Chapter 185 - Repetitive trauma and occupational vascular problems Flashcards
Arterial disorder associated with occupational or recreational activities
MANUAL LABOUR 1) hand-arm vibration syndrome 2) hypothenar hammer syndrome EXPOSURE 1) acro-osteolysis 2) electrical burns 3) extreme thermal injuries ATHLETIC 1) chronic hand ischemia 2) quadrilateral space syndrome 3) humeral head compression of axillary artery 4) TOS
First case of hand-arm vibration syndrome
1911 Loriga on italian miners with dead fingers Hamilton 1918 - cold and pneumatic drills in stone cutters
Other historic names of hand-arm vibration syndrome
1) dead finger to Raynaud of occupational origin 2) traumatic vasospastic disease 3) vibration-induced white finger
Taylor and Pelmear staging system for HAVS
TABLE 185.1
Percentage of HAVS that progress to ulceration and gangrene
1%
Onset and severity of HAVS related to what factor in the exposure
1) amount of acceleration 2) years of exposure
Hypothesized mechanism of HAVS
1) endothelial damage with plt adhesion 2) sympathetic hyperactivity 3) smoking 4) lower level of serotonin 5) polymorphism of HTR1B
Diagnostic tests of HAVS
1) Cold provocation test 2) Duplex 3) arteriography 4) MRA (diferentiate HAVS from hypothenar hammer)
Arteriography of HAVS
1) multiple segmental occlusions 2) corkscrew configuration of vessels in hand
Rate of HAVS with Raynaud phenomenon
91%
Rate of abnormal cold response in HAVS
53%
Rate of reduced SBP in HAVS
31%
Treatment of HAVS
1) stop vibration 2) CCB Nifedipine 30-120 mg/day 3) prostanoid IV (PE1, prostacyclin, iloprost) for digital gangrene 4) cervical or digital sympathectomy (rare) 5) gloves and PPE limit exposure to cold and vibration
Guyon canal
Pisiform and hamate forms this Ulnar artery and never travel through this
Ulnar artery in Guyon canal is covered by
1) skin 2) sc tissue 3) palmaris brevis muscle
First descriptions of hypothenar hammer syndrome is by
Conn Later Von Rosen (1934) and Guttani (1773) also published on this
Incidence of HHS
1.1-1.6% of hand ischemia
Arterial abnormality in HHS
1) thrombotic occlusion (intimal damage) 2) aneurysm formation (medial damage)
Theory of Ferris on etiology of HHS
1) underlying FMD 2) second hit trauma cause HHS 3) 92% patients have controlateral asymptomatic abnormalities in ulnar artery
Difference between HHS and typical Raynauds
1) 3 ulnar finger involvement 2) lack of thumb involvement 3) no hyperemic redness
Treatment of HHS
1) smoke cessation 2) hand protection 3) avoid exposure to cold and trauma 4) CCB 5) antiplatelet 6) anticoagulation in necrosis 7) surgery if aneurysm - ligation or reconstruction
Occupational acro-osteolysis caused by exposure to
Polyvinyl chloride First described by Wilson
Symptoms of occupational acro-osteolysis
1) hand ischemia 2) resorption of distal phalangeal tufts (like scleroderma) 3) raynaud phenomenon 4) hypervascularity adjacent to bone resorption
Treatment of acro-osteolysis
supportive only
Electrical burn voltage and type of tissue damaged
< 1000 V = immediate skin and soft tissue > 1000 V = travel from entry to exit point causing damage throughout
Arterial injury by electrical burns
1) arterial necrosis 2) thrombus or bleeding 3) spasm 4) aneurysm
Extreme thermal injury to cold type of occupations
1) slaughterhouse 2) canning factories 3) fisheries
Symptoms of extreme thermal injury and treatment
Raynaud phenomenon supportive care only
Hand ischemia in athletes found in
1) frisbee 2) handball 3) karate 4) baseball catchers 5) baseball pitchers
Percentage of baseball catchers that have digital artery occlusion
40%
Ligament that compress digital artery in pitcher hyperextension
Cleland ligament
Treatment of hand ischemia in athletes
1) dextran IV 2) pain control 3) pentoxyfylline 4) CCB 5) botox (vasospasm) 6) release of Cleland ligament 7) periarterial digital sympathectomy
Quadrilateral space definition
1) teres minor superiorly 2) humeral shaft laterally 3) teres major inferiorly
Structures in the quadrilateral space
1) posterior humeral circumflex artery 2) axillary nerve
Quadrilateral space syndrome first described by
Cahill and Palmer 1983
Motion that causes compression of the posterior humeral circumflex artery
abduction and external rotation of arm (cocked position)
Two types of quadrilateral space syndrome
1) Vascular 2) neurogenic
Treatment of vQSS
1) thrombolytic 2) aneurysm resection must preserve one of the two humeral circumflex arteries
Structures that are supplied by the humeral circumflex arteries
Humeral head
Treatment of nQSS
1) antiinflammatory 2) physiotherapy 3) limit activities 4) neurolysis and excision of fibrous bands
Cause of neuro QSS
1) repetitive microtrauma to connective tissue 2) fibrous band build up
Symptoms of neuro QSS
1) muscle atrophy 2) paresis 3) paresthesia 4) shoulder pain 5) tenderness in quadrilateral space
Humeral head compression of axillary artery at which segment of axillary artery
distal 1/3
Motion that causes HHC of axillary artery
Externally rotated and abduction Downward compression on the artery
Symptoms of HCC of axillary artery
1) Raynaud 2) embolization 3) fatigue
Treatment of HCC of axillary artery
1) patch repair 2) lifestyle modification 3) bypass
Causes of arterial TOS in athletes
1) hypertrophy of scalene 2) hypertrophy of pec minor
