title: Evidence-based Comprehensive Approach to Forearm Arterial Laceration.
abstract: BACKGROUND
  Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge.
  
  
  CONCLUSIONS
  The optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury.
  
  
  CONCLUSIONS
  Management in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.
authors.affiliation: University of Arizona Medical Center, Department of Surgery, Division of Vascular Surgery, Tucson, Arizona.
authors.forename: Janice N
authors.initials: JN
authors.lastname: Thai
authors.affiliation: National Autonomous University of Honduras School of Medicine, Tegucigalpa, Honduras.
authors.forename: Jose A
authors.initials: JA
authors.lastname: Pacheco
authors.affiliation: University of Arizona Medical Center, Department of Orthopaedic Surgery, Tucson, Arizona.
authors.forename: David S
authors.initials: DS
authors.lastname: Margolis
authors.affiliation: University of Arizona Medical Center, Department of Surgery, Tucson, Arizona.
authors.forename: Tianyi
authors.initials: T
authors.lastname: Swartz
authors.affiliation: The Institute for Plastic Surgery, Tucson, Arizona.
authors.forename: Brandon Z
authors.initials: BZ
authors.lastname: Massey
authors.affiliation: University of Arizona Medical Center, Department of Emergency Medicine, Tucson, Arizona.
authors.forename: John A
authors.initials: JA
authors.lastname: Guisto
authors.affiliation: University of Arizona Medical Center, Department of Orthopaedic Surgery, Tucson, Arizona.
authors.forename: Jordan L
authors.initials: JL
authors.lastname: Smith
authors.affiliation: University of Arizona Medical Center, Department of Orthopaedic Surgery, Tucson, Arizona.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Sheppard
mesh_terms: D001158:Arteries / Q000293:injuries* / Q000601:surgery; D005542:Forearm / Q000098:blood supply; D005543:Forearm Injuries / Q000628:therapy*; D006801:Humans; D022125:Lacerations / Q000628:therapy*; D008026:Ligation; D014111:Tourniquets; D014193:Trauma Centers