Timing of Distal Upper Extremity Arterial Repair in Well-perfused Limb

A 32-year old right-handed male presented to emergency room after going through a glass window during an altercation. At the time of the presentation, the patient admitted to the use of alcohol, and was not able to give clear history. Upon close physical exam, isolated, right distal volar-ulnar forearm laceration was identified with active bleeding (Figure 1). The patient demonstrated stable vital signs without evidence of distress along with well-perfused distal fingertips and palpable radial pulse. On further evaluation, the patient lost resting cascade of ring finger and small finger with no active flexion, but all joints were supple without radiographic evidence of fracture or dislocation (Figure 2). The patient also reported complete numbness on the ulnar digits along with the ulnar border of the hand. The initial management of the patient consisted of applying direct pressure on the wound with pressure dressing. While mobilizing the operating room for possible exploration, complete hemostasis was achieved approximately 30 minutes after the initiation of the pressure dressing. The patient remained stable throughout the management, and maintained well-perfused distal fingertips. At this time, decision was made to observe the patient overnight. The patient was kept in ulnar gutter splint in extension block fashion. The patient remained stable overnight, and upon confirming stable hemoglobin in the morning, decision was made to schedule elective exploration of the wound and possible nerve, artery, and tendon repair. The patient was brought to the operating room approximately 35 hours after the initial presentation. He was prepped and draped in the usual manner. Upon exploration of the wound, complete transection of ulnar artery, flexor carpi ulnaris, flexor digitorum profundus and flexor digitorum superficialis to small and ring finger were identified. Approximately 80 percent transection of flexor digitorum superficialis to middle finger and 90 percent laceration of ulnar nerve were identified as well. After irrigation and debridement, all distal and proximal structures were identified. The profundus tendons were repaired, followed by superficialis tendons. After the flexor tendon repairs, ulnar nerve was repaired, followed by ulnar artery and flexor carpi ulnaris. The patient tolerated the procedure well, and the total tourniquet time was 135 minutes. The patient was kept in dorsal blocking splint post-operatively. At 3-month follow up, the patient demonstrated full grip with mild stiffness of the repaired fingers, improvement in ulnar-sided sensation, and well-perfused distal fingertips with palpable ulnar pulse.