Vascular Trauma

*Krzysztof Szaniewski, Tomasz Byrczek and Tomasz Sikora*

#### **Abstract**

Trauma is a leading cause of death and disability in young adults in developed countries with the high impact on future patient quality of life and productivity. The traumatic injury of the vessels is one of the most dangerous types of injury, requiring a fast and reliable diagnosis and, in vast majority of cases, immediate surgical treatment. In this chapter, the authors describe various types of vascular injuries according to injury types and locations. The prehospital care algorithms in patients with vascular trauma are proposed with the emphasis on bleeding control techniques and transportation technique to the nearest hospital. In the next subsection, the various peripheral vascular injuries of specific body areas are described. The truncal vessel trauma is discussed in the next subsection, focusing on fast diagnosis and decision on surgery. In the last subsection, a problem of iatrogenic vascular injury is described due to a rapid increase of minimally invasive techniques in which a vascular injury, as a complication of therapy, may occur.

**Keywords:** vascular trauma, vascular injury, peripheral vessels injury, truncal vessels injury, iatrogenic vascular trauma, aortic injury

#### **1. Introduction**

Trauma has become a leading cause of death among young adults in industrialized nations. In the United States in 2010, trauma was the cause of death in 63% of patients aged 1–24 years and 42% of the patients in the ages 25–44. Furthermore, trauma results with lowered patient's productivity with high economic impact. A vascular trauma incidence is estimated between 1.6 and 2% in adults during peace and between 6 and 12% during war. Most of the civilian casualties are injured by penetrating objects like firearm bullets, blades, or machine parts. In Europe, where access to firearms is limited, most of the penetrating vascular injuries result from criminal acts (e.g., knife stabbing), traffic, and labor accidents [1, 2].

#### **2. Prehospital care in patients with vascular injury**

#### **2.1 On-site emergency procedures and medical transport**

Fast initial diagnosis, patient's vital signs stabilization together with effective bleeding control, and quick transport to the hospital are crucial factors influencing future prognosis.

After the evaluation of the overall security condition on trauma site (traffic accident, disaster site, explosion area), it is important to predetermine a possible trauma mechanism in order to predict possible vascular injury as well as collateral damage of the adjacent tissues [2].

The next step is the patient examination. After the initial evaluation of vital signs and recording the state of a victim's consciousness (GCS), a CABC rule should be applied (**Table 1**).

After CABC, a trauma extent assessment as well as medical examination are performed (SAMPLE) (**Table 2**). The medical examination should cover all body areas in direction from head to toe including the patient's back and extremities. The aim of that procedure is to find any eventual collateral damage which can be life-threatening. The additional information from other victims or witnesses should be gathered, if possible [3].

After the finishing of medical examination, the patient should be qualified to one of the following groups:


During the transportation, especially with unstable patient in severe condition, the information to the admitting center (ATMIST scheme) should be sent (**Table 3**) [5].

The portable ultrasound devices are helpful in fast initial diagnosis of the injuries of large vessels of the chest or abdomen with the use of eFAST protocol (chest, pericardium, and abdomen) [6].

Below we propose a procedure of prehospital care in vascular trauma:


#### **2.2 Specific procedures of bleeding control according to area of the injury**

#### **Vascular injury of the extremities:**

• Direct wound compression.


**59**

*Vascular Trauma*

**Table 2.**

**Table 3.**

*ATMIST algorithm.*

A Age

T Time of the event M Mechanism I Injuries S Symptoms

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

P Past—medical history and pregnancies L Lunch—last meal, time, and volume

E Event—what has happened

S Symptoms (bleeding, ischemia, shock, fractures, wounds, etc.)

M Medicines—recently used or prescribed medicines

*SAMPLE rule in the examination of the victim of an accident.*

A Allergies (drugs, food, chemicals (e.g., disinfectants), materials (plaster dressing, etc.))

• Limb elevation.

T Treatment (already performed)

compression.

• Direct compression.

• Compression dressing.

limited [9, 10].

• Specific compression systems.

○ Compression dressing.

dressing and injury site [3, 8].

released, while the second stays closed [3, 7].

**Vascular injuries in the connection areas (armpits, groins):**

○ JETT (Junctional Emergency Treatment Tool).

• Tourniquet: usually applied on arm or thigh, less often in distal areas (forearm, below the knee) usually 8 cm above the suspected vascular lesion. An effective modification of that technique is to apply two tourniquets, one high on the limb and the second 8 cm above the wound. Then the first one is

• Packing of the bottom of the wound with sterile gauze with continuous

• Hemostatic dressings and substances: in the form of dressing, powder or foam—usually a 3–5 min time is needed to initiate coagulation between a

○ SAM Junctional Tourniquet: the systems which are applied on inguinal or axillary regions where traditional compression system application is

#### *Vascular Trauma DOI: http://dx.doi.org/10.5772/intechopen.88285*


**Table 2.**

*Emergency Medicine and Trauma*

be applied (**Table 1**).

be gathered, if possible [3].

one of the following groups:

transport follows the initial care.

1.Initial examination, CABC, SAMPLE

2.Control of the visible external bleeding

6.Medical transport and ATMIST

**Vascular injury of the extremities:**

• Direct wound compression.

perfusion

*CABC rule in prehospital care of the patient.*

3.Evaluation of possible internal bleeding(s)

5.Bleeding control specific to the vascular injury area

pericardium, and abdomen) [6].

damage of the adjacent tissues [2].

trauma mechanism in order to predict possible vascular injury as well as collateral

The next step is the patient examination. After the initial evaluation of vital signs and recording the state of a victim's consciousness (GCS), a CABC rule should

After CABC, a trauma extent assessment as well as medical examination are performed (SAMPLE) (**Table 2**). The medical examination should cover all body areas in direction from head to toe including the patient's back and extremities. The aim of that procedure is to find any eventual collateral damage which can be life-threatening. The additional information from other victims or witnesses should

After the finishing of medical examination, the patient should be qualified to

1.LOAD & GO—victim in extremely severe condition. Only a basic set of medical procedures is performed necessary to support life. The transport has a priority [4].

During the transportation, especially with unstable patient in severe condition, the information to the admitting center (ATMIST scheme) should be sent (**Table 3**) [5]. The portable ultrasound devices are helpful in fast initial diagnosis of the injuries of large vessels of the chest or abdomen with the use of eFAST protocol (chest,

4.Intravenous access (intramedullar), fluid supply, hypovolemic shock treatment

2.STAY & PLAY—all necessary procedures may be performed on-site. The

Below we propose a procedure of prehospital care in vascular trauma:

**2.2 Specific procedures of bleeding control according to area of the injury**

C Control bleeding—the bleeding controls a visible and life-threatening hemorrhage

C Circulation—central and peripheral circulation assessment, blood pressure, capillary flow, and skin

A Airways—secure the airways and evaluate possible obturation causes

B Breathe—ventilation rate, volume, and effectiveness

**58**

**Table 1.**

*SAMPLE rule in the examination of the victim of an accident.*


**Table 3.** *ATMIST algorithm.*

• Limb elevation.

○ Compression dressing.


#### **Vascular injuries in the connection areas (armpits, groins):**

	- JETT (Junctional Emergency Treatment Tool).
	- SAM Junctional Tourniquet: the systems which are applied on inguinal or axillary regions where traditional compression system application is limited [9, 10].

#### **Neck vasculature lesions:**


#### **Vascular injuries of the head:**


#### **Vascular injury of the chest:**


#### **Vascular injury of the abdomen:**

	- Abdominal aortic and junctional tourniquet (AAJT)
	- Resuscitative endovascular balloon occlusion of the aorta (REBOA) [11, 12]

#### **Vascular injury of the pelvis:**


#### **2.3 Hypovolemic shock and fluid therapy**

Patients in hypovolemic shock with controlled external bleeding should be administered with 500–1000 ml of crystalloids, with a constant blood pressure control. Blood pressure may be maintained near to normal values. In patients where there is no possibility to control the external or internal bleeding, crystalloids volume should allow to maintain the systolic blood pressure on the perfusion level (80–90 mmHg) to prevent anaerobic metabolism in supplied tissue. Exceptionally in patients with the traumatic lesion of the central nervous system, the systolic blood pressure should be maintained on higher levels of 100–110 mmHg, which secures cerebral perfusion pressure on the level of 60 mmHg [13].

### **3. Peripheral vascular injury**

Isolated vascular injury of the extremities is the most common vascular injury type during the peace in high-volume trauma center in Europe. The incidence rises

**61**

*Vascular Trauma*

blunt trauma.

**3.1 Diagnosis**

life-threatening hemorrhage.

life support techniques.

especially ASA and VKA.

**3.2 Medical examination**

which the blood flow was stopped.

trauma probability is very low [16].

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

risk of the peripheral limb ischemia.

in highly urbanized area due to traffic and labor accidents and varies between 1 and 2% of total number of traumatic patients admitted to the ER [14]. In our center, the incidence of the vascular trauma among all traumatic patients was 3% in a 5-year period (2014–2018). In the upper limbs, the regions of elevated risk are the armpit, the medial part of the arm, and the ulnar fossa due to a superficial position of the vascular structures. In the lower limb, attention should be focused on injuries of the groin, the medial thigh area, and the popliteal fossa. The ligation of the artery in vascular injury below the brachial bifurcation or knee trifurcation usually has no

The vascular damage may be caused by penetrating object (like knife blade, a part of a machinery, steel rod, etc.) or may have been an effect of the blunt trauma with the force acting directly on the vessel wall or by the surrounding tissues like bone fragments or luxated joints. Penetrating injuries, mostly with low energy character, constitute 70–90% of cases [15]. Blunt vascular trauma may be the effect of the vessel contusion and secondary thrombosis, which is often a result of the knee joint or upper arm luxation and dislocation of the humerus/tibia causing the

According to an extent of the wound, in penetrating vascular injury, various clinical manifestations may occur, from puncture wound with minimal bleeding and minute signs of the peripheral ischemia to a large laceration of the skin with

The on-site evaluation and diagnosis was described earlier in this chapter; in hospital, the physician after gathering information from the medical emergency service team should also try to obtain information from the patient especially about the traumatic mechanism and possible time of eventual ischemia. The mechanism of injury has a prognostic value. High-energy injuries (penetrating or blunt) have elevated risk of vascular damage, and the risk of amputation is higher in high-energy blunt trauma. Collateral damage of surrounding tissues and adjacent structures may require separate intervention (e.g., orthopedic surgery), or in the case of extensive polytrauma, complex interdisciplinary approach with advanced

It is generally agreed that after 6 hours of the limb ischemia, irreversible changes occur in the nervous and musculatory systems, though it is important to precisely evaluate the onset time. The time may be counted from the injury time or if the ischemic process is iatrogenic (e.g., tourniquet, pressure dressing) from the time in

Concomitant diseases and patient's medical history are also important (arteriosclerosis, cardiac diseases, diabetes), as well as medications are prescribed,

The decision of immediate surgery, especially when active bleeding is concerned, is crucial at the first minutes of examination, due to a high mortality rate in the case of misdiagnosis. A vast majority of victims presenting "hard signs" of vascular trauma require an immediate operation with sensitivity above 90%; on the other hand, if no "hard sign" is present (**Table 4**) (**Figures 1** and **2**), the vascular

"Soft signs" are not so specific in the prediction of the vascular injuries, and immediate open repair usually is not necessary. A single soft sign increases a chance

#### *Vascular Trauma DOI: http://dx.doi.org/10.5772/intechopen.88285*

*Emergency Medicine and Trauma*

**Neck vasculature lesions:**

• Direct compression.

• Hemostatic media.

**Vascular injuries of the head:**

• Direct compression.

**Vascular injury of the chest:**

• Direct compression.

• Occlusive dressing.

• Occlusive dressing.

• Hemostatic foams

**Vascular injury of the pelvis:**

• Hemostatic foams.

**3. Peripheral vascular injury**

**2.3 Hypovolemic shock and fluid therapy**

• Pelvic belt.

• Emergency thoracotomy.

**Vascular injury of the abdomen:**

• Compression with contralateral hand.

• Haemostatic suture of the skin vessels.

○ Abdominal aortic and junctional tourniquet (AAJT)

○ Resuscitative endovascular balloon occlusion of the aorta (REBOA) [11, 12]

Patients in hypovolemic shock with controlled external bleeding should be administered with 500–1000 ml of crystalloids, with a constant blood pressure control. Blood pressure may be maintained near to normal values. In patients where there is no possibility to control the external or internal bleeding, crystalloids volume should allow to maintain the systolic blood pressure on the perfusion level (80–90 mmHg) to prevent anaerobic metabolism in supplied tissue. Exceptionally in patients with the traumatic lesion of the central nervous system, the systolic blood pressure should be maintained on higher levels of 100–110 mmHg, which

Isolated vascular injury of the extremities is the most common vascular injury type during the peace in high-volume trauma center in Europe. The incidence rises

secures cerebral perfusion pressure on the level of 60 mmHg [13].

**60**

in highly urbanized area due to traffic and labor accidents and varies between 1 and 2% of total number of traumatic patients admitted to the ER [14]. In our center, the incidence of the vascular trauma among all traumatic patients was 3% in a 5-year period (2014–2018). In the upper limbs, the regions of elevated risk are the armpit, the medial part of the arm, and the ulnar fossa due to a superficial position of the vascular structures. In the lower limb, attention should be focused on injuries of the groin, the medial thigh area, and the popliteal fossa. The ligation of the artery in vascular injury below the brachial bifurcation or knee trifurcation usually has no risk of the peripheral limb ischemia.

The vascular damage may be caused by penetrating object (like knife blade, a part of a machinery, steel rod, etc.) or may have been an effect of the blunt trauma with the force acting directly on the vessel wall or by the surrounding tissues like bone fragments or luxated joints. Penetrating injuries, mostly with low energy character, constitute 70–90% of cases [15]. Blunt vascular trauma may be the effect of the vessel contusion and secondary thrombosis, which is often a result of the knee joint or upper arm luxation and dislocation of the humerus/tibia causing the blunt trauma.

According to an extent of the wound, in penetrating vascular injury, various clinical manifestations may occur, from puncture wound with minimal bleeding and minute signs of the peripheral ischemia to a large laceration of the skin with life-threatening hemorrhage.

#### **3.1 Diagnosis**

The on-site evaluation and diagnosis was described earlier in this chapter; in hospital, the physician after gathering information from the medical emergency service team should also try to obtain information from the patient especially about the traumatic mechanism and possible time of eventual ischemia. The mechanism of injury has a prognostic value. High-energy injuries (penetrating or blunt) have elevated risk of vascular damage, and the risk of amputation is higher in high-energy blunt trauma. Collateral damage of surrounding tissues and adjacent structures may require separate intervention (e.g., orthopedic surgery), or in the case of extensive polytrauma, complex interdisciplinary approach with advanced life support techniques.

It is generally agreed that after 6 hours of the limb ischemia, irreversible changes occur in the nervous and musculatory systems, though it is important to precisely evaluate the onset time. The time may be counted from the injury time or if the ischemic process is iatrogenic (e.g., tourniquet, pressure dressing) from the time in which the blood flow was stopped.

Concomitant diseases and patient's medical history are also important (arteriosclerosis, cardiac diseases, diabetes), as well as medications are prescribed, especially ASA and VKA.

#### **3.2 Medical examination**

The decision of immediate surgery, especially when active bleeding is concerned, is crucial at the first minutes of examination, due to a high mortality rate in the case of misdiagnosis. A vast majority of victims presenting "hard signs" of vascular trauma require an immediate operation with sensitivity above 90%; on the other hand, if no "hard sign" is present (**Table 4**) (**Figures 1** and **2**), the vascular trauma probability is very low [16].

"Soft signs" are not so specific in the prediction of the vascular injuries, and immediate open repair usually is not necessary. A single soft sign increases a chance


#### **Table 4.**

*Hard and soft signs of vascular trauma.*

of vascular injury in 10%, and two or more soft signs can have a vascular injury rate of 25% [17, 18] (**Figure 1**).

The pulse and extremity blood supply should be evaluated in the first place. A physical examination and the pulse palpation of **all extremities** should be performed.

The bleeding should be stopped as soon as possible by the use of compression dressing and tourniquet or if the situation allows temporary shunting of the damaged artery or vein. The vessel clamping or ligation can be done only in the last resort, when the patient's life is directly at risk. If the damaged vessel is clearly visible and ischaemic symptoms occur, the patient should be referred to vascular surgery in order to perform emergency revascularization. After the bleeding control, the focus should be directed on the chances of the limb salvage. The MESS score is the most popular tool in assessment of the extremity salvage chance [cite

**63**

*Vascular Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

tion and thrombosis [18–20].

tion of vascular injury [21].

aged vessels should be identified and clamped.

**3.3 Treatment**

**Figure 2.**

insufficient diameter.

mess]. Afterwards, if ischaemic signs are present, the limb condition should be rated according to TASC II categorization. Quite often there is no sign of active bleeding, especially in young patients where even a total intersection of femoral or brachial artery does not end with massive hemorrhage due to a vessel end contrac-

*The algorithm of the management of the peripheral vascular injury patient.*

Ankle-brachial index (ABI) or arterial pressure index (API) is a useful adjunct to physical examination. ABI value <0.9 has 87% sensitivity and 97% specificity in the assessment of vascular trauma, reaching 95% of sensitivity when focused on big arterial trunks. ABI value below 0.9 is an direct indication for further imaging as US, CT angiography, or MRI. On the other hand, ABI value >0.9 with no signs of the orthopedic injury allows to release the patient from ER, with the further referral to outpatient clinic in the next few days for reassessment of eventual delayed presenta-

In the first option of treatment, especially in patients presenting with TASC II and III category , the treatment of choice is an open repair. Both stumps of the dam-

After the thrombectomy and vessel stump preparation, an anastomosis is performed. The best option is end-to-end anastomosis without any conduit; however that option is only possible in directly cut vessels where the surgeon is able to mobilize vessel stumps from the surrounding tissue very often soaked with the blood and tissue liquids. If there is any tension between arterial or venous stumps, the better option is to make a conduit, preferably from autologous vein. Reversed great saphenous vein (GSV) graft is the most popular choice; however, there are other possibilities like small saphenous vein and basilic or radio-cephalic vein. However, SSV and other peripheral veins are more difficult to harvest and may have

If the vein is not available, the surgeon faces a decision whether to use a homologous material (if available) like frozen bovine graft or frozen homograft

**Figure 1.** *A typical "hard sign" of the blunt vascular injury of the groin.*

*Emergency Medicine and Trauma*

**Hard signs Soft signs** Active pulsatile bleeding Pulse deficit Rapidly expanding hematoma Neurological deficit Pulselessness Paleness of the extremity Acute ischemia Nonexpanding hematoma

Vascular thrill — Bruit —

of 25% [17, 18] (**Figure 1**).

*Hard and soft signs of vascular trauma.*

performed.

**Table 4.**

of vascular injury in 10%, and two or more soft signs can have a vascular injury rate

The pulse and extremity blood supply should be evaluated in the first place. A physical examination and the pulse palpation of **all extremities** should be

The bleeding should be stopped as soon as possible by the use of compression dressing and tourniquet or if the situation allows temporary shunting of the damaged artery or vein. The vessel clamping or ligation can be done only in the last resort, when the patient's life is directly at risk. If the damaged vessel is clearly visible and ischaemic symptoms occur, the patient should be referred to vascular surgery in order to perform emergency revascularization. After the bleeding control, the focus should be directed on the chances of the limb salvage. The MESS score is the most popular tool in assessment of the extremity salvage chance [cite

**62**

**Figure 1.**

*A typical "hard sign" of the blunt vascular injury of the groin.*

*The algorithm of the management of the peripheral vascular injury patient.*

mess]. Afterwards, if ischaemic signs are present, the limb condition should be rated according to TASC II categorization. Quite often there is no sign of active bleeding, especially in young patients where even a total intersection of femoral or brachial artery does not end with massive hemorrhage due to a vessel end contraction and thrombosis [18–20].

Ankle-brachial index (ABI) or arterial pressure index (API) is a useful adjunct to physical examination. ABI value <0.9 has 87% sensitivity and 97% specificity in the assessment of vascular trauma, reaching 95% of sensitivity when focused on big arterial trunks. ABI value below 0.9 is an direct indication for further imaging as US, CT angiography, or MRI. On the other hand, ABI value >0.9 with no signs of the orthopedic injury allows to release the patient from ER, with the further referral to outpatient clinic in the next few days for reassessment of eventual delayed presentation of vascular injury [21].

#### **3.3 Treatment**

In the first option of treatment, especially in patients presenting with TASC II and III category , the treatment of choice is an open repair. Both stumps of the damaged vessels should be identified and clamped.

After the thrombectomy and vessel stump preparation, an anastomosis is performed. The best option is end-to-end anastomosis without any conduit; however that option is only possible in directly cut vessels where the surgeon is able to mobilize vessel stumps from the surrounding tissue very often soaked with the blood and tissue liquids. If there is any tension between arterial or venous stumps, the better option is to make a conduit, preferably from autologous vein. Reversed great saphenous vein (GSV) graft is the most popular choice; however, there are other possibilities like small saphenous vein and basilic or radio-cephalic vein. However, SSV and other peripheral veins are more difficult to harvest and may have insufficient diameter.

If the vein is not available, the surgeon faces a decision whether to use a homologous material (if available) like frozen bovine graft or frozen homograft


#### **Table 5.**

*Material for grafting in vascular injury.*

or to use synthetic prosthesis. If the synthetic prosthesis has to be used as a conduit, the most infection-resistant option available on shelf should be utilized (**Table 5**).

The endovascular modality is limited only to cases with preserved continuity of the vessel, which can be visualized only in CT angiography, and we recommend that option to patients with TASC I category (viable limb). Usually endovascular approach is effective in arterial puncture with pseudoaneurysm formation or arterial thrombosis in cases of isolated blunt trauma mostly in popliteal and axial region or in cases of arm luxation (**Figures 3**–**5**).

#### **Figure 3.**

*Blunt trauma of the popliteal fossa resolved by the endovascular approach. (a) thrombosis of the popliteal artery, (b) restored flow in the vessel*

**65**

**Figure 5.**

*Vascular Trauma*

**Figure 4.**

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

*The pseudoaneurysm sac successfully closed by biothrombin injection (arrow) [22].*

*The pseudoaneurysm of the right axillary artery successfully resolved by trans-catheter thrombin injection. (a) a CT scan of the lesion, (b) arteriography image of the lesion before the injection, (c) a balloon catheter occluding the aneurysm "jet", (d) angiographic image of the axillary artery after the treatment [22].*

#### **Figure 4.**

*Emergency Medicine and Trauma*

Autologous vein GSV, SSV, RCV, BV

Silver-coated prosthesis (Braun, Intergard)

**Surgical material**

Frozen bovine graft

Rifampin-soaked Dacron

*Material for grafting in vascular injury.*

Homograft

PTFE

**Table 5.**

(**Table 5**).

or in cases of arm luxation (**Figures 3**–**5**).

or to use synthetic prosthesis. If the synthetic prosthesis has to be used as a conduit, the most infection-resistant option available on shelf should be utilized

The endovascular modality is limited only to cases with preserved continuity of the vessel, which can be visualized only in CT angiography, and we recommend that option to patients with TASC I category (viable limb). Usually endovascular approach is effective in arterial puncture with pseudoaneurysm formation or arterial thrombosis in cases of isolated blunt trauma mostly in popliteal and axial region

*Blunt trauma of the popliteal fossa resolved by the endovascular approach. (a) thrombosis of the popliteal artery,* 

**64**

**Figure 3.**

*(b) restored flow in the vessel*

*The pseudoaneurysm sac successfully closed by biothrombin injection (arrow) [22].*

#### **Figure 5.**

*The pseudoaneurysm of the right axillary artery successfully resolved by trans-catheter thrombin injection. (a) a CT scan of the lesion, (b) arteriography image of the lesion before the injection, (c) a balloon catheter occluding the aneurysm "jet", (d) angiographic image of the axillary artery after the treatment [22].*

#### **4. Truncal large vessels trauma**

#### **4.1 Thoracic aorta injury**

The traumatic damage of the thoracic aorta is usually an effect of traffic accidents or sudden fall resulting from acceleration-deceleration mechanisms. Less often it is a result of the penetrating injury like knife stabbing or gunshot. In that case the damage of the aortic wall is usually complete with massive hemorrhage into mediastinum or pleural cavity, which is in most cases fatal. In blunt trauma, the most common site of injury is the descending aorta left from subclavian artery ostium and below the aortic ligament. In most cases, the intimal tear occurs resulting in acute dissection progressing downwards to the visceral arteries and to the aortic bifurcation. Sometimes we can observe almost complete aortic wall tear, pseudoaneurysm formation in the chest and progressing dissection.

The computed angiotomography is a routine examination which allows to diagnose the thoracic aorta injury with high accuracy and has become a standard procedure in chest injuries. If there is no possibility of CT scanning, a transesophageal ultrasound can be used however in a very limited fashion.

From the beginning of the century, a thoracic endovascular stent-graft implantation (TEVAR) has become a routine procedure in salvaging patients with aortic injury, decreasing a perioperative mortality from 70% to 15–30%. If open surgical procedure has to be performed, a chance of survival drops dramatically to 15–20%. The open repair usually requires high aortic clamping, and the risk of the neurological deficit resulting from spinal cord ischemia is significantly higher than during the TEVAR. In TEVAR, however, the risk of spinal cord ischemia is also significant (23%), especially in cases when the graft fabric covers the ostium of the left subclavian artery (LSA) and suppresses the collateral circulation from internal mammary artery (LIMA) to the intercostals. If the patient is in stable condition, a surgeon can bypass the left subclavian ostium, by performing a carotid-subclavian conduit preserving the flow in LSA and LIMA. Another popular neuroprotective option is the drainage of the cerebrospinal fluid to reduce the pressure from eventual spine edema. In many centers that procedure is performed routinely during TEVAR or open repair when LSA closure is necessary [4, 23, 24].

#### **4.2 Large veins of the chest**

The rupture of the large veins in the chest is usually fatal, and patients do no reach the hospital. However, if the patient's condition allows for medial thoracotomy with sternotomy to expose superior vena cava, there is a chance to control the bleeding and after the patient stabilization to reconstruct the damaged vessel. There are some reports of successful endovascular treatment of vena cava injury [25–27]; however all concern iatrogenic injuries.

#### **4.3 Abdominal aorta and iliac arteries**

Abdominal aorta injuries result more often from penetrating mechanism than from blunt trauma. The location of the vessel makes it relatively resistant for blunt injury. If blunt aortic injury occurs, it is usually a part of extensive polytrauma with spine fracture and multiple adjacent organ damage. An exception may be an abdominal aortic rupture during blunt trauma of the abdomen without any collateral damage, which can occur during a car accident or a fall. More frequent are penetrating injures being a result of a criminal act or labor accident. The patient

**67**

**Figure 6.**

*REBOA technique in salvaging the patient with an aortic rupture.*

*Vascular Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

stent-graft implantation (EVAR) is an effective option.

usually presents symptoms of hypovolemic shock, and the first steps should be done to stabilize the vital signs and blood pressure and secure the adequate volume of blood and plasma. The CT scan is a standard procedure confirming an initial diagnosis with visible hematoma in retroperitoneal space. The REBOA procedure (**Figure 6**) is useful during patient stabilization and preparation to surgery or endovascular repair. In open repair a medial abdominal access is used to expose the aorta for clamping and vascular reconstruction usually by the use of polyester or PTFE graft [28]. Less often a simple suture of patch from polyester or autologous vein is used. If there is additional collateral damage like intestine tear, hepatic or renal injury or pelvic fracture, it can be done simultaneously. In cases of isolated aortic damage, usually resulting from penetrating mechanism, an endovascular

Blunt iliac artery injuries usually result in pelvic polytrauma with multiple fractures of the pelvis and possible damage of the bladder, uterus, intestines and ureter. In most cases an interdisciplinary approach of specialized trauma team is necessary, and a vascular surgeon's job is to restore the blood flow stopped by thrombosis of the iliac artery or to stop the bleeding and to perform the vascular reconstruction. In cases of hypogastric artery injury, the vessel ligation is the most common solution. In common iliac artery or external iliac artery injury, a reconstruction with the use of artificial bypass is the first choice. The venous grafting has a limited application due to not sufficient diameters of available veins. In cases in which an infection risk is elevated, silver knitted grafts are the most popular option. The isolated blunt external

#### *Vascular Trauma DOI: http://dx.doi.org/10.5772/intechopen.88285*

*Emergency Medicine and Trauma*

**4.1 Thoracic aorta injury**

**4. Truncal large vessels trauma**

The traumatic damage of the thoracic aorta is usually an effect of traffic accidents or sudden fall resulting from acceleration-deceleration mechanisms. Less often it is a result of the penetrating injury like knife stabbing or gunshot. In that case the damage of the aortic wall is usually complete with massive hemorrhage into mediastinum or pleural cavity, which is in most cases fatal. In blunt trauma, the most common site of injury is the descending aorta left from subclavian artery ostium and below the aortic ligament. In most cases, the intimal tear occurs resulting in acute dissection progressing downwards to the visceral arteries and to the aortic bifurcation. Sometimes we can observe almost complete aortic wall tear,

pseudoaneurysm formation in the chest and progressing dissection.

geal ultrasound can be used however in a very limited fashion.

open repair when LSA closure is necessary [4, 23, 24].

**4.2 Large veins of the chest**

however all concern iatrogenic injuries.

**4.3 Abdominal aorta and iliac arteries**

The computed angiotomography is a routine examination which allows to diagnose the thoracic aorta injury with high accuracy and has become a standard procedure in chest injuries. If there is no possibility of CT scanning, a transesopha-

From the beginning of the century, a thoracic endovascular stent-graft implantation (TEVAR) has become a routine procedure in salvaging patients with aortic injury, decreasing a perioperative mortality from 70% to 15–30%. If open surgical procedure has to be performed, a chance of survival drops dramatically to 15–20%. The open repair usually requires high aortic clamping, and the risk of the neurological deficit resulting from spinal cord ischemia is significantly higher than during the TEVAR. In TEVAR, however, the risk of spinal cord ischemia is also significant (23%), especially in cases when the graft fabric covers the ostium of the left subclavian artery (LSA) and suppresses the collateral circulation from internal mammary artery (LIMA) to the intercostals. If the patient is in stable condition, a surgeon can bypass the left subclavian ostium, by performing a carotid-subclavian conduit preserving the flow in LSA and LIMA. Another popular neuroprotective option is the drainage of the cerebrospinal fluid to reduce the pressure from eventual spine edema. In many centers that procedure is performed routinely during TEVAR or

The rupture of the large veins in the chest is usually fatal, and patients do no reach the hospital. However, if the patient's condition allows for medial thoracotomy with sternotomy to expose superior vena cava, there is a chance to control the bleeding and after the patient stabilization to reconstruct the damaged vessel. There are some reports of successful endovascular treatment of vena cava injury [25–27];

Abdominal aorta injuries result more often from penetrating mechanism than from blunt trauma. The location of the vessel makes it relatively resistant for blunt injury. If blunt aortic injury occurs, it is usually a part of extensive polytrauma with spine fracture and multiple adjacent organ damage. An exception may be an abdominal aortic rupture during blunt trauma of the abdomen without any collateral damage, which can occur during a car accident or a fall. More frequent are penetrating injures being a result of a criminal act or labor accident. The patient

**66**

usually presents symptoms of hypovolemic shock, and the first steps should be done to stabilize the vital signs and blood pressure and secure the adequate volume of blood and plasma. The CT scan is a standard procedure confirming an initial diagnosis with visible hematoma in retroperitoneal space. The REBOA procedure (**Figure 6**) is useful during patient stabilization and preparation to surgery or endovascular repair. In open repair a medial abdominal access is used to expose the aorta for clamping and vascular reconstruction usually by the use of polyester or PTFE graft [28]. Less often a simple suture of patch from polyester or autologous vein is used. If there is additional collateral damage like intestine tear, hepatic or renal injury or pelvic fracture, it can be done simultaneously. In cases of isolated aortic damage, usually resulting from penetrating mechanism, an endovascular stent-graft implantation (EVAR) is an effective option.

Blunt iliac artery injuries usually result in pelvic polytrauma with multiple fractures of the pelvis and possible damage of the bladder, uterus, intestines and ureter. In most cases an interdisciplinary approach of specialized trauma team is necessary, and a vascular surgeon's job is to restore the blood flow stopped by thrombosis of the iliac artery or to stop the bleeding and to perform the vascular reconstruction. In cases of hypogastric artery injury, the vessel ligation is the most common solution. In common iliac artery or external iliac artery injury, a reconstruction with the use of artificial bypass is the first choice. The venous grafting has a limited application due to not sufficient diameters of available veins. In cases in which an infection risk is elevated, silver knitted grafts are the most popular option. The isolated blunt external

**Figure 6.** *REBOA technique in salvaging the patient with an aortic rupture.*

#### *Emergency Medicine and Trauma*

iliac artery above the inguinal ligament resulting in its thrombosis and chronic limb ischemia in young patients resulting from a bike accident were reported [29].

Penetrating external iliac artery injuries especially in the region of inguinal ligament, known as death triangle injury, are challenging cases where fast decision of surgery is life-saving. The bleeding control in that region is difficult and possible only by direct compression or by modified REBOA procedure when the balloon is opened in the common iliac artery. The open repair is a gold standard because most of the injuries result from a knife stabbing or gunshot, and endovascular endografting has a limited application.

#### **4.4 The injury of the inferior vena cava and iliac veins**

A penetrating injury of the inferior vena cava usually produces a large retroperitoneal hematoma having a tendency to self-cease with the drop of the blood pressure and compression produced by the hematoma. That condition is however unstable, and the patient may die suddenly among the symptoms of irreversible hypovolemic shock. Urgent surgical exploration is necessary to seal the rupture in the vein wall. As much as possible the VCI should be exposed to find the rupture, and after the compression of the inflow and outflow site, suture it or reconstruct by the use of artificial graft (usually PTFE). Recently, there have been reports of successful treatment of the VCI ruptures by the use of covered stents or stent grafts however in majority concerning iatrogenic damage [14, 30–33].

The blunt injury of IVC is a very rare condition, with a prevalence of 1% of all blunt abdominal traumas resulting in dissection, pseudoaneurysm formation, or IVC thrombosis. In the literature there are single reports in the management of IVS blunt injuries usually catheter-directed techniques [16, 34, 35].

#### **4.5 The injury of the carotid arteries and jugular vein**

The penetrating injuries of the carotid arteries and jugular veins are mostly resulting in a stabbing effect or an effect of the gunshot. The bleeding control in the case of open wound of the neck is a crucial element of the further success. In the case of the venous injury, a direct compression on the ruptured vessel is usually sufficient to transport the patient to the operation room and to perform exploration and vessel reconstruction. The problem occurs in the case of arterial damage with high-volume blood outflow. Too much compression may lead to severe neurological deficits so pressure should be administered only to stop the bleeding. Additional wound packing may also be helpful. In our opinion every penetrating vascular injury of the neck should be surgically explored in order to prevent a secondary damage as uncontrolled hematoma expansion leading to neurological and respiratory deficits which is supported by the data from the literature [36, 37]. The unstable patients are qualified to immediate surgery, while the stable ones after fast-track imaging in order to localize the exact lesion location should also undergo surgical exploration (**Figure 7**).

Blunt injury of the cervical vessels is a relatively rare condition with prevalence <0.1% and however related to increased mortality and morbidity due to a cerebral infarction. The symptoms of the cerebral ischemia may occur up to 72 h after an accident due to an embolisation from the local vessel thrombosis or dissection. The CT angiography scans should be performed in all patients suffering the injury of the neck in stable condition without signs of rapidly developing hematoma in order to exclude a sub-intimal dissection or thrombosis which can be a source of embolic material. In these patients an endovascular option is a good solution for covering a damaged area with a closed cell stent or stent-graft.

**69**

*Vascular Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

**5. Iatrogenic vascular injury**

*Left carotid artery injury with the compressing hematoma (arrow).*

**Figure 7.**

the vessel and urgent laparotomy or thoracotomy.

In the recent years, in the development of mini-invasive and endovascular techniques, an increase of iatrogenic vascular injuries is observed. A most common complication of the vascular access in endovascular approach is hematoma and pseudoaneurysm in the access site [22, 38]. The rate of these incidents varies between 0.5 and 1.0% and recently was decreased by the use of various vascular sealing systems. A perforation or tear of the arterial wall not in the access site is the second very frequent complication of the endovascular procedure. The typical location of the perforation is iliac arteries, when during the approach to the target lesion (coronary arteries, carotid arteries, abdominal aorta) a hydrophilic guidewire perforates the vessel typically in the location of arteriosclerotic plaque [5, 39]. If the guidewire perforation is noticed quickly, usually it has no consequences besides small extravasation which may require a low-pressure balloon inflation to seal the leak. Sometimes, however, the perforation is not noticed, and some larger bore devices (balloons, stent-graft parts) may be pushed outside the arteries producing a large diameter tear in the arterial wall. If there is no possibility to seal the leak by the use of stent-graft, the only solution is to open the low-pressure balloon inside

In open repair, the iatrogenic traumatic vascular trauma has been observed mostly during orthopedic repositions, general surgery procedures, gynecology, and neurosurgery. After an introduction of the laparoscopic techniques at the beginning of the last decade of the XX century, an incidence of unintentional rupture of the large vessels in abdominal and pelvic region during the introduction of the trocars increased. That type of the injury may have very dramatic outcome, with massive and rapidly increasing hematoma especially when the abdominal part of vena cava or iliac veins are concerned. In that case only an instant conversion and pressure packing may stop the bleeding and save the patient. After a bleeding control is achieved, the vascular reconstruction may take place which is very often limited to pacing a vascular suture

on the vein; less frequently the patch, bypass or ligation is needed [40–42].

*Emergency Medicine and Trauma*

ing has a limited application.

**4.4 The injury of the inferior vena cava and iliac veins**

however in majority concerning iatrogenic damage [14, 30–33].

blunt injuries usually catheter-directed techniques [16, 34, 35].

**4.5 The injury of the carotid arteries and jugular vein**

surgical exploration (**Figure 7**).

damaged area with a closed cell stent or stent-graft.

iliac artery above the inguinal ligament resulting in its thrombosis and chronic limb ischemia in young patients resulting from a bike accident were reported [29]. Penetrating external iliac artery injuries especially in the region of inguinal ligament, known as death triangle injury, are challenging cases where fast decision of surgery is life-saving. The bleeding control in that region is difficult and possible only by direct compression or by modified REBOA procedure when the balloon is opened in the common iliac artery. The open repair is a gold standard because most of the injuries result from a knife stabbing or gunshot, and endovascular endograft-

A penetrating injury of the inferior vena cava usually produces a large retroperitoneal hematoma having a tendency to self-cease with the drop of the blood pressure and compression produced by the hematoma. That condition is however unstable, and the patient may die suddenly among the symptoms of irreversible hypovolemic shock. Urgent surgical exploration is necessary to seal the rupture in the vein wall. As much as possible the VCI should be exposed to find the rupture, and after the compression of the inflow and outflow site, suture it or reconstruct by the use of artificial graft (usually PTFE). Recently, there have been reports of successful treatment of the VCI ruptures by the use of covered stents or stent grafts

The blunt injury of IVC is a very rare condition, with a prevalence of 1% of all blunt abdominal traumas resulting in dissection, pseudoaneurysm formation, or IVC thrombosis. In the literature there are single reports in the management of IVS

The penetrating injuries of the carotid arteries and jugular veins are mostly resulting in a stabbing effect or an effect of the gunshot. The bleeding control in the case of open wound of the neck is a crucial element of the further success. In the case of the venous injury, a direct compression on the ruptured vessel is usually sufficient to transport the patient to the operation room and to perform exploration and vessel reconstruction. The problem occurs in the case of arterial damage with high-volume blood outflow. Too much compression may lead to severe neurological deficits so pressure should be administered only to stop the bleeding. Additional wound packing may also be helpful. In our opinion every penetrating vascular injury of the neck should be surgically explored in order to prevent a secondary damage as uncontrolled hematoma expansion leading to neurological and respiratory deficits which is supported by the data from the literature [36, 37]. The unstable patients are qualified to immediate surgery, while the stable ones after fast-track imaging in order to localize the exact lesion location should also undergo

Blunt injury of the cervical vessels is a relatively rare condition with prevalence <0.1% and however related to increased mortality and morbidity due to a cerebral infarction. The symptoms of the cerebral ischemia may occur up to 72 h after an accident due to an embolisation from the local vessel thrombosis or dissection. The CT angiography scans should be performed in all patients suffering the injury of the neck in stable condition without signs of rapidly developing hematoma in order to exclude a sub-intimal dissection or thrombosis which can be a source of embolic material. In these patients an endovascular option is a good solution for covering a

**68**

**Figure 7.** *Left carotid artery injury with the compressing hematoma (arrow).*

#### **5. Iatrogenic vascular injury**

In the recent years, in the development of mini-invasive and endovascular techniques, an increase of iatrogenic vascular injuries is observed. A most common complication of the vascular access in endovascular approach is hematoma and pseudoaneurysm in the access site [22, 38]. The rate of these incidents varies between 0.5 and 1.0% and recently was decreased by the use of various vascular sealing systems. A perforation or tear of the arterial wall not in the access site is the second very frequent complication of the endovascular procedure. The typical location of the perforation is iliac arteries, when during the approach to the target lesion (coronary arteries, carotid arteries, abdominal aorta) a hydrophilic guidewire perforates the vessel typically in the location of arteriosclerotic plaque [5, 39]. If the guidewire perforation is noticed quickly, usually it has no consequences besides small extravasation which may require a low-pressure balloon inflation to seal the leak. Sometimes, however, the perforation is not noticed, and some larger bore devices (balloons, stent-graft parts) may be pushed outside the arteries producing a large diameter tear in the arterial wall. If there is no possibility to seal the leak by the use of stent-graft, the only solution is to open the low-pressure balloon inside the vessel and urgent laparotomy or thoracotomy.

In open repair, the iatrogenic traumatic vascular trauma has been observed mostly during orthopedic repositions, general surgery procedures, gynecology, and neurosurgery. After an introduction of the laparoscopic techniques at the beginning of the last decade of the XX century, an incidence of unintentional rupture of the large vessels in abdominal and pelvic region during the introduction of the trocars increased. That type of the injury may have very dramatic outcome, with massive and rapidly increasing hematoma especially when the abdominal part of vena cava or iliac veins are concerned. In that case only an instant conversion and pressure packing may stop the bleeding and save the patient. After a bleeding control is achieved, the vascular reconstruction may take place which is very often limited to pacing a vascular suture on the vein; less frequently the patch, bypass or ligation is needed [40–42].

When arterial vessels are damaged, a massive bleeding is not so often; in some cases, one can observe a pseudoaneurysm formation, vessel thrombosis, or retroperitoneal hematoma which also requires an urgent surgery; however, the symptoms are not so dramatic and chances are better. In that case, a vascular reconstruction usually ends with suturing the damaged artery. Sometimes, a thrombectomy is performed, with more extensive reconstructions with patches or bypasses. In the pelvic region, when hypogastric artery is damaged, very often a ligation of the vessel is one of the options.

Injuries of the hepatic arteries or vascular structures of hepatic ligament are less frequent and cause mostly by thermal mechanism during electrocoagulation [43].

Vascular injury during the orthopedic surgery is not a frequent complication with an incidence of 0.05–0.1%. However due to a large number of procedures performed, it concerns patients in almost every hospital in which total hip and knee arthroplasty is performed, as well as urgent repositions of the spine and long bones of the extremities with stabilization by the use of external or internal material [44, 45]. During the hip or knee replacement, the mechanism of injury is usually indirect, resulting from torsion and elongation forces resulting in intimal tear and vessel thrombosis. In rare cases the misplaced fixation screws of the acetabulum caused active bleeding or thrombosis of external iliac artery. During the open repositions, the mechanism is usually directly caused by a stabilization material and fixation screws resulting in arterial damage. In that case, the time of diagnosis is crucial, especially when iliac, femoral, or brachial arteries are involved. In some cases like popliteal artery thrombosis after a total knee replacement, an endovascular option is possible. However, in most cases, an arterial reconstruction is the only possible solution. Repositions of the bones of forearm and below the knee have a significantly lower risk of ischaemic complication due to the anatomic reasons, but an active bleeding or pseudoaneurysms may occur. In that area, however, a ligation of the single main arterial trunk like radial or tibial artery usually has no ischaemic consequences.

#### **6. Conclusions**

Vascular injuries are not a frequent condition; however, they are one of the most dangerous and challenging cases for medical personnel in the field of proper diagnostics and therapy. In the vast majority of cases, regardless of whether they concern civilian or warfare victims, there are penetrating injuries resulting in massive bleeding or limb-threatening ischemia. The implementation of proper treatment already at the prehospital stage is an essential factor for the patient survival and the limb salvage.

Fast initial assessment of the patient's condition based on the CABC algorithm, adopting an appropriate transport strategy (Load & Go or Stay & Play), application of bleeding control techniques adequate to the area of injury, and early prevention of hypovolemic shock are the key factors for prehospital treatment.

Due to the rapid development of minimally invasive techniques in various fields of medicine (cardiology, neurology, abdominal surgery, urology), the number of iatrogenic vascular injuries increased. Despite the low incidence of such events, iatrogenic injuries are quite common due to high volumes of minimally invasive procedures performed and require the involvement of a vascular surgeon.

The vascular trauma is very often a part of polytrauma requiring the interdisciplinary trauma team of various specialists to perform a wide range of operations in one time such as vascular reconstructions together with reconstructive orthopedics or reconstruction of the urinary tract. The vascular trauma patients and especially patients with polytrauma should be transported to specialized trauma centers with the high reference level.

**71**

**Author details**

Krzysztof Szaniewski\*, Tomasz Byrczek and Tomasz Sikora

\*Address all correspondence to: kszaniewski@gmail.com

St. Barbara Hospital, Sosnowiec, Poland

provided the original work is properly cited.

Department of Vascular Surgery and Emergency Department, Trauma Center,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Vascular Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

*Vascular Trauma DOI: http://dx.doi.org/10.5772/intechopen.88285*

*Emergency Medicine and Trauma*

the vessel is one of the options.

**6. Conclusions**

When arterial vessels are damaged, a massive bleeding is not so often; in some cases, one can observe a pseudoaneurysm formation, vessel thrombosis, or retroperitoneal hematoma which also requires an urgent surgery; however, the symptoms are not so dramatic and chances are better. In that case, a vascular reconstruction usually ends with suturing the damaged artery. Sometimes, a thrombectomy is performed, with more extensive reconstructions with patches or bypasses. In the pelvic region, when hypogastric artery is damaged, very often a ligation of

Injuries of the hepatic arteries or vascular structures of hepatic ligament are less frequent and cause mostly by thermal mechanism during electrocoagulation [43]. Vascular injury during the orthopedic surgery is not a frequent complication with an incidence of 0.05–0.1%. However due to a large number of procedures performed, it concerns patients in almost every hospital in which total hip and knee arthroplasty is performed, as well as urgent repositions of the spine and long bones of the extremities with stabilization by the use of external or internal material [44, 45]. During the hip or knee replacement, the mechanism of injury is usually indirect, resulting from torsion and elongation forces resulting in intimal tear and vessel thrombosis. In rare cases the misplaced fixation screws of the acetabulum caused active bleeding or thrombosis of external iliac artery. During the open repositions, the mechanism is usually directly caused by a stabilization material and fixation screws resulting in arterial damage. In that case, the time of diagnosis is crucial, especially when iliac, femoral, or brachial arteries are involved. In some cases like popliteal artery thrombosis after a total knee replacement, an endovascular option is possible. However, in most cases, an arterial reconstruction is the only possible solution. Repositions of the bones of forearm and below the knee have a significantly lower risk of ischaemic complication due to the anatomic reasons, but an active bleeding or pseudoaneurysms may occur. In that area, however, a ligation of the single main arterial trunk

like radial or tibial artery usually has no ischaemic consequences.

of hypovolemic shock are the key factors for prehospital treatment.

Vascular injuries are not a frequent condition; however, they are one of the most dangerous and challenging cases for medical personnel in the field of proper diagnostics and therapy. In the vast majority of cases, regardless of whether they concern civilian or warfare victims, there are penetrating injuries resulting in massive bleeding or limb-threatening ischemia. The implementation of proper treatment already at the prehospital stage is an essential factor for the patient survival and the limb salvage. Fast initial assessment of the patient's condition based on the CABC algorithm, adopting an appropriate transport strategy (Load & Go or Stay & Play), application of bleeding control techniques adequate to the area of injury, and early prevention

Due to the rapid development of minimally invasive techniques in various fields of medicine (cardiology, neurology, abdominal surgery, urology), the number of iatrogenic vascular injuries increased. Despite the low incidence of such events, iatrogenic injuries are quite common due to high volumes of minimally invasive procedures performed and require the involvement of a vascular surgeon.

The vascular trauma is very often a part of polytrauma requiring the interdisciplinary trauma team of various specialists to perform a wide range of operations in one time such as vascular reconstructions together with reconstructive orthopedics or reconstruction of the urinary tract. The vascular trauma patients and especially patients with polytrauma should be transported to specialized trauma centers with

**70**

the high reference level.

#### **Author details**

Krzysztof Szaniewski\*, Tomasz Byrczek and Tomasz Sikora Department of Vascular Surgery and Emergency Department, Trauma Center, St. Barbara Hospital, Sosnowiec, Poland

\*Address all correspondence to: kszaniewski@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Sidawy AN, Perler BA. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019

[2] Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: The East practice management guidelines work group. The Journal of Trauma. 2002;**53**(3):602-615

[3] Guła P, Machała W, Wydawnictwo Lekarskie PZWL. Postępowanie w obrażeniach ciała w praktyce SOR. Warszawa: Wydawnictwo Lekarskie PZWL; 2017

[4] Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: Current therapies, outcomes, and challenges. Annals of Vascular Diseases. 2019;**12**(1):1-5

[5] Mehta V, Pandit BN, Mehra P, Nigam A, Vyas A, Yusuf J, et al. Massive bleeding from guidewire perforation of an external iliac artery: Treatment with hand-made stent-graft placement. Cardiovascular and Interventional Radiology. 2016;**39**(1):106-110

[6] Sosada K, Żurawiński W, Wydawnictwo Lekarskie PZWL. Ostre stany zagrożenia życia w obrażeniach ciała. Warszawa: PZWL Wydawnictwo Lekarskie; 2018

[7] Davidovic LB, Cinara IS, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil and war peripheral arterial trauma: review of risk factors associated with limb loss. Vascular. 2005;**13**(3):141-147

[8] Prichayudh S, Rassamee P, Sriussadaporn S, Pak-Art R, Sriussadaporn S, Kritayakirana K, et al. Abdominal vascular injuries: Blunt vs. penetrating. Injury. 2019;**50**(1):137-141

[9] Johnson JE, Sims RK, Hamilton DJ, Kragh JF. Safety and effectiveness evidence of SAM(r) junctional tourniquet to control inguinal hemorrhage in a perfused cadaver model. Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals. 2014;**14**(2):21-25

[10] Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery. 2019;**86**(3):532-539

[11] Coleman JJ, Zarzaur BL. Surgical management of abdominal trauma. The Surgical Clinics of North America. 2017;**97**(5):1107-1117

[12] Trellopoulos G, Georgiadis GS, Aslanidou EA, Nikolopoulos ES, Pitta X, Papachristodoulou A, et al. Endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock. The Journal of Cardiovascular Surgery. 2012;**53**(4):495-506

[13] Malgras B, Prunet B, Lesaffre X, Boddaert G, Travers S, Cungi P-J, et al. Damage control: Concept and implementation. Journal of Visceral Surgery. 2017;**154**(Suppl 1):S19-S29

[14] Branco BC, Musonza T, Long MA, Chung J, Todd SR, Wall MJ, et al. Survival trends after inferior vena cava and aortic injuries in the United States. Journal of Vascular Surgery. 2018;**68**(6):1880-1888

[15] Badole C, Patond K, Mk K. Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Indian Journal of Orthopaedics. 2007;**41**(3):183

**73**

*Vascular Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.88285*

[16] Cheaito A, Tillou A, Lewis C, Cryer H. Management of traumatic blunt IVC injury. International Journal of Surgery

com/10.1002/14651858.CD006642.pub3.

[24] Son S-A, Jung H, Cho JY, Oh T-H, Do YW, Lim KH, et al. Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: A single-center experience. European Journal of Trauma and Emergency Surgery. 2019. [cited 2019 June 15]; Available from: http://link.springer. com/10.1007/s00068-019-01166-6

[25] Altuwaijri T, Nouh T, Alburakan A, Altoijry A. Long-term follow-up of endovascular repair of iatrogenic superior vena cava injury: A case report. Medicine (Baltimore).

[26] Azizzadeh A, Pham MT, Estrera AL, Coogan SM, Safi HJ. Endovascular repair of an iatrogenic superior vena caval injury: A case report. Journal of Vascular Surgery. 2007;**46**(3):569-571

[27] Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Annals of Surgery. 1989;**209**(6):698-705-707

[28] Weale R, Kong V, Manchev V, Bekker W, Oosthuizen G, Brysiewicz P, et al. Management of intra-abdominal vascular injury in trauma laparotomy: A South African experience. Canadian Journal of Surgery. 2018;**61**(3):158-164

[29] Kazibudzki M, Orawczyk T, Ludyga T, Krupowies A. Cyclist's injury—The cause of symptoms of chronic ischaemia of the lower limb young patients. Chirurgia Polska.

[30] Matsumoto S, Jung K, Smith A, Coimbra R. Management of IVC injury: Repair or ligation? A propensity score matching analysis using the national trauma data bank. Journal

2005;**7**(4):292-295

ISSN: 1465-1858

2018;**97**(50):e13610

[17] Brunner MP, Cronin EM, Wazni O, Baranowski B, Saliba WI, Sabik JF, et al. Outcomes of patients requiring emergent surgical or endovascular intervention for catastrophic complications during transvenous lead extraction. Heart Rhythm. 2014;**11**(3):419-425

[18] Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;**30**(5):568-572-573

[19] Loja MN, Sammann A, DuBose J, Li C-S, Liu Y, Savage S, et al. The mangled extremity score and amputation: Time for a revision. Journal of Trauma and Acute Care Surgery. 2017;**82**(3):518-523

[20] Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-society consensus for the management of peripheral arterial disease (TASC II). Journal of Vascular

Surgery. 2007;**45**(1):S5-S67

2010;**16**(6):602-608

2004;**6**(1):7-18

[21] Feliciano DV. Management of peripheral arterial injury. Current Opinion in Critical Care.

[22] Orawczyk T, Urbanek T, Biolik G, Ziaja D, Szaniewski K, Kuczmik W, et al. Thrombin injection in obliteration of femoral false aneurysms—Own experience. Chirurgia Polska.

[23] Pang D, Hildebrand D, Bachoo P.

Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. In: Cochrane Vascular Group, editor. Cochrane Database Syst Rev. Hoboken, New Jersey, USA: John Wiley & Sons, Ltd; 2019. [cited 2019 Jun 15]; Available from: http://doi.wiley.

Case Reports. 2016;**28**:26-30

[16] Cheaito A, Tillou A, Lewis C, Cryer H. Management of traumatic blunt IVC injury. International Journal of Surgery Case Reports. 2016;**28**:26-30

[17] Brunner MP, Cronin EM, Wazni O, Baranowski B, Saliba WI, Sabik JF, et al. Outcomes of patients requiring emergent surgical or endovascular intervention for catastrophic complications during transvenous lead extraction. Heart Rhythm. 2014;**11**(3):419-425

[18] Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;**30**(5):568-572-573

[19] Loja MN, Sammann A, DuBose J, Li C-S, Liu Y, Savage S, et al. The mangled extremity score and amputation: Time for a revision. Journal of Trauma and Acute Care Surgery. 2017;**82**(3):518-523

[20] Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-society consensus for the management of peripheral arterial disease (TASC II). Journal of Vascular Surgery. 2007;**45**(1):S5-S67

[21] Feliciano DV. Management of peripheral arterial injury. Current Opinion in Critical Care. 2010;**16**(6):602-608

[22] Orawczyk T, Urbanek T, Biolik G, Ziaja D, Szaniewski K, Kuczmik W, et al. Thrombin injection in obliteration of femoral false aneurysms—Own experience. Chirurgia Polska. 2004;**6**(1):7-18

[23] Pang D, Hildebrand D, Bachoo P. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. In: Cochrane Vascular Group, editor. Cochrane Database Syst Rev. Hoboken, New Jersey, USA: John Wiley & Sons, Ltd; 2019. [cited 2019 Jun 15]; Available from: http://doi.wiley.

com/10.1002/14651858.CD006642.pub3. ISSN: 1465-1858

[24] Son S-A, Jung H, Cho JY, Oh T-H, Do YW, Lim KH, et al. Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: A single-center experience. European Journal of Trauma and Emergency Surgery. 2019. [cited 2019 June 15]; Available from: http://link.springer. com/10.1007/s00068-019-01166-6

[25] Altuwaijri T, Nouh T, Alburakan A, Altoijry A. Long-term follow-up of endovascular repair of iatrogenic superior vena cava injury: A case report. Medicine (Baltimore). 2018;**97**(50):e13610

[26] Azizzadeh A, Pham MT, Estrera AL, Coogan SM, Safi HJ. Endovascular repair of an iatrogenic superior vena caval injury: A case report. Journal of Vascular Surgery. 2007;**46**(3):569-571

[27] Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Annals of Surgery. 1989;**209**(6):698-705-707

[28] Weale R, Kong V, Manchev V, Bekker W, Oosthuizen G, Brysiewicz P, et al. Management of intra-abdominal vascular injury in trauma laparotomy: A South African experience. Canadian Journal of Surgery. 2018;**61**(3):158-164

[29] Kazibudzki M, Orawczyk T, Ludyga T, Krupowies A. Cyclist's injury—The cause of symptoms of chronic ischaemia of the lower limb young patients. Chirurgia Polska. 2005;**7**(4):292-295

[30] Matsumoto S, Jung K, Smith A, Coimbra R. Management of IVC injury: Repair or ligation? A propensity score matching analysis using the national trauma data bank. Journal

**72**

*Emergency Medicine and Trauma*

Elsevier; 2019

**References**

[1] Sidawy AN, Perler BA. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA:

[9] Johnson JE, Sims RK, Hamilton DJ, Kragh JF. Safety and effectiveness evidence of SAM(r) junctional tourniquet to control inguinal hemorrhage in a perfused cadaver model. Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals.

[10] Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery.

[11] Coleman JJ, Zarzaur BL. Surgical management of abdominal trauma. The Surgical Clinics of North America.

[12] Trellopoulos G, Georgiadis GS, Aslanidou EA, Nikolopoulos ES, Pitta X, Papachristodoulou A, et al. Endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock. The Journal of Cardiovascular Surgery.

[13] Malgras B, Prunet B, Lesaffre X, Boddaert G, Travers S, Cungi P-J, et al. Damage control: Concept and implementation. Journal of Visceral Surgery. 2017;**154**(Suppl 1):S19-S29

[14] Branco BC, Musonza T, Long MA, Chung J, Todd SR, Wall MJ, et al. Survival trends after inferior vena cava and aortic injuries in the United States. Journal of Vascular Surgery.

[15] Badole C, Patond K, Mk K. Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Indian Journal of Orthopaedics.

2018;**68**(6):1880-1888

2007;**41**(3):183

2014;**14**(2):21-25

2019;**86**(3):532-539

2017;**97**(5):1107-1117

2012;**53**(4):495-506

[2] Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: The East practice management guidelines work group. The Journal of

Trauma. 2002;**53**(3):602-615

Lekarskie PZWL; 2017

2019;**12**(1):1-5

Lekarskie; 2018

2005;**13**(3):141-147

[3] Guła P, Machała W, Wydawnictwo Lekarskie PZWL. Postępowanie w obrażeniach ciała w praktyce SOR. Warszawa: Wydawnictwo

[4] Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: Current therapies, outcomes, and challenges. Annals of Vascular Diseases.

[5] Mehta V, Pandit BN, Mehra P, Nigam A, Vyas A, Yusuf J, et al. Massive bleeding from guidewire perforation of an external iliac artery: Treatment with hand-made stent-graft placement. Cardiovascular and Interventional Radiology. 2016;**39**(1):106-110

Wydawnictwo Lekarskie PZWL. Ostre stany zagrożenia życia w obrażeniach ciała. Warszawa: PZWL Wydawnictwo

[7] Davidovic LB, Cinara IS, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil and war peripheral

[8] Prichayudh S, Rassamee P, Sriussadaporn S, Pak-Art R,

arterial trauma: review of risk factors associated with limb loss. Vascular.

Sriussadaporn S, Kritayakirana K, et al. Abdominal vascular injuries: Blunt vs. penetrating. Injury. 2019;**50**(1):137-141

[6] Sosada K, Żurawiński W,

of the American College of Surgeons. 2018;**226**(5):752-759.e2

[31] Morishita H, Yamagami T, Matsumoto T, Takeuchi Y, Sato O, Nishimura T. Endovascular repair of a perforation of the vena caval wall caused by the retrieval of a gunther tulip filter after long-term implantation. Cardiovascular and Interventional Radiology. 2011;**34**(S2):321-323

[32] de Naeyer G, Degrieck I. Emergent infrahepatic vena cava stenting for life-threatening perforation. Journal of Vascular Surgery. 2005;**41**(3):552-554

[33] Starzl TE, Kaupp HA, Beheler EM, Freeark RJ. Penetrating injuries of the inferior vena cava. The Surgical Clinics of North America. 1963;**43**:387-400

[34] Kunkala M, Jenkins DH, McEachen J, Stockland A, Zielinski MD. Nonoperative management of traumatic suprahepatic inferior vena cava pseudoaneurysms. Journal of Vascular Surgery. 2011;**54**(6):80S-82S

[35] Sabat J, Hsu C-H, Chu Q, Tan T-W. The mortality for surgical repair is similar to ligation in patients with traumatic portal vein injury. Journal of Vascular Surgery. Venous and Lymphatic Disorders. 2019;**7**(3):399-404

[36] Nowicki J, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and management. Annals of the Royal College of Surgeons of England. 2018;**100**(1):6-11

[37] Rutman AM, Vranic JE, Mossa-Basha M. Imaging and management of blunt cerebrovascular injury. Radiographics. 2018;**38**(2):542-563

[38] Eleshra A, Kim D, Park HS, Lee T. Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases. Annals of Surgical Treatment and Research. 2019;**96**(6):305-312

[39] Awan MU, Omar B, Qureshi G, Awan GM. Successful treatment of iatrogenic external iliac artery perforation with covered stent: Case report and review of the literature. Cardiology Research. 2017;**8**(5):246-253

[40] Guloglu R, Dilege S, Aksoy M, Alimoglu O, Yavuz N, Mihmanli M, et al. Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2004;**14**(2):73-76

[41] Hauser J, Lehnhardt M, Steinau H-U, Homann H-H. Trocar injury of the retroperitoneal vessels followed by life-threatening postischemic compartment syndrome of both lower extremities. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2008;**18**(2):222-224

[42] Li Z, Zhao L, Wang K, Cheng J, Zhao Y, Ren W. Characteristics and treatment of vascular injuries: a review of 387 cases at a Chinese center. International Journal of Clinical and Experimental Medicine. 2014;**7**(12):4710-4719

[43] Gupta V, Gupta V, Joshi P, Kumar S, Kulkarni R, Chopra N, et al. Management of post cholecystectomy vascular injuries. The Surgeon. 2018. [cited 2019 June 17]. Available from: https://linkinghub.elsevier.com/ retrieve/pii/S1479666X18301203

[44] Lopera JE, Restrepo CS, Gonzales A, Trimmer CK, Arko F. Aortoiliac vascular injuries after misplacement of fixation screws. Journal of Trauma—Injury, Infection and Critical Care. 2010;**69**(4):870-875

[45] Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. The Journal of Arthroplasty. 2008;**23**(8):1115-1121

**75**

**Chapter 6**

**Abstract**

nail surgery

**1. Introduction**

the 4–30-year-old age group [1].

**2.1 Surrounding soft tissues**

Nail Trauma

*Rebeca Astorga Veganzones*

The nails are important elements of the finger, not only aesthetically, but also for its functionality. Not only to protecting the tip of the finger helps us but also to perform meticulously fine dexterity activities. Due to the high incidence of nail injuries seen in a trauma emergency service, it is essential to know, at least, basic aspects of the anatomy and physiology of the nail and what should be the appropriate treatment based on the injury presented by the patient. Injuries such as subungual hematomas are resolved in short time, however, more complex lesions require minor surgical intervention to obtain good results. In this chapter, additionally to reviewing the anatomy-physiological

aspects of the nail, the principles of treatment of nail traumas are detailed.

the nails facilitate the pinch of small objects and have a cosmetic role.

sequels. Hence, to know anatomy and physiology, it is fundamental.

**2. Anatomy and physiology of the nail unit**

has a profound impact on the other components.

**Keywords:** nail anatomy, nail physiology, nail trauma, subungual hematoma,

Although commonly said nail, it is a unit and it is an important element in the distal digit. It is a complex structure that is truly vital to daily life and civilized existence. Fingernails have an important role in hand function, to protect the dorsal surface of the distal phalanges and increase sensitive of the fingertip. Furthermore,

Fingertip injuries account for 15–24% of all hand injuries, particularly affecting

To achieve an optimal outcome, a good initial treatment is necessary because an inadequate or insufficient treatment can derivate in aesthetics and functionality

The structural and functional features of the nail unit are unique, clinics and surgeons must understand them thoroughly. Although this chapter discusses each component individually, it is important to understand how the basic structural components of the distal digit interrelate. Abnormality of one of these structures

The nail anatomy unit compromises the nail plate, the surrounding soft tissues, and their vasculature and innervation based upon the distal phalanx (**Figure 1**).

*Hyponychium*: it is the distal limit of the adhesion of the nail plate and it is a histologically specialized area making the transition between the nail bed and pulp

## **Chapter 6** Nail Trauma

*Rebeca Astorga Veganzones*

### **Abstract**

*Emergency Medicine and Trauma*

[31] Morishita H, Yamagami T, Matsumoto T, Takeuchi Y, Sato O, Nishimura T. Endovascular repair of a perforation of the vena caval wall caused by the retrieval of a gunther tulip filter after long-term implantation. Cardiovascular and Interventional Radiology. 2011;**34**(S2):321-323

2018;**226**(5):752-759.e2

of the American College of Surgeons.

[39] Awan MU, Omar B, Qureshi G, Awan GM. Successful treatment of iatrogenic external iliac artery perforation with covered stent: Case report and review of the literature. Cardiology Research. 2017;**8**(5):246-253

[40] Guloglu R, Dilege S, Aksoy M, Alimoglu O, Yavuz N, Mihmanli M, et al. Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy. Journal of

Techniques. 2004;**14**(2):73-76

2008;**18**(2):222-224

2014;**7**(12):4710-4719

Laparoendoscopic & Advanced Surgical

[41] Hauser J, Lehnhardt M, Steinau H-U, Homann H-H. Trocar injury of the retroperitoneal vessels followed by life-threatening postischemic compartment syndrome of both lower extremities. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques.

[42] Li Z, Zhao L, Wang K, Cheng J, Zhao Y, Ren W. Characteristics and treatment of vascular injuries: a review of 387 cases at a Chinese center. International Journal of Clinical and Experimental Medicine.

[43] Gupta V, Gupta V, Joshi P, Kumar S, Kulkarni R, Chopra N, et al. Management of post cholecystectomy vascular injuries. The Surgeon. 2018. [cited 2019 June 17]. Available from: https://linkinghub.elsevier.com/ retrieve/pii/S1479666X18301203

[44] Lopera JE, Restrepo CS, Gonzales A, Trimmer CK, Arko F. Aortoiliac vascular injuries after misplacement of fixation screws. Journal of Trauma—Injury,

Infection and Critical Care.

[45] Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. The Journal of Arthroplasty. 2008;**23**(8):1115-1121

2010;**69**(4):870-875

[32] de Naeyer G, Degrieck I. Emergent infrahepatic vena cava stenting for life-threatening perforation. Journal of Vascular Surgery. 2005;**41**(3):552-554

[33] Starzl TE, Kaupp HA, Beheler EM, Freeark RJ. Penetrating injuries of the inferior vena cava. The Surgical Clinics of North America. 1963;**43**:387-400

[35] Sabat J, Hsu C-H, Chu Q, Tan T-W. The mortality for surgical repair is similar to ligation in patients with traumatic portal vein injury. Journal of Vascular Surgery. Venous and Lymphatic

[34] Kunkala M, Jenkins DH, McEachen J, Stockland A, Zielinski MD. Nonoperative management of traumatic suprahepatic inferior vena cava pseudoaneurysms. Journal of Vascular Surgery. 2011;**54**(6):80S-82S

Disorders. 2019;**7**(3):399-404

[36] Nowicki J, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and management. Annals of the Royal College of Surgeons of

England. 2018;**100**(1):6-11

[37] Rutman AM, Vranic JE, Mossa-Basha M. Imaging and management of blunt cerebrovascular injury. Radiographics. 2018;**38**(2):542-563

[38] Eleshra A, Kim D, Park HS, Lee T. Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases. Annals of Surgical Treatment and Research.

2019;**96**(6):305-312

**74**

The nails are important elements of the finger, not only aesthetically, but also for its functionality. Not only to protecting the tip of the finger helps us but also to perform meticulously fine dexterity activities. Due to the high incidence of nail injuries seen in a trauma emergency service, it is essential to know, at least, basic aspects of the anatomy and physiology of the nail and what should be the appropriate treatment based on the injury presented by the patient. Injuries such as subungual hematomas are resolved in short time, however, more complex lesions require minor surgical intervention to obtain good results. In this chapter, additionally to reviewing the anatomy-physiological aspects of the nail, the principles of treatment of nail traumas are detailed.

**Keywords:** nail anatomy, nail physiology, nail trauma, subungual hematoma, nail surgery

#### **1. Introduction**

Although commonly said nail, it is a unit and it is an important element in the distal digit. It is a complex structure that is truly vital to daily life and civilized existence. Fingernails have an important role in hand function, to protect the dorsal surface of the distal phalanges and increase sensitive of the fingertip. Furthermore, the nails facilitate the pinch of small objects and have a cosmetic role.

Fingertip injuries account for 15–24% of all hand injuries, particularly affecting the 4–30-year-old age group [1].

To achieve an optimal outcome, a good initial treatment is necessary because an inadequate or insufficient treatment can derivate in aesthetics and functionality sequels. Hence, to know anatomy and physiology, it is fundamental.

#### **2. Anatomy and physiology of the nail unit**

The structural and functional features of the nail unit are unique, clinics and surgeons must understand them thoroughly. Although this chapter discusses each component individually, it is important to understand how the basic structural components of the distal digit interrelate. Abnormality of one of these structures has a profound impact on the other components.

The nail anatomy unit compromises the nail plate, the surrounding soft tissues, and their vasculature and innervation based upon the distal phalanx (**Figure 1**).

#### **2.1 Surrounding soft tissues**

*Hyponychium*: it is the distal limit of the adhesion of the nail plate and it is a histologically specialized area making the transition between the nail bed and pulp

#### **Figure 1.**

*Nail anatomy: 1. proximal nail fold; 2. eponychium; 3. nail plate; 4. hyponychium; 5. nail bed; 6. subungual subcutaneous; 7. nail matrix; and 8. distal phalanx.*

tissue. It has the function as mechanical barrier because prevent accumulation of foreign bodies between the nail plate and the nail bed.

*Paronychium*: it includes all soft tissues lateral to the nail. The lateral nail folds provide the cushioned cutaneous lateral margins of the nail and is again histologically specialized because protects adjacent nail structures from contamination.

*Eponychium*: it is a lip of skin that is adherent to the dorsal aspect of the nail plate and conceals all or part of the nail matrix, which is clinically manifest as the "lunula." It combines with the nail plate to provide protective layer over the matrix. This protection extends to blocking from ultraviolet radiation, diminish risk of malignance. Eponychium also combine with the cuticle to provide a seal against irritants and other agents that might disturb matrix function and hence nail growth. So that, remove the cuticle with manicure should be discouraged.

#### **2.2 Nail plate (nail)**

The nail plate is only produced by the nail matrix. It is a modified form of stratum corneum cells arranged in successive layers that overlying the nail bed and matrix. Its deep surface is streaked with longitudinal grooves that contribute to fastening it to the underlying nail bed.

It is curved in both longitudinal and transverse axes. This allows it to be embedded in nail folds at its proximal and lateral margins, which provide strong attachment and make the free edge a useful tool.

The tissues beneath the nail plate are divided into nail matrix (15–25%) and the nail bed (75–85%).

*Nail matrix or germinative* (*dorsal matrix*), is where the nail-forming epithelial structure. It extends to the distal edge of the lunula, that is the visible distal portion of the conventional matrix as a pale blue-gray half-moon structure emerging from under the proximal nail fold.

Histologically this area has a multilayered epithelium whose duplication is the basic of nail plate formation. The proximal matrix is more productive than distal matrix near to the nail bed.

*Nail bed or sterile matrix* (*ventral matrix*), is the tissue that the nail plate rests on and adheres to. It extends from the distal margin of the lunula to the hyponychium and it has a pattern of longitudinal epidermal ridges stretching to the lunula. This

**77**

**Figure 2.**

*Nail Trauma*

**2.3 Vascular supply**

*2.3.1 Arterial supply*

blood supply (**Figure 2**).

*2.3.2 Venous drainage*

**2.4 Nerve supply**

are minor variations.

*DOI: http://dx.doi.org/10.5772/intechopen.86697*

more matt surface of cornified epithelium.

part has a low rate of proliferation and complement of keratin expression that lacks the keratins of terminal differentiation seen in normal skin, but this is reversible, and when a nail is avulsed, these keratins are expressed as a nail bed develops the

The nail unit is vascularized by the terminal branches of the palmar digital arteries that these are connected by dorsal and palmar arches. There are three arches to blood supply the nail unit, so that, it can survive with extensive damage to the

The small vessels of the nail bed are orientated in the same axis than the ridges.

It is by deep and superficial systems. The deep system corresponds to the arterial, and the superficial system exist dorsal and palmar digital veins (**Figure 2**).

The distal digits have sensory and autonomic nerves. The sensory nerves are to terminal branches are derived from fine oblique branches of the volar collateral nerves to the second, third and fourth fingers. In the first and fifth digit, there are dorsal collateral nerves that supply the innervation. These branches usually run to the nail folds and pass under the nail bed at the level of the lunula, although there

Autonomic nerves end in fine arborizations where there are special receptors that are essentials for vascular control or two-point discrimination. Clearly, loss of the sensory function or the fingertips greatly impairs all function of the entire hand. Tactile sensory perception is the only or the five sense nor confined to the head, so that, loss of the sensory function of the fingertips is "to render the eyes of the finger blind."

*Vascularity of the nail: 1. superficial arterial arcade; 2. proximal subungual arterial arcade system; 3. distal* 

*subungual arterial arcade system; 4. distal venous arch; and 5. lateral ligaments to flint.*

#### *Nail Trauma DOI: http://dx.doi.org/10.5772/intechopen.86697*

part has a low rate of proliferation and complement of keratin expression that lacks the keratins of terminal differentiation seen in normal skin, but this is reversible, and when a nail is avulsed, these keratins are expressed as a nail bed develops the more matt surface of cornified epithelium.

#### **2.3 Vascular supply**

*Emergency Medicine and Trauma*

tissue. It has the function as mechanical barrier because prevent accumulation of

*Nail anatomy: 1. proximal nail fold; 2. eponychium; 3. nail plate; 4. hyponychium; 5. nail bed; 6. subungual* 

growth. So that, remove the cuticle with manicure should be discouraged.

The nail plate is only produced by the nail matrix. It is a modified form of stratum corneum cells arranged in successive layers that overlying the nail bed and matrix. Its deep surface is streaked with longitudinal grooves that contribute to

It is curved in both longitudinal and transverse axes. This allows it to be embedded in nail folds at its proximal and lateral margins, which provide strong attach-

The tissues beneath the nail plate are divided into nail matrix (15–25%) and the

*Nail matrix or germinative* (*dorsal matrix*), is where the nail-forming epithelial structure. It extends to the distal edge of the lunula, that is the visible distal portion of the conventional matrix as a pale blue-gray half-moon structure emerging from

Histologically this area has a multilayered epithelium whose duplication is the basic of nail plate formation. The proximal matrix is more productive than distal

*Nail bed or sterile matrix* (*ventral matrix*), is the tissue that the nail plate rests on and adheres to. It extends from the distal margin of the lunula to the hyponychium and it has a pattern of longitudinal epidermal ridges stretching to the lunula. This

*Paronychium*: it includes all soft tissues lateral to the nail. The lateral nail folds provide the cushioned cutaneous lateral margins of the nail and is again histologically specialized because protects adjacent nail structures from contamination. *Eponychium*: it is a lip of skin that is adherent to the dorsal aspect of the nail plate and conceals all or part of the nail matrix, which is clinically manifest as the "lunula." It combines with the nail plate to provide protective layer over the matrix. This protection extends to blocking from ultraviolet radiation, diminish risk of malignance. Eponychium also combine with the cuticle to provide a seal against irritants and other agents that might disturb matrix function and hence nail

foreign bodies between the nail plate and the nail bed.

*subcutaneous; 7. nail matrix; and 8. distal phalanx.*

**76**

**2.2 Nail plate (nail)**

**Figure 1.**

nail bed (75–85%).

under the proximal nail fold.

matrix near to the nail bed.

fastening it to the underlying nail bed.

ment and make the free edge a useful tool.

#### *2.3.1 Arterial supply*

The nail unit is vascularized by the terminal branches of the palmar digital arteries that these are connected by dorsal and palmar arches. There are three arches to blood supply the nail unit, so that, it can survive with extensive damage to the blood supply (**Figure 2**).

The small vessels of the nail bed are orientated in the same axis than the ridges.

#### *2.3.2 Venous drainage*

It is by deep and superficial systems. The deep system corresponds to the arterial, and the superficial system exist dorsal and palmar digital veins (**Figure 2**).

#### **2.4 Nerve supply**

The distal digits have sensory and autonomic nerves. The sensory nerves are to terminal branches are derived from fine oblique branches of the volar collateral nerves to the second, third and fourth fingers. In the first and fifth digit, there are dorsal collateral nerves that supply the innervation. These branches usually run to the nail folds and pass under the nail bed at the level of the lunula, although there are minor variations.

Autonomic nerves end in fine arborizations where there are special receptors that are essentials for vascular control or two-point discrimination. Clearly, loss of the sensory function or the fingertips greatly impairs all function of the entire hand. Tactile sensory perception is the only or the five sense nor confined to the head, so that, loss of the sensory function of the fingertips is "to render the eyes of the finger blind."

#### **Figure 2.**

*Vascularity of the nail: 1. superficial arterial arcade; 2. proximal subungual arterial arcade system; 3. distal subungual arterial arcade system; 4. distal venous arch; and 5. lateral ligaments to flint.*

#### **3. Aims of nail treatment**

Fingernails have an important role in hand function, because they protect the dorsal surface of the distal phalanges and increase sensitive of the fingertip. Furthermore, the nails facilitate the pinch of small objects and a cosmetic role. Hence, the aims of nail treatment are restoring a nail's length, morphology, and a normal appearance.

#### **4. Principles of nail surgery**

The nail trauma surgery can be do in the emergency department, but if the patient presents some digits with nail trauma or important lesions with a complex repair, we must think in an operative theater for do the treatment.

The patient should always be lying on a stretcher and good anesthesia is of paramount important. Any local anesthetic can be used (lidocaine, mepivacaine, etc.). We think that ropivacaine 1% is the election choice because have a long duration (8–12 h) and nail surgery usually is appreciated by patient as is often followed by intense pain. Technique of proximal digital anesthesia block make possible to do all types of nail surgery.

Except for subungual hematoma and nail avulsion, sterile prepping is a must for nail operations. Donning a sterile glove and cutting a tiny hole into the corresponding finger, which is then rolled back, not only gives a sterile file but also exsanguinates the finger and is an efficient tourniquet [2]. After realizing the tourniquet, bleeding is usually copious, and a thick padded dressing is necessary.

#### **The major principles of repairs are the following:**


#### **5. Material for nail treatment**

It's important a sterile ambient, like any other surgical treatment. But it is almost always ambulatory surgery. Antibiotics are needed in most injuries and the use of magnification is essential for nail bed repair.

Very few special instruments are necessary for nail surgery. The suture material must be absorbable and of a small caliber. We use a Vicryl 6/0 for nail bed repair, and a non-absorbable monofilament for repair the surrounding soft tissue injuries and to fix the nail plate when we must remove it.

**79**

**Figure 3.**

*like a graft.*

*Nail Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.86697*

Fingertip and nail bed injuries are seen at all ages, with a peak incidence in 4–30 years old patients [4]. In the emergency department is important to detail in the clinical history the mechanism of injuries, the time it occurred, dominant hand, the patient's job and the context in which the trauma occurred to consider the pos-

(anteroposterior and lateral) is mandatory when a nail trauma is.

Depending on the injury mechanism we will have to consider possible associated injuries. Fingertip injuries most frequently result from a crush injury, often from the hinge side of a door [5]. Approximately 50% of nail bed injuries presenting to hospital are associated with distal phalangeal fractures [6]. Simple radiographic

Nail bed is a highly vascular structure. If the nail is not broken with the trauma, blood collects beneath the nail and the pressure of which may cause pain. In these cases, it is a necessary treat. Drainage of the hematoma can be done by a paper clip heated or battery-powered ophthalmic cautery. Touch to nail at 90-degree angle over the central area of hematoma. The key of the treatment is to ensure that the hematoma is not older than 48 h and a round hole completely through the nail, which stay open to drain.

Once a hole is created it is expected that blood will drain out from the hematoma

If more than 50% of the nail bed is undermined by hematoma, the nail should be removed and explored the nail bed and the distal phalanx because can be affected.

These traumas occur when the mechanism of injury has a component of hyperflexion. The nail plate must be replaced in the nail fold. Before this, it is necessary

*Dislocation of the nail plate; with the reposition of the proximal nail plate, the nail bed avulsed is holding* 

resolving most of the patient's pain. It may take more than one trephination to decompress the hematoma completely. Take care when advancing through the nail to avoid damage to the nail bed. Bandage site with sterile gauze in instruct patient to

**6. Nail trauma assessment**

sible contaminants of the wound.

**7. Treatment of nail injuries**

**7.1 Subungual hematoma**

keep digit clean and dry.

**7.2 Dislocation of the nail plate**

#### **6. Nail trauma assessment**

*Emergency Medicine and Trauma*

**3. Aims of nail treatment**

**4. Principles of nail surgery**

normal appearance.

all types of nail surgery.

form, of the nail sheet.

prosthesis can be used [3].

**5. Material for nail treatment**

magnification is essential for nail bed repair.

and to fix the nail plate when we must remove it.

bed is perfect.

necessary.

Fingernails have an important role in hand function, because they protect the dorsal surface of the distal phalanges and increase sensitive of the fingertip. Furthermore, the nails facilitate the pinch of small objects and a cosmetic role. Hence, the aims of nail treatment are restoring a nail's length, morphology, and a

The nail trauma surgery can be do in the emergency department, but if the patient presents some digits with nail trauma or important lesions with a complex

The patient should always be lying on a stretcher and good anesthesia is of paramount important. Any local anesthetic can be used (lidocaine, mepivacaine, etc.). We think that ropivacaine 1% is the election choice because have a long duration (8–12 h) and nail surgery usually is appreciated by patient as is often followed by intense pain. Technique of proximal digital anesthesia block make possible to do

Except for subungual hematoma and nail avulsion, sterile prepping is a must for nail operations. Donning a sterile glove and cutting a tiny hole into the corresponding finger, which is then rolled back, not only gives a sterile file but also exsanguinates the finger and is an efficient tourniquet [2]. After realizing the tourniquet, bleeding is usually copious, and a thick padded dressing is

• The nail bed is in direct relation to the periosteum of F3, a reduction defect and/or a prominence bone causes a deformation of the bed and, secondary

• The adhesion of the nail sheet is only possible if the reconstruction of the nail

• The growth of the nail sheet is only possible from of the matrix, so that any

• Where possible, keep the nail sheet to replace it after the repair; failing that, a

It's important a sterile ambient, like any other surgical treatment. But it is almost always ambulatory surgery. Antibiotics are needed in most injuries and the use of

Very few special instruments are necessary for nail surgery. The suture material must be absorbable and of a small caliber. We use a Vicryl 6/0 for nail bed repair, and a non-absorbable monofilament for repair the surrounding soft tissue injuries

repair, we must think in an operative theater for do the treatment.

**The major principles of repairs are the following:**

injury of the matrix must be repaired carefully.

**78**

Fingertip and nail bed injuries are seen at all ages, with a peak incidence in 4–30 years old patients [4]. In the emergency department is important to detail in the clinical history the mechanism of injuries, the time it occurred, dominant hand, the patient's job and the context in which the trauma occurred to consider the possible contaminants of the wound.

Depending on the injury mechanism we will have to consider possible associated injuries. Fingertip injuries most frequently result from a crush injury, often from the hinge side of a door [5]. Approximately 50% of nail bed injuries presenting to hospital are associated with distal phalangeal fractures [6]. Simple radiographic (anteroposterior and lateral) is mandatory when a nail trauma is.

### **7. Treatment of nail injuries**

#### **7.1 Subungual hematoma**

Nail bed is a highly vascular structure. If the nail is not broken with the trauma, blood collects beneath the nail and the pressure of which may cause pain. In these cases, it is a necessary treat. Drainage of the hematoma can be done by a paper clip heated or battery-powered ophthalmic cautery. Touch to nail at 90-degree angle over the central area of hematoma. The key of the treatment is to ensure that the hematoma is not older than 48 h and a round hole completely through the nail, which stay open to drain.

Once a hole is created it is expected that blood will drain out from the hematoma resolving most of the patient's pain. It may take more than one trephination to decompress the hematoma completely. Take care when advancing through the nail to avoid damage to the nail bed. Bandage site with sterile gauze in instruct patient to keep digit clean and dry.

If more than 50% of the nail bed is undermined by hematoma, the nail should be removed and explored the nail bed and the distal phalanx because can be affected.

#### **7.2 Dislocation of the nail plate**

These traumas occur when the mechanism of injury has a component of hyperflexion. The nail plate must be replaced in the nail fold. Before this, it is necessary

#### **Figure 3.**

*Dislocation of the nail plate; with the reposition of the proximal nail plate, the nail bed avulsed is holding like a graft.*

#### *Emergency Medicine and Trauma*

to verify the absence of any injury to the bed under local anesthesia. When the nail bed is injured, but it is a small fragment and it's adhered to the nail plate, with the reposition of the nail it is enough because it is like holding a graft (**Figure 3**).

A radiography is mandatory to ensure the absence of distal phalanx fracture because is often present. When there is a distal phalanx fracture associated, the nail plate reinstated and it is enough to stabilize the fracture, and no osteosynthesis or additional splinting is required. But generally, a distal phalanx fracture associated a dislocation of the nail base have a nail bed injury.

The nail plate is replaced into the nail fold to prevent scarring between the dorsal roof and the ventral floor. If more exposure of the nail fold is required, incisions are made at the proximal edge like **Figure 4** from the eponychium because are easier to approximate and cause less scarring than an incision made straight proximal.

#### **7.3 Nail bed injuries and distal phalanx fracture**

It is an injury similar than anterior apart, but the base of the nail remains in place. Classically, a fingertip crushed by the door. It is a frequent injuries of the nail unit and nail bed injuries are easily overlooked especially in children as they are less cooperative and more difficult to do an adequate inspection of the lesions [7].

**Figure 4.** *Kanavel incisions.*

#### **Figure 5.**

*A 20-year-old man with second finger entrapment of his right hand with a door. The wounds affect paronychium and the lateral edges of the pulp.*

**81**

**Figure 7.**

*Nail Trauma*

deformities.

**Figure 6.**

*Example of nail trauma in a woman.*

*Left: wound in the nail bed. Right: nail bed sutured.*

fragment (**Figure 5**).

*DOI: http://dx.doi.org/10.5772/intechopen.86697*

The impact of the nail complex results from palmar displacement of the distal

The proximal nail plate is gentle elevated. Care should be taken to elevate the nail plate without the nail bed and the other tissue. And the distal nail plate is elevating too. Now, the nail bed is explored, and irregularities of the edges may be trimmed into a straight line if it can be closed without tension. After the nail bed is approximated with an absorbable suture 6/0 or 7/0, the nail plate is replaced into

Approximately 50% of nail bed injuries have an associated fracture of the distal phalanx [8]. An associated fracture with a wound in the nail indicates a high energy trauma. The nail plate replaced serves as a splint, and usually osteosynthesis is not necessary. But an osteosynthesis by an axial wire is essential when the distal phalanx fragment is big, or the fracture is instable. A proper alignment of the bone fragments must be done because otherwise it may generate future nail

**Figure 6** shows the case of a middle-aged woman with entrapment of the third finger of her left hand with the door of her vehicle. She had an associated fracture

the nail fold and held with 4/0 or 5/0 suture to hyponychium.

#### *Nail Trauma DOI: http://dx.doi.org/10.5772/intechopen.86697*

*Emergency Medicine and Trauma*

dislocation of the nail base have a nail bed injury.

**7.3 Nail bed injuries and distal phalanx fracture**

to verify the absence of any injury to the bed under local anesthesia. When the nail bed is injured, but it is a small fragment and it's adhered to the nail plate, with the reposition of the nail it is enough because it is like holding a graft (**Figure 3**). A radiography is mandatory to ensure the absence of distal phalanx fracture because is often present. When there is a distal phalanx fracture associated, the nail plate reinstated and it is enough to stabilize the fracture, and no osteosynthesis or additional splinting is required. But generally, a distal phalanx fracture associated a

The nail plate is replaced into the nail fold to prevent scarring between the dorsal roof and the ventral floor. If more exposure of the nail fold is required, incisions are made at the proximal edge like **Figure 4** from the eponychium because are easier to approximate and cause less scarring than an incision made straight proximal.

It is an injury similar than anterior apart, but the base of the nail remains in place. Classically, a fingertip crushed by the door. It is a frequent injuries of the nail unit and nail bed injuries are easily overlooked especially in children as they are less cooperative and more difficult to do an adequate inspection of the lesions [7].

*A 20-year-old man with second finger entrapment of his right hand with a door. The wounds affect* 

**80**

**Figure 5.**

**Figure 4.** *Kanavel incisions.*

*paronychium and the lateral edges of the pulp.*

The impact of the nail complex results from palmar displacement of the distal fragment (**Figure 5**).

The proximal nail plate is gentle elevated. Care should be taken to elevate the nail plate without the nail bed and the other tissue. And the distal nail plate is elevating too. Now, the nail bed is explored, and irregularities of the edges may be trimmed into a straight line if it can be closed without tension. After the nail bed is approximated with an absorbable suture 6/0 or 7/0, the nail plate is replaced into the nail fold and held with 4/0 or 5/0 suture to hyponychium.

Approximately 50% of nail bed injuries have an associated fracture of the distal phalanx [8]. An associated fracture with a wound in the nail indicates a high energy trauma. The nail plate replaced serves as a splint, and usually osteosynthesis is not necessary. But an osteosynthesis by an axial wire is essential when the distal phalanx fragment is big, or the fracture is instable. A proper alignment of the bone fragments must be done because otherwise it may generate future nail deformities.

**Figure 6** shows the case of a middle-aged woman with entrapment of the third finger of her left hand with the door of her vehicle. She had an associated fracture

**Figure 6.** *Example of nail trauma in a woman.*

**Figure 7.** *Left: wound in the nail bed. Right: nail bed sutured.*

of the distal phalanx. After elevated the nail plate, we observe a wound in the nail bed, which is approximated with an absorbable suture 6/0 (**Figure 7**). Then, the nail plate is again repositioned and fixed. The nail plate has a double function; protection of the nail bed repaired and like a splint for the fracture (**Figure 8**).

#### **7.4 Crushing injuries**

These types of injuries resulting from a wide area of force applied to the nail. This energy causes an explosive type of injury in the nail bed with many fragments (**Figure 9**). In this type of lesion, it is important that all fragments of the nail be attached to the periosteum. So that, when the nail plate is being raised, we must be careful in these. No fragments of nail bed should be debrided and discarded because it is extremely difficult to replace. Like the anterior apart, these fragments are approximated whit fine suture, and the nail plate or a synthetic substitute is used to mold the fragments prevent scaring.

#### **7.5 Nail bed avulsions or tissue loss**

Tissue lost affecting the distal half of the nail bed are more common than affecting the proximal half, because the distal end of the nail is more exposed to trauma. Many methods or treatment have been described, but still today it continues generating doubts about which is the best method to reposition the lost nail bed.

Depending on the size of the fragment of nail bed avulsed:


Some authors consider the nail bed to have regenerative capacity and recommend, for limited tissue losses, promoting this healing by placement the nail plate or a substitute when the latter has been missed [3].

**83**

*Nail Trauma*

*DOI: http://dx.doi.org/10.5772/intechopen.86697*

so they are not of interest for this chapter.

free the proximal interphalangeal joint to avoid stiffness.

collection (hematoma, infection) and of pain.

**8. Care after treatment**

**Figure 9.**

*Crushing injury of the nail.*

nated traumatism.

When the fragment avulsed is missed, diverse treatments have been suggested, like skin grafts [9], reversal dermal grafts [10] or palatal mucosal grafts [11]. Even, porcine xenotransplants has been proposed . But we still have not found a histological tissue that can restore nail plate. So that, nail bed grafts are the best option actually, which can be full thickness grafts [12] or thin nail bed grafts [13, 14]. These techniques are highly specialized that must be performed by expert hand surgeons,

After performing the appropriate treatment based on the trauma presented by the patient, a cure of the injured finger should be made. The dressing chosen to perform the cure should be non-stick dressing (Vaseline) and must allow to leave

The first dressing change should be due in 48–72 h, to verify the absence of

The hand should be carried high with a sling. Analgesics are essential in 24–48 h and antibiotics may be necessary in some situations, especially in highly contami-

**Figure 8.** *Nail plate repositioned.*

*Emergency Medicine and Trauma*

**7.4 Crushing injuries**

used to mold the fragments prevent scaring.

**7.5 Nail bed avulsions or tissue loss**

of the distal phalanx. After elevated the nail plate, we observe a wound in the nail bed, which is approximated with an absorbable suture 6/0 (**Figure 7**). Then, the nail plate is again repositioned and fixed. The nail plate has a double function; protection of the nail bed repaired and like a splint for the fracture (**Figure 8**).

These types of injuries resulting from a wide area of force applied to the nail. This energy causes an explosive type of injury in the nail bed with many fragments (**Figure 9**). In this type of lesion, it is important that all fragments of the nail be attached to the periosteum. So that, when the nail plate is being raised, we must be careful in these. No fragments of nail bed should be debrided and discarded because it is extremely difficult to replace. Like the anterior apart, these fragments are approximated whit fine suture, and the nail plate or a synthetic substitute is

Tissue lost affecting the distal half of the nail bed are more common than affecting the proximal half, because the distal end of the nail is more exposed to trauma. Many methods or treatment have been described, but still today it continues generating doubts about which is the best method to reposition the lost nail bed.

• Less than 1–2 mm, it can be replaced as accurately as possible with the nail

• Larger than 2 mm, the nail around the edge is removed of the nail bed and the

Some authors consider the nail bed to have regenerative capacity and recommend, for limited tissue losses, promoting this healing by placement the nail plate

Depending on the size of the fragment of nail bed avulsed:

fragment avulsed is suturing in their place, if it is possible.

plate and held in place with Steri-Strips or suture.

or a substitute when the latter has been missed [3].

**82**

**Figure 8.**

*Nail plate repositioned.*

**Figure 9.** *Crushing injury of the nail.*

When the fragment avulsed is missed, diverse treatments have been suggested, like skin grafts [9], reversal dermal grafts [10] or palatal mucosal grafts [11]. Even, porcine xenotransplants has been proposed . But we still have not found a histological tissue that can restore nail plate. So that, nail bed grafts are the best option actually, which can be full thickness grafts [12] or thin nail bed grafts [13, 14]. These techniques are highly specialized that must be performed by expert hand surgeons, so they are not of interest for this chapter.

#### **8. Care after treatment**

After performing the appropriate treatment based on the trauma presented by the patient, a cure of the injured finger should be made. The dressing chosen to perform the cure should be non-stick dressing (Vaseline) and must allow to leave free the proximal interphalangeal joint to avoid stiffness.

The first dressing change should be due in 48–72 h, to verify the absence of collection (hematoma, infection) and of pain.

The hand should be carried high with a sling. Analgesics are essential in 24–48 h and antibiotics may be necessary in some situations, especially in highly contaminated traumatism.

### **9. Conclusion**

The pattern of fingernail injury depends in the energy and direction of trauma. Management of a fingernail injury should be selected based on injury type and extent and requires accurate knowledge of nail anatomy and physiology. An effective emergency treatment is mandatory to prevent secondary deformities and reduce the risk of secondary reconstruction of the nail bed, which often gives unpredictable results.

### **Conflict of interest**

The author declares no conflicts of interest.

#### **Author details**

Rebeca Astorga Veganzones University Hospital of Burgos, Burgos, Spain

\*Address all correspondence to: rebecaastorga25@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**85**

*Nail Trauma*

**References**

2014;**30**:742-745

[2] Hasegawa K et al. The

2001;**26**(2):283-290

1989;**14**:236-241

2015;**15**:133-136

2015;**20**:410-414

*DOI: http://dx.doi.org/10.5772/intechopen.86697*

department. Pediatric Emergency Care.

grafts. The Journal of Hand Surgery.

[11] Fernandez-Mejia S, Dominguez-Cherit J, Pichardo-Velazquez P, Gonzalez-Olvera S. Treatment of nail bed defects with hard palate mucosal grafts. Journal of Cutaneous Medicine

[12] Ersek RA, Gadaria U, Denton DR. Nail bed avulsions treated with porcine xenografts. The Journal of Hand Surgery.

[13] Lazar A, Abimelec P, Dumontier C. Full thickness skin graft for nail unit reconstruction. Journal of Hand Surgery

[14] Matsuba HM, Spear SL. Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone. Plastic and Reconstructive Surgery.

and Surgery. 2006;**12**:69-72

(British). 2005;**30**:194-198

1983;**8**:594-598

1985;**10**:152-153

1988;**81**:440-443

microvasculature of the nail bed, nail matrix, and nail fold of a normal human fingertip. The Journal of Hand Surgery.

[3] Ogunro EO. External fixation of injured nail bed with the INRO surgical nail splint. The Journal of Hand Surgery.

[4] Nanninga GL et al. Case report of nail bed injury after blunt trauma; what lie beneath the nail? International Journal of Surgery Case Reports.

[5] Yildirimer L et al. Experience of nail bed injuries at a tertiary hand trauma unit: A 12-month review and cost analysis. The Journal of Hand Surgery, European Volume. 2019;**44**(4):419-423

[6] Satku M, Puhaindran ME, Chong AK. Characteristics of fingertip injuries in children in Singapore. Hand Surgery.

[7] Yorlets RR, Busa K, Eberlin KR, et al. Fingertip injuries in children: Epidemiology, financial burden, and implications for prevention. Hand (New

York, N.Y.). 2017;**12**(4):342-347

Hand Surgery. 1984;**9A**:247-252

[10] Clayburgh RH, Wood MB, Cooney WP 3rd. Nail bed repair and reconstruction by reverse dermal

[8] Zook EG, Guy RJ, Russell RC. A study of nail bed injuries. Causes, treatment and prognosis. The Journal of

[9] Flatt A. Nail bed injuries. British Journal of Plastic Surgery. 1956;**8**:38-43

[1] Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency

### **References**

*Emergency Medicine and Trauma*

The pattern of fingernail injury depends in the energy and direction of trauma. Management of a fingernail injury should be selected based on injury type and extent and requires accurate knowledge of nail anatomy and physiology. An effective emergency treatment is mandatory to prevent secondary deformities and reduce the risk of secondary reconstruction of the nail bed, which often gives

**9. Conclusion**

unpredictable results.

**Conflict of interest**

The author declares no conflicts of interest.

**84**

**Author details**

Rebeca Astorga Veganzones

University Hospital of Burgos, Burgos, Spain

provided the original work is properly cited.

\*Address all correspondence to: rebecaastorga25@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

[1] Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatric Emergency Care. 2014;**30**:742-745

[2] Hasegawa K et al. The microvasculature of the nail bed, nail matrix, and nail fold of a normal human fingertip. The Journal of Hand Surgery. 2001;**26**(2):283-290

[3] Ogunro EO. External fixation of injured nail bed with the INRO surgical nail splint. The Journal of Hand Surgery. 1989;**14**:236-241

[4] Nanninga GL et al. Case report of nail bed injury after blunt trauma; what lie beneath the nail? International Journal of Surgery Case Reports. 2015;**15**:133-136

[5] Yildirimer L et al. Experience of nail bed injuries at a tertiary hand trauma unit: A 12-month review and cost analysis. The Journal of Hand Surgery, European Volume. 2019;**44**(4):419-423

[6] Satku M, Puhaindran ME, Chong AK. Characteristics of fingertip injuries in children in Singapore. Hand Surgery. 2015;**20**:410-414

[7] Yorlets RR, Busa K, Eberlin KR, et al. Fingertip injuries in children: Epidemiology, financial burden, and implications for prevention. Hand (New York, N.Y.). 2017;**12**(4):342-347

[8] Zook EG, Guy RJ, Russell RC. A study of nail bed injuries. Causes, treatment and prognosis. The Journal of Hand Surgery. 1984;**9A**:247-252

[9] Flatt A. Nail bed injuries. British Journal of Plastic Surgery. 1956;**8**:38-43

[10] Clayburgh RH, Wood MB, Cooney WP 3rd. Nail bed repair and reconstruction by reverse dermal

grafts. The Journal of Hand Surgery. 1983;**8**:594-598

[11] Fernandez-Mejia S, Dominguez-Cherit J, Pichardo-Velazquez P, Gonzalez-Olvera S. Treatment of nail bed defects with hard palate mucosal grafts. Journal of Cutaneous Medicine and Surgery. 2006;**12**:69-72

[12] Ersek RA, Gadaria U, Denton DR. Nail bed avulsions treated with porcine xenografts. The Journal of Hand Surgery. 1985;**10**:152-153

[13] Lazar A, Abimelec P, Dumontier C. Full thickness skin graft for nail unit reconstruction. Journal of Hand Surgery (British). 2005;**30**:194-198

[14] Matsuba HM, Spear SL. Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone. Plastic and Reconstructive Surgery. 1988;**81**:440-443

## *Edited by Ozgur Karcioglu and Müge Günalp Eneyli*

From prehospital evaluation to management in the emergency department, Emergency Medicine and Trauma provides easily accessible information on the evaluation, diagnosis, and management of trauma care.

Recognition of the multidisciplinary nature and complexity of trauma care, especially the philosophy of a teamwork approach, must be an integral part of trauma management.

To help make logical diagnoses and treatment plans , you will learn:

	- How to demonstrate the ability to adopt a holistic (multidisciplinary, biopsychosocial) approach to trauma patients

This book is designed not only for emergency medical providers but also for medical students.

Published in London, UK © 2019 IntechOpen © digicomphoto / iStock

Emergency Medicine and Trauma

Emergency Medicine

and Trauma

*Edited by Ozgur Karcioglu and Müge Günalp Eneyli*