title: Arterial injuries at the elbow carry a high risk of muscle necrosis and warrant urgent revascularisation.
abstract: BACKGROUND
  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.
authors.affiliation: University Hospital of South Manchester NHS Foundation Trust, UK. allowrie@ukgateway.net
authors.forename: A G
authors.initials: AG
authors.lastname: Lowrie
authors.forename: M G
authors.initials: MG
authors.lastname: Berry
authors.forename: J J R
authors.initials: JJ
authors.lastname: Kirkpatrick
authors.forename: V C
authors.initials: VC
authors.lastname: Lees
authors.forename: D A
authors.initials: DA
authors.lastname: McGrouther
mesh_terms: D000293:Adolescent; D000328:Adult; D001158:Arteries / Q000293:injuries* / Q000601:surgery; D001916:Brachial Artery / Q000293:injuries / Q000601:surgery; D004550:Elbow / Q000294:innervation; D005260:Female; D006801:Humans; D008297:Male; D018482:Muscle, Skeletal / Q000473:pathology*; D009336:Necrosis / Q000517:prevention & control; D017534:Radial Artery / Q000293:injuries / Q000601:surgery; D020127:Recovery of Function; D015424:Reperfusion / Q000379:methods; D012307:Risk Factors; D016896:Treatment Outcome; D017535:Ulnar Artery / Q000293:injuries / Q000601:surgery; D057772:Vascular System Injuries / Q000209:etiology / Q000601:surgery*; D055815:Young Adult; D000092464:Elbow Injuries