Exposures in the Upper Extremities

Fig. 10.1

(a) and (b) The axillary artery can be exposed through skin incision 2 cm below to the midpoint of the clavicle, following the curve into the deltopectoral groove for 5–7 cm. If necessary, the clavicle should be divided


Fig. 10.2

Incision through deltopectoral groove. The intermuscular groove between the pectoralis major and deltoid muscles is separated. The deltoid muscle is retracted laterally, and the pectoralis major muscle is retracted medially. The cephalic vein is mobilized from the deltoid muscle. The vein can be ligated


Fig. 10.3

The pectoralis major muscle is exposed. The pectoralis major tendon is divided 2–3 cm by the humerus insertion. The pectoralis minor muscle is below the pectoralis major muscle


Fig. 10.4

(a) and (b) The pectoralis minor tendon muscle is divided near the coracoid process. Nerves should be protected. After sectioning the pectoralis minor, the neurovascular bundle is exposed. For free-tension mobilization of the axillary artery, the lateral thoracic artery (located on the inferior surface of axillary artery) is ligated. The vascular control of the axillary vessels is achieved by silastic vessel loop

Vascular Repair

Axillary artery injury requires prompt diagnosis and treatment. Blind clamping can lead to a devastating injury. 5000 units of a heparin bolus are used if the vascular trauma is an isolated injury. Once the hemorrhage is controlled, the injured end of the artery should be debrided to the level of normal arterial wall. Fogarty balloon catheters must be passed proximally and distally to clear the thrombus and ensure adequate flow. The local heparinized saline is flushed into the artery proximally and distally. The vascular injury may be repaired with running or interrupted sutures or primary anastomosis. If the injury cannot be repaired by primary anastomosis, it is necessary to perform an interposition graft. The optimal graft is autologous greater saphenous vein harvested from an uninjured leg. A synthetic graft is an acceptable second choice. A vein patch can be used to close the arterial injury. Temporary shunts are used for damage control until definitive repair is achieved. The venous laceration should always be adequately controlled and treated. All muscle sections should be repaired with absorbable suture.

Brachial Artery Injury

Surgical Anatomy

The brachial artery is the direct continuation of the axillary artery. This artery extends from the lower border of the teres major muscle to the antecubital fossa, where it bifurcates into ulnar and radial arteries, below the elbow. The axillary artery lies in the groove between the biceps and triceps muscles. The proximal portion of the brachial artery runs medial to the humerus, and, distally, it crosses anterior to this bone. The profunda brachial artery (or deep brachial artery) arises on the posteromedial surface of the brachial artery, distally to the border of the teres major muscle, and the radial nerve accompanies it. The brachial artery is usually accompanied by two veins. In the upper half of the arm, the ulnar nerve is posterior to the artery, and in the middle half it lies behind the medial epicondyle. The basilic vein lies in the subcutaneous tissue from the antecubital fossa to the mid arm, where it penetrates the fascia to join one of the brachial veins. The cephalic vein runs superficially and enters the deltopectoral groove to drain into the junction of the brachial and axillary veins. The brachial artery lies next to the median nerve.

Vascular Exposure

The patient is placed in the supine position with the injured arm abducted 90 degrees with the palm facing up. Skin preparation includes hand, arm, axilla, neck, chest, and bilateral groins for vein harvest (Figs. 10.5 and 10.6).

The incision is deepened through subcutaneous tissue. The basilic vein runs in this level, which can be retracted laterally for its protection. The arterial exposure requires superior retraction of the biceps and inferior retraction of the triceps muscle. The ulnar nerve is protected with inferior retraction of the triceps muscle (Figs. 10.7, 10.8, and 10.9).


Fig. 10.5

Skin longitudinal incision in the groove between the biceps and triceps brachial muscles, on the medial aspect of the arm. The incision can be extended to increase proximal or distal exposure


Fig. 10.6

(a) If the distal brachial artery is injured, the original incision can be extended distally, across the antecubital fossa, toward the radium by an S-shaped incision. This incision is performed to prevent wound contracture. (b) If the proximal brachial artery is injured and more exposure is necessary, the original incision can be extended to the deltopectoral groove for proximal vascular control at the axillary artery level. (c), If the brachial artery bifurcation is injured, an S-shaped incision allows trifurcation vascular control

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Oct 20, 2020 | Posted by in GENERAL SURGERY | Comments Off on Exposures in the Upper Extremities

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