Vascular Disorders of the Hand

Anatomy

  • Blood supply is from the radial and ulna arteries.
  • Some people have a residual median artery as well.
  • Split into:
    • Deep Palmar Arch (Radial)
    • Superficial Palmar Arch (Ulna)
  • Flow distribution:
    • Radial artery & deep arch: 50%
    • Ulna artery: 25%
    • Equal contribution: 25%

Radial Artery and Deep Palmar Arch

  • Before snuffbox, radial artery gives:
    • Superficial palmar vessel → completes the superficial palmar arch.
  • After snuffbox, Terminal Radial artery splits into:
    • Princeps Pollicis → digital vessels to thumb.
    • Radialis Indicis → radial digital artery to index finger.
  • Then radial artery dives between:
    • Two heads of 1st dorsal interosseous and adductor pollicis.
  • Deep palmar arch formation:
    • 80% contribution from radial artery.
    • Located 1 cm proximal to superficial arch.
    • Three palmar metacarpal branches → contribute to common digital arteries (2nd – 4th web spaces).

Ulna Artery and Superficial Palmar Arch

  • Terminal ulna artery is the chief contributor to the Superficial Palmar Arch.
  • Lies at level of 1st web space (thumb extended).
  • 5 Main branches:
    • Deep palmar branch → completes deep arch.
    • Ulna digital artery → little finger.
    • 3 common palmar digital arteries → split to form digital arteries.

Dorsal Blood Supply

  • Less dominant than palmar blood supply.
  • Derived mainly from radial artery.
  • Forms dorsal carpal arch at the wrist.
  • Gives off dorsal metacarpal branches.

Diagnosis

Allen’s Test

  • Screening tool for vascular sufficiency.

Cold Stimulation Testing

  • Measures time for hand to return to normal after ice bath submergence.
    • 10 min → normal.
    • 20 min → abnormal.

Imaging Techniques

  • Doppler
  • Arteriography
  • Colour Duplex (as effective as arteriography).
  • Triple Phase Bone Scan:
    • 1st phase → Maps arterial tree.
    • 2nd phase → Shows perfusion.
    • 3rd phase → Not useful for vascular disease.

Occlusive Arterial Conditions

Embolic Disease

  • Originates from the heart → affects major vessels or microvessels.
  • Treatment: Embolectomy ± streptokinase.

Small Vessel Disease

  • Associated with connective tissue diseases:
    • Sjogren syndrome
    • SLE
    • Scleroderma
    • RA
  • Buerger’s Disease → male smokers.

Hypothenar Hammer Syndrome

  • Post-traumatic thrombosis or aneurysm of ulna artery.
  • Caused by blunt injury to hypothenar eminence.
  • Symptoms:
    • Cold insensitivity.
    • Nerve compression.
  • Management:
    • Thrombectomy.
    • Vein grafting.

Vasospastic Diseases

Colour Changes

  1. White → Flow cessation.
  2. Blue → Cyanosis.
  3. Red → Reperfusion (painful and tingling).

Raynaud’s Phenomenon

  • Underlying vascular cause.
  • Asymmetrical.
  • Treatment: Target underlying condition.

Raynaud’s Disease

  • Idiopathic (no known cause).
  • Bilateral.
  • Young to middle-aged women.
  • Management:
    • Calcium channel blockers.
    • Sympathectomy (if severe).

Frostbite

  • Extracellular fluid freezes → ice crystal formation.
  • Causes intracellular dehydration and cell necrosis.
  • Management:
    • Rapid rewarming in 40°C water.
    • Address core temperature.
    • Debridement/amputation if gangrene occurs.

Thoracic Outlet Syndrome (TOS)

Anatomy

  • Subclavian artery and brachial plexus roots exit between:
    • Anterior & middle scalene.
  • Nerves → Superior to artery.
  • Subclavian vein → Anterior to anterior scalene.
  • Costoclavicular ligament → Lies anterior to subclavian vein.
  • All structures between clavicle and 1st rib.

Causes of Obstruction

  • Cervical rib (may be cartilaginous, seen on MRI).
  • Anomalous scalene insertion.
  • Clavicle or 1st rib fractures/malunion.
  • Apical lung tumour.
  • Postural causes.

Types of TOS

  1. Neurologic (most common in orthopaedics).
  2. Arterial.
  3. Venous.

Neurologic TOS

  • Young women most affected.
  • T1 and C7 involvement → Pain along inside of arm.
  • May cause intrinsic hand weakness.
  • Clawing of all fingers (unlike isolated ulnar nerve compression).

Provocative Tests

  • Adson’s Test:
    • Extend neck, turn towards affected side, deep breath.
    • Positive → Reduced radial pulse.
  • Wright’s Test:
    • Arm abducted & externally rotated.
  • Roo’s Test:
    • Arms above head, open & close fingers rapidly.
    • Look for neurologic symptoms or pulse change.

Investigations

  • CXR → Detects cervical rib or long C7.
  • MRI.
  • NCS/EMG → Often not useful.

Differential Diagnoses

  • Ulnar nerve compression.
  • Tumour.
  • Cervical degenerative disease.

Management

  • Operative exploration if non-operative treatment fails.
  • Supraclavicular approach.

Venous Compression (TOS)

  • Pain & swelling of arm on overhead use.
  • Common in bodybuilders.
  • May present with venous thrombosis.

Diagnosis

  • Duplex scan.
  • Venography.

Management

  • Surgical release if non-operative treatment fails.
  • Anticoagulation for thrombosis.

Arterial Compression (TOS)

  • Rarest form of TOS.
  • Unilateral Raynaud’s as presenting feature.
  • Usually due to tumour or aneurysm.

Diagnosis

  • MRA.
  • Duplex ultrasound.
  • Bruits over affected area.

Management

  • Surgical intervention if:
    • Non-operative measures fail.
    • Aneurysm/tumour present.
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