine BA, Gaskill HV, spite of the successful treatment of as - Injury Scale: 1990 Revision . Des Sirinek KR. Civilian vascular trauma sociated vascular injuries. Plaines (IL): The Association; 1990. This study is limited because of its of the upper extremity. J Trauma 6. Goris RJ. The injury severity score. 1986;26:63-7. retrospective design and has the biases World J Surg 1983;8:12-8. and potential for confounding inher - 19. Creagh TA, Broe PJ, Grace PA, ent with this methodology. In addi - 7. Jennett B, Bond M. Assessment of Bouchier-Hayes DJ. Blunt trauma- tion, even though the primary out - outcome after severe brain damage: a induced upper extremity vascular in - practical scale. Lancet 1975;1:480-4. juries. J R Coll Surg Edinb 1991;36: come measure utilized (GOS) is useful 158-60. in retrospective studies, a more sensi - 8. Frutiger A, Ryf C, Bilat C, Rosso R, tive, disease-specific measurement Furrer M, Cantieni R, et al. Five 20. van Wijngaarden M, Omert L, Ro - driguez A, Smith TR. Management tool may have provided a more accu - years’ follow-up of severely injured of blunt vascular trauma to the ex - rate assessment of functional impair - ICU patients. J Trauma 1991;311: 216-26. tremities. Surg Gynecol Obstet 1993; ment. Even with these limitations, this 177: 41-8. study describes important long-term 9. van der Sluis CK, ten Duis HJ, 21. Sturm JT, Bodily KC, Rothenberger outcome results and may serve to Geertzen JH. Multiple injuries: an DA, Perry JF Jr. Arterial injuries of stimulate further research in this area. overview of the outcome. J Trauma 1995;38:681-6. the extremities following blunt In conclusion, precise revascular - trauma. J Trauma 1980;20:933-6. ization of an injured extremity is read - 10. Visser PA, Hermreck AS, Pierce GE, 22. Johnson SF, Johnson SB, Strodel ily achievable. However, further im - Thomas JH, Hardin CA. Prognosis WE, Barker DE, Kearney PA. provements in the long-term out - of nerve injuries incurred during acute trauma to peripheral arteries. Brachial plexus injury: association comes for these patients appear to rely Am J Surg 1980;140:596-9. with subclavian and axillary vascular on the development and application trauma. J Trauma 1991;31:1546-50. of new techniques of nerve repair, 11. Peacock JB, Proctor HJ. Factors lim - 23. Modrall JG, Weaver FA, Yellin AE. since the presence of vascular damage iting extremity function following vascular injury. J Trauma 1977;17: Vascular considerations in extremity is no longer the rate-limiting step to - 532-5. trauma. Orthop Clin North Am 1993; ward recovery from such injuries. 24:557-63. 12. Heberer G, Becker HM, Dittmer, Stelter WJ. Vascular injuries in poly - 24. Schlickewei W, Kuner EH, Mullaji References trauma. World J Surg 1983;7:68-79. AB, Götze B. Upper and lower limb fractures with concomitant arterial in - 13. Graham JM, Mattox KL, Feliciano J Bone Joint Surg [Br] 1. DeBakey ME, Simeone FA. Battle in - jury. 1992;74: DV, DeBakey ME. Vascular injuries juries of the arteries in World War II. 181-8. of the axilla. Ann Surg 1982;195: An analysis of 2471 cases. Ann Surg 232-8. 25. Rhodes M, Aronson J, Moerkirk G, 1946;123:534-79. Petrash E. Quality of life after the 2. Adinolfi MF, Hardin WD, O’Connell 14. Zelenock GB, Kazmers A, Graham . J Trauma 1988;28: RC, Kerstein MD. Amputations after LM, Erlandson EE, Cronenwett JL, 931-8. Whitehouse WM, et al. Nonpenetrat - vascular trauma in civilians. South 26. Ballard JL, Bunt TJ, Malone JM. ing subclavian artery injuries. Arch Med J 1983;76:1241-3,1248. Management of small artery vascular Surg 1985;120:685-92. 3. Myers SI, Harward TR, Maher DP, trauma. Am J Surg 1992;164:316-9. 15. Sitzmann JV, Ernst CB. Management Melissinos EG, Lowry PA. Complex 27. Hardin WD, O’Connell RC, Adinolfi of arm arterial injuries. Surgery upper extremity vascular trauma in an MF, Kerstein MD. Traumatic arterial 1984;96:895-901. urban population. J Vasc Surg 1990; injuries of the upper extremity: deter - 12: 305-9. 16. Kruse-Andersen S, Lorentzen JE, minants of disability. Am J Surg 1985; 150: 266-70. 270 JCC, Vol. 40, N o 4, août 1997