Foreign body arterial embolus to the hand

Michael L. Bentz, MD, and Neil Ford Jones, MD, Pittsburgh, Pa.

I ntravascular foreign body emboli to the upper extremity, although distinctly uncommon, can

result from penetrating central or peripheral arterial trauma. L-3 These have previously been reported in the axillary and brachial arteries4‘9 but not in the arteries

of the forearm or hand. A novel case of metal embolus

from the radial artery in the forearm to the deep palmar arch in the hand is described. Plain x-ray films and

physical examination supported the diagnosis. Physical examination, Doppler evaluation, and occasionally an-

giography can reliably define the urgency of surgical

intervention.

Case report

A 31-year-old right-handed accountant sustained a pene- trating injury to the middle third of the anterior aspect of his left forearm while striking a metal chisel with a metal hammer. He noted that a metal fragment flew from the chisel into his forearm, causing an egg-sized hematoma, which appeared immediately. He manually decompressed the hematoma, ap- plied direct pressure to the site, and went to the emergency room complaining of local pain but with no associated neu-

rovascular complaints. He had no history of previous upper extremity injuries. On examination, a 2 mm puncture wound

was noted over the anteroradial aspect of the left midforearm (Fig. 1). No exit wound was noted; nor were any other acute

or chronic wounds noted on the entire extremity. There was no active bleeding, but the area was slightly swollen. No thrill

was palpable, and no bruits were auscultated. Radial and ulnar arterial pulses were palpable, and an Allen test confirmed that

From the Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pa.

Received for publication Aug. 27, 1991; accepted in revised form Nov. 15, 1991.

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.

Reprint requests: Michael L. Bentz, MD, Division of Plastic and

Reconstructive Surgery, University of Pittsburgh School of Med-

icine, Scaife Hall 662, Pittsburgh, PA 15261.

3/l/35404

both arteries were patent. Capillary refill was normal in all

digits of the left hand, and sensory and motor examinations were unremarkable. Transcutaneous Doppler examination re- vealed that the superficial palmar arch was patent with intact common and proper digital artery signals. Anteroposterior

and lateral films of the left upper extremity demonstrated a

radiopaque 2 mm foreign body in the midpalm, but no foreign bodies were noted in the forearm (Fig. 2). The patient was discharged on a regimen of oral cephalosporin after the ex-

tremity was cleansed, dressed, and splinted. Two days later a brachial arteriogram with runoff was obtained via the stan-

dard femoral approach. No extravasation, intimal injury, or pseudoaneurysm was noted in the forearm. The superficial palmar arch was intact and patent. All common and proper

digital arteries were patent. A radiopaque foreign body, con- sistent with a metal fragment, was noted distally in the patent deep palmar arch (Figs. 3 and 4). No surgical intervention was thought to be indicated in the absence of distal thrombosis

or pseudoaneurysm at the entrance site. Follow-up over 6 months has revealed no adverse sequela of this unusual arterial

embolus to the hand.

Discussion

Traumatic intravascular emboli of the upper extrem-

ity are uncommon. To our knowledge, there have been

no previous reports of an intra-arterial traumatic em-

bolus to the radial or ulnar artery or to the superficial or deep palmar arches. If such an event is suspected, a thorough history and physical examination should be

performed, including percutaneous Doppler assessment of the arterial circulation from the subclavian artery to the proper digital arteries. Plain x-ray films in at least

two planes should be obtained to identify foreign bodies

both proximal and distal to the entrance wound. Patients

with persistent arterial bleeding or evidence of ischemia

warrant operative exploration, after emergency angi- ography to define the arterial anatomy both at the en- trance wound and distal to the site of embolization. Symptom-free patients with normal physical exami- nation and Doppler examination findings should un- dergo semielective angiography to identify pseudo- aneurysms in the vicinity of the entrance wound and embolus-associated distal thrombosis. In the absence

484 THE JOURNAL OF HAND SURGERY

Vol. 17A. No. 3

May 1992 Foreign body embolus to hund 485

Fig. 1. Entrance wound (EW) on radial aspect of anterior surface of forearm

Fig. 2. Anteroposterior and lateral x-ray films show embolus (FB) within palm

486 Bentz and Jones The Journal of

HAND SURGERY

Fig. 3. Radial artery (RA) angiogram demonstrates embolus (FB) in deep palmar arch (DPA) adjacent to ulnar artery (UA).

of a pseudoaneurysm, arteriovenous fistula, luminal oc-

clusion, or ongoing bleeding, patients can be discharged

with clear instructions concerning the signs and symp- toms of vascular compromise. Discharge medications should include a broad-spectrum oral antibiotic for in- travascular foreign body prophylaxis against bacterial

emboli .

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Fig. 4. Ulnar artery (UA) angiogram demonstrates patent superficial palmar arch (SPA) and the adjacent embolus

(FB) within lumen of deep palmar arch, which remains

patent.

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