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Traumatic vasospasm and its complications
TRAUMATIC
VASOSPASM CAMPBELL
AND ITS COMPLICATIONS GARDNER,
M.D.
Montreal, Quebec RIMARILY this articIe is proposes to iIIustrate that vasospasm foIIowing trauma is not aIways an innocuous and sleeting affair, but depending upon its severity and duration, may produce VoIkmann’s contracture, necrosis of the muscIes or even gangrene of the entire Iimb. Secondly, in the cases about to be presented many types of treatment were tried and all faiIed, and we are most anxious to hear whether some of you have had simiIar experiences and have been abIe to overcome this periIous lesion.
P
CASE
REPORTS
CASE I. A French-Canadian soIdier, twenty years oId, whiIe up a tree during battIe exercise, was shot in the right thigh from beIow. He was admitted to No. I Canadian General HospitaI eight hours after his injury. He was not suffering from shock, his bIood pressure being I 2ojSo. In accordance with our custom he was x-rayed and no foreign body was seen. A bIood transfusion was started, an anesthetic was given and his dressings were removed. Two large communicating wounds were seen, both about 5 inches above the knee. Between them the vastus IateraIis and intermedius had been bIown away and the IateraI surface of the femur exposed. The short head of the biceps formed the media1 aspect of the wound and was undisturbed. The sciatic nerve was not seen. A thorough excision was done, suIfaniIamide powder dusted in, the wound was packed lightly with gauze, no sutures were inserted, and a cIosed pIaster appIied foIIowing the Trueta method. The patient returned to the ward in exceIIent condition and that night was quite comfortabIe and happy. The foIIowing day the patient looked weI1, temperature and puIse were normaI, but he compIained bitterIy about pain in the Ieg and inabiIity to move his toes. On testing he was insensitive to pain or touch. There was no sweIIing or blueness of the toes and they were not coId, but on his insistence the cast was cut down. This reIieved him for a few hours but the pain returned with redoubled intensity. AccordingIy, the cast was removed. The toes were not swoIIen, bIue or coId but there was an area on the media1 aspect of the great toe, suggestive of commencing gangrene. There was no sensation and no active movement of toes, foot or ankle.
Posterior tibia1 and dorsaIis pedis pulsation were absent on the right side and the posterior tibia1 puIsation was absent on the Ieft. The caIf was swoIIen, stony hard but not edematous as if there had been a large hemorrhage into the deep structures. It was exqu’isiteIy painful. The site of the wound was not painfu1 and there was no evidence of infection. The femoral artery was puIsating normaIIy and the popIitea1 was also feIt. A diagnosis of earIy VoIkmann’s contracture was made and it was decided to expIore the popIitea1 space to see whether the vesse1 had been damaged. The patient was anesthetized, turned on his face and the popIitea1 space Iaid open by a midIine incision. The vessel was found to be pulsating quite normaIIy. The incision was then extended down the caIf of the Ieg and as the aponeurosis was divided, the calf muscIes IiteraIIy burst out of their retaining sheaths. They were brownish red in coIor, dry in texture, and bIed hardIy at aI1. The posterior tibia1 vessel was then exposed just above the ankIe and was found to be no Iarger than a thread, in tight spasm, and not puIsating. It was foIlowed upward and as the retaining fascia of the deeper muscIes was divided, they resembIed in every way the appearance of those more superficial. AIthough originaIIy we had been abIe to fee1 the vesse1 puIsating just above the point at which we exposed the Iower end, as we foIIowed it upward it went into spasm as we touched it. This process continued Iike a mirage in the desert unti1 we reached our origina point of entrance at the Iower end of the popIitea1 space. Here, too, the same process was repeated and aIthough we couId fee1 the vessel just above puIsating vigorously, the part exposed to our eyes was now contracted to the size of a knitting needIe and remained puIseIess. We gave papaverine without any noticeabIe change. We injected acety1 choline into the vesse1 without effect, but we were abIe to ascertain that r’here was a tiny stream of bIood passing down the Iumen. We next proceeded to do a periarteria1 sympathectomy and this had no resuIt. A spina anesthetic was then given without resuIt and so we gave up and closed the wound. We considered doing an arterectomy but thought it would be useIess as we had no idea where to do it; and as there was a tiny stream of bIood flowing down the posterior tibial, we beIieved it might even be detrimenta1. FolIowing the operation his foot was coId and
American
Journal
of Surgery
Gardner-Traumatic mottled. On the day after it Iooked much as it had before the operation. He complained of loss of vision in his right eye and our ophthalmologist found a small hemorrhage or thrombosis of his retina. For thirteen days we remained indecisive. The Ieg was dressed severa times and it was obvious that the caIf muscIes were meIting away. No movement or sensation returned to the foot nor was any puIsation felt, but the extremity remained warm and showed no signs of gangrene. FinaIIy, secondary infection supervened and it was thought unwise to jeopardize the man’s life for a useless member. Therefore, a supracondyIar amputation was done. The femorai artery and vein appeared perfectIy normaI. The sciatic nerve, as we puIIed it down to divide it, showed on its IateraI surface where it passed cIose to the origina wound, a greenish, mottled appearance as would occur from a resorbing hemorrhage. The nerve was cut off and did not bIeed. The stump was Ieft open. The patient subsequentIy made an uninterrupted recovery. The leg was thoroughIy dissected. The muscIes in both the anterior and posterior compartments had undergone the same process; they were a11 a greyish green mush. The pIantar muscIes of the foot, on the contrary, had not degenerated but appeared white to pink, Iooking Iike iish flesh. The main artery vein and nerve were removed in one piece from the site of amputation to the ankIe. PathoIogic examination of the calf muscles showed in some areas compIeteIy degenerated muscIe in which onIy vague outIines of fragmented fibers remained. In other areas there was frank suppuration with dense masses of acute inflammatory ceIIs. The whole picture was one of muscIe infarction with, in certain areas of the caIf, the added picture of infection. This certainIy wouId appear to resemble the pathologic picture of a Volkmann’s contracture. The sections of the artery, vein and nerve showed the artery and nerve to be norma at a11 IeveIs. The sciatic nerve showed a resorbing hemorrhage within it. CASE II. This soIdier, age twenty-five, was admitted with a simpIe cornminuted fracture of the middIe third of the left tibia and fibula. WhiIe in traction in a BohIer frame under anesthetic he deveIoped convuIsions, which were thought to be due to ether. These were finaIIy controIIed by pentothaI@ and he was left in traction. Four days Iater the toes were swoIIen and bIue. No puIsation of dorsaIis pedis or posterior tibia1 was paIpabIe. There was no sensation and no movement. Assuming this to be due to vasospasm a spina anesthetic was given. There was no improvement in circuIation. Papaverine was aIso tried without effect. It was noted there was much sweIIing and bIistering at the site of fracture. There was a sIow
March,
1932
Vasospasm
469
deveIopment of gangrene of the tots and of the skin overlying the fracture. With the onset of amputation brIow the knee secondary infection, was performed. The muscles throughout the leg were pale, greyish pink and soft, with the fish flesh appearance typical of VoIkmann’s contracture. The vasospasm in this case was originally thought to be due to the irritation of the vessels by the rough bone ends occurring during convuIsion, but no damage to the vessels was found by the pathoIogist on seria1 section. CASEIII. A young soldier suffered a simpIe fracture of his humerus whiIe on battle exercise. On entering the C.C.S. his arm was coId and pulseless and it was assumed that the end of the bone was pressing on the brachia1 artery. AccordingIy, the brachia1 artery was exposed and a point on it was seen which might have been damaged. However, despite various IocaI treatments, the puIsation did not return. Accordingly, this area of the artery was excised but the spasm persisted, gangrene ensued and amputation was Iater done. Examination of the vesseIs showed no organic lesion. CASE IV. A boy of tweIve feI1 from a tree and sustained simple fracture of the cIavicIe. The arm became cold and puIseIess within tweIve hours, and despite cervical bIocks and other forms of treatment, gangrene ensued. Again, subsequent examination of the vessels reveaIed normal structure throughout. CASE v. A soIdier sustained a buIIet wound of the Ieft thigh, severing the vesseIs and subsequentIy requiring amputation. WhiIe in the hospita1 his right arm became coId and puIseIess, and he deveIoped a11 the signs and symptoms of Volkmann’s contracture aIthough he had sustained no known injury to this arm. AIthough the arm was use&, he refused amputation. CASE VI. A young soIdier sustained a gunshot wound of the right side of the neck, and was admitted aImost unconscious, dyspneic and showed left-sided hemipIegia. Emergency tracheotomy was done but no other operation was performed. He remained hemipIegic and died two days Iater. At autopsy, no head injury was found. On expIoration of the neck, there was a wound of the superior thyroid artery extending approximateIy to the externa1 carotid but not involving it. The common, internal and external carotid arteries were compIeteIy normal and no thrombosis couId be found after a compIete search of the base of the skuI1 and into the brain. The right hemisphere was swoIIen, purpIish and showed petechia1 hemorrhages. Here then is a patient with no wound, thrombosis or emboIism of the major arteries, whose condition can onIy be expIained on the basis of a carotid spasm.
470
Gardner-Traumatic
The evidence \vouId seem suficiently compIete to conclude that: (I) Spasm of the vessels either aIone or combined with an organic Iesion, depending upon the degree and duration of ischemia which occurs, may produce Volkmann’s contracture, necrosis of the muscIes or gangrene of the Iimb. (2) In our hands the treatment of certain severe cases of spasm has been whoIIy unsatisfactory. (3) VoIkmann’s contracture is not a separate entity but mereIy a stage between the compIete recovery of the Iimb and tota gangrene, the muscIes perishing because of their great need for oxygen. FinaIIy, with many doubts and no experimentaI proof, we suggest that this vascuIar spasm may arise as a resuIt of a reaction of the
Vasospasm whoIe organism to emotiona disturbance possibIy acting through the endocrine system and that the trauma is merely a Iocal trigger mechanism. This theory is supported to some extent by cases of juveniIe gangrene described by Homans, Kroh and Martin, where a limb has perished without any demonstabIe trauma, and also by the fact that spasm may persist aIthough a11 the nerves to the limb are actuaIIy or functionaIIy severed. We suggest, therefore, that as IocaI treatment has been so unsatisfactory, it might be we11 to widen the scope of our investigations and seek an answer in a genera1 rather than a IocaI remedy. Acknowledgment: We wish to thank Drs. Luke, Armour, Robertson and MacNaughton for their permission to mention their cases.
American
Journal
of Surgery
VASOSPASM CAMPBELL
AND ITS COMPLICATIONS GARDNER,
M.D.
Montreal, Quebec RIMARILY this articIe is proposes to iIIustrate that vasospasm foIIowing trauma is not aIways an innocuous and sleeting affair, but depending upon its severity and duration, may produce VoIkmann’s contracture, necrosis of the muscIes or even gangrene of the entire Iimb. Secondly, in the cases about to be presented many types of treatment were tried and all faiIed, and we are most anxious to hear whether some of you have had simiIar experiences and have been abIe to overcome this periIous lesion.
P
CASE
REPORTS
CASE I. A French-Canadian soIdier, twenty years oId, whiIe up a tree during battIe exercise, was shot in the right thigh from beIow. He was admitted to No. I Canadian General HospitaI eight hours after his injury. He was not suffering from shock, his bIood pressure being I 2ojSo. In accordance with our custom he was x-rayed and no foreign body was seen. A bIood transfusion was started, an anesthetic was given and his dressings were removed. Two large communicating wounds were seen, both about 5 inches above the knee. Between them the vastus IateraIis and intermedius had been bIown away and the IateraI surface of the femur exposed. The short head of the biceps formed the media1 aspect of the wound and was undisturbed. The sciatic nerve was not seen. A thorough excision was done, suIfaniIamide powder dusted in, the wound was packed lightly with gauze, no sutures were inserted, and a cIosed pIaster appIied foIIowing the Trueta method. The patient returned to the ward in exceIIent condition and that night was quite comfortabIe and happy. The foIIowing day the patient looked weI1, temperature and puIse were normaI, but he compIained bitterIy about pain in the Ieg and inabiIity to move his toes. On testing he was insensitive to pain or touch. There was no sweIIing or blueness of the toes and they were not coId, but on his insistence the cast was cut down. This reIieved him for a few hours but the pain returned with redoubled intensity. AccordingIy, the cast was removed. The toes were not swoIIen, bIue or coId but there was an area on the media1 aspect of the great toe, suggestive of commencing gangrene. There was no sensation and no active movement of toes, foot or ankle.
Posterior tibia1 and dorsaIis pedis pulsation were absent on the right side and the posterior tibia1 puIsation was absent on the Ieft. The caIf was swoIIen, stony hard but not edematous as if there had been a large hemorrhage into the deep structures. It was exqu’isiteIy painful. The site of the wound was not painfu1 and there was no evidence of infection. The femoral artery was puIsating normaIIy and the popIitea1 was also feIt. A diagnosis of earIy VoIkmann’s contracture was made and it was decided to expIore the popIitea1 space to see whether the vesse1 had been damaged. The patient was anesthetized, turned on his face and the popIitea1 space Iaid open by a midIine incision. The vessel was found to be pulsating quite normaIIy. The incision was then extended down the caIf of the Ieg and as the aponeurosis was divided, the calf muscIes IiteraIIy burst out of their retaining sheaths. They were brownish red in coIor, dry in texture, and bIed hardIy at aI1. The posterior tibia1 vessel was then exposed just above the ankIe and was found to be no Iarger than a thread, in tight spasm, and not puIsating. It was foIlowed upward and as the retaining fascia of the deeper muscIes was divided, they resembIed in every way the appearance of those more superficial. AIthough originaIIy we had been abIe to fee1 the vesse1 puIsating just above the point at which we exposed the Iower end, as we foIIowed it upward it went into spasm as we touched it. This process continued Iike a mirage in the desert unti1 we reached our origina point of entrance at the Iower end of the popIitea1 space. Here, too, the same process was repeated and aIthough we couId fee1 the vessel just above puIsating vigorously, the part exposed to our eyes was now contracted to the size of a knitting needIe and remained puIseIess. We gave papaverine without any noticeabIe change. We injected acety1 choline into the vesse1 without effect, but we were abIe to ascertain that r’here was a tiny stream of bIood passing down the Iumen. We next proceeded to do a periarteria1 sympathectomy and this had no resuIt. A spina anesthetic was then given without resuIt and so we gave up and closed the wound. We considered doing an arterectomy but thought it would be useIess as we had no idea where to do it; and as there was a tiny stream of bIood flowing down the posterior tibial, we beIieved it might even be detrimenta1. FolIowing the operation his foot was coId and
American
Journal
of Surgery
Gardner-Traumatic mottled. On the day after it Iooked much as it had before the operation. He complained of loss of vision in his right eye and our ophthalmologist found a small hemorrhage or thrombosis of his retina. For thirteen days we remained indecisive. The Ieg was dressed severa times and it was obvious that the caIf muscIes were meIting away. No movement or sensation returned to the foot nor was any puIsation felt, but the extremity remained warm and showed no signs of gangrene. FinaIIy, secondary infection supervened and it was thought unwise to jeopardize the man’s life for a useless member. Therefore, a supracondyIar amputation was done. The femorai artery and vein appeared perfectIy normaI. The sciatic nerve, as we puIIed it down to divide it, showed on its IateraI surface where it passed cIose to the origina wound, a greenish, mottled appearance as would occur from a resorbing hemorrhage. The nerve was cut off and did not bIeed. The stump was Ieft open. The patient subsequentIy made an uninterrupted recovery. The leg was thoroughIy dissected. The muscIes in both the anterior and posterior compartments had undergone the same process; they were a11 a greyish green mush. The pIantar muscIes of the foot, on the contrary, had not degenerated but appeared white to pink, Iooking Iike iish flesh. The main artery vein and nerve were removed in one piece from the site of amputation to the ankIe. PathoIogic examination of the calf muscles showed in some areas compIeteIy degenerated muscIe in which onIy vague outIines of fragmented fibers remained. In other areas there was frank suppuration with dense masses of acute inflammatory ceIIs. The whole picture was one of muscIe infarction with, in certain areas of the caIf, the added picture of infection. This certainIy wouId appear to resemble the pathologic picture of a Volkmann’s contracture. The sections of the artery, vein and nerve showed the artery and nerve to be norma at a11 IeveIs. The sciatic nerve showed a resorbing hemorrhage within it. CASE II. This soIdier, age twenty-five, was admitted with a simpIe cornminuted fracture of the middIe third of the left tibia and fibula. WhiIe in traction in a BohIer frame under anesthetic he deveIoped convuIsions, which were thought to be due to ether. These were finaIIy controIIed by pentothaI@ and he was left in traction. Four days Iater the toes were swoIIen and bIue. No puIsation of dorsaIis pedis or posterior tibia1 was paIpabIe. There was no sensation and no movement. Assuming this to be due to vasospasm a spina anesthetic was given. There was no improvement in circuIation. Papaverine was aIso tried without effect. It was noted there was much sweIIing and bIistering at the site of fracture. There was a sIow
March,
1932
Vasospasm
469
deveIopment of gangrene of the tots and of the skin overlying the fracture. With the onset of amputation brIow the knee secondary infection, was performed. The muscles throughout the leg were pale, greyish pink and soft, with the fish flesh appearance typical of VoIkmann’s contracture. The vasospasm in this case was originally thought to be due to the irritation of the vessels by the rough bone ends occurring during convuIsion, but no damage to the vessels was found by the pathoIogist on seria1 section. CASEIII. A young soldier suffered a simpIe fracture of his humerus whiIe on battle exercise. On entering the C.C.S. his arm was coId and pulseless and it was assumed that the end of the bone was pressing on the brachia1 artery. AccordingIy, the brachia1 artery was exposed and a point on it was seen which might have been damaged. However, despite various IocaI treatments, the puIsation did not return. Accordingly, this area of the artery was excised but the spasm persisted, gangrene ensued and amputation was Iater done. Examination of the vesseIs showed no organic lesion. CASE IV. A boy of tweIve feI1 from a tree and sustained simple fracture of the cIavicIe. The arm became cold and puIseIess within tweIve hours, and despite cervical bIocks and other forms of treatment, gangrene ensued. Again, subsequent examination of the vessels reveaIed normal structure throughout. CASE v. A soIdier sustained a buIIet wound of the Ieft thigh, severing the vesseIs and subsequentIy requiring amputation. WhiIe in the hospita1 his right arm became coId and puIseIess, and he deveIoped a11 the signs and symptoms of Volkmann’s contracture aIthough he had sustained no known injury to this arm. AIthough the arm was use&, he refused amputation. CASE VI. A young soIdier sustained a gunshot wound of the right side of the neck, and was admitted aImost unconscious, dyspneic and showed left-sided hemipIegia. Emergency tracheotomy was done but no other operation was performed. He remained hemipIegic and died two days Iater. At autopsy, no head injury was found. On expIoration of the neck, there was a wound of the superior thyroid artery extending approximateIy to the externa1 carotid but not involving it. The common, internal and external carotid arteries were compIeteIy normal and no thrombosis couId be found after a compIete search of the base of the skuI1 and into the brain. The right hemisphere was swoIIen, purpIish and showed petechia1 hemorrhages. Here then is a patient with no wound, thrombosis or emboIism of the major arteries, whose condition can onIy be expIained on the basis of a carotid spasm.
470
Gardner-Traumatic
The evidence \vouId seem suficiently compIete to conclude that: (I) Spasm of the vessels either aIone or combined with an organic Iesion, depending upon the degree and duration of ischemia which occurs, may produce Volkmann’s contracture, necrosis of the muscIes or gangrene of the Iimb. (2) In our hands the treatment of certain severe cases of spasm has been whoIIy unsatisfactory. (3) VoIkmann’s contracture is not a separate entity but mereIy a stage between the compIete recovery of the Iimb and tota gangrene, the muscIes perishing because of their great need for oxygen. FinaIIy, with many doubts and no experimentaI proof, we suggest that this vascuIar spasm may arise as a resuIt of a reaction of the
Vasospasm whoIe organism to emotiona disturbance possibIy acting through the endocrine system and that the trauma is merely a Iocal trigger mechanism. This theory is supported to some extent by cases of juveniIe gangrene described by Homans, Kroh and Martin, where a limb has perished without any demonstabIe trauma, and also by the fact that spasm may persist aIthough a11 the nerves to the limb are actuaIIy or functionaIIy severed. We suggest, therefore, that as IocaI treatment has been so unsatisfactory, it might be we11 to widen the scope of our investigations and seek an answer in a genera1 rather than a IocaI remedy. Acknowledgment: We wish to thank Drs. Luke, Armour, Robertson and MacNaughton for their permission to mention their cases.
American
Journal
of Surgery