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Digital periarterial sympathectomy for ischaemic digital pain and ulcers
DIGITAL PERIARTERIAL ISCHAEMIC DIGITAL T. A. EL-GAMMAL
SYMPATHECTOMY FOR PAIN AND ULCERS and W. F. BLAIR
From the Division of Hand and Microsurgery, Department of Orthopaedics, University of Iowa Hospitals and Clinics, U.S.A.
Digital periarterial sympathectomy was performed on 11 digits in three patients with chronic digital ischaemia which was a manifestation of either Raynaud’s disease, C.R.E.S.T. syndrome or traumatic ulnar artery thrombosis. Before operation, all patients had pain in the affected fingers and five digits had ulcers, two of which were infected. Using the operating microscope, the adventitia was stripped circmuferentially over the distal 2 cm. of the common digital arteries, the bifurcation and the proximal 1 cm. of the proper digital arteries distal to the bifurcation. The same procedure was repeated, at the wrist level, for the ulnar artery and/or the radial artery and its dorsal branch. Follow-up ranged from three to 16 months. After two weeks, all patients reported relief of pain and the ulcers were progressively healing. By three months, all ulcers had healed. Journal of Hand Surgery (British Volume, 1991) 16B: 382-38.5
Barcroft and Walker (1949) found that, following cervicothoracic sympathectomy, the blood flow increases in normal hands by a factor of six. However, the long-term results of cervico-thoracic sympathectomy for ischaemia of the fingers have been generally discouraging (Flatt, 1980). Pick (1970) pointed out that, in contrast to the lower extremity, relapse after sympathectomy of the upper extremity is very frequent and is attributed to incomplete denervation, regeneration of autonomic nerve fibres and reorganisation and activation of alternative pathways. He also pointed out that sympathectomy is relatively more successful for the relief of hyperhydrosis than for alleviation of vascular disease. The concept of digital sympathectomy was first introduced by Flatt (1980) with the premise that the more distally the operation interrupts the sympathetic fibres, the more effective the results will be. The operation consisted of stripping the adventitia over a length of 3 to 4 mm. from the proper digital arteries, distal to the junction of the distal perforating artery with the common digital artery. His series included eight patients operated upon for digital vascular insufficiency due to frostbite, crush injury, scleroderma and Raynaud’s disease. Followup ranged from one to 17 years. Ulcers healed, pain improved (although not markedly in the crushed fingers) and skin temperature increased by 1 to 3°F. Wilgis et al. (1981) performed adventitial stripping in addition to isolation and division of the sympathetic branches arising distally from the digital nerves. The procedure was done on 18 digits in ten patients with chronic digital ischaemia. All these patients responded before the operation to digital block, with measured increase in digital perfusion. All but one patient experienced improvement in digital circulation, as manifested by pulse volume recordings and radioisotope studies after the operation. Pain was relieved almost immediately after the operation and ulcers healed within two weeks. Egloff et al. (1982) reported improvement of symptoms in all 13 patients with Raynaud’s disease 382
followed for three to 13 months post-operatively; the only reported complication was hypoaesthesia in the pulp of the operated finger. Reisman (1984) reported on 51 digital sympathectomies in 42 patients (including those operated upon by Wilgis et al.). The average follow-up was 26 months. 49 digits (96%) had complete recovery subjectively and the ulcers healed within three weeks. Pulse volume recording and radionuclide scans demonstrated a marked increase in digital blood flow. The temperature of the operated digits often increased as much as 6°C. within one or two days after operation. There were no complications except delayed healing in patients taking steroids and in patients with scleroderma. There was no recurrence of symptoms. He pointed out that patients who do not have an increase in pulse volume recording after digital nerve block should not undergo digital sympathectomy. We report our experience with periarterial digital sympathectomy in 11 digits in three patients with chronic digital ischaemia due to Raynaud’s disease, C.R.E.S.T. syndrome and traumatic ulnar artery thrombosis. The indications for the operation in our series were to relieve pain and induce healing of the digital ulcers. Operative technique The digital arteries were exposed through a Y-shaped incision in the distal palm, overlying the bifurcation of the common digital artery (Fig. 1). The digital arteries to the radial side of the index and the ulnar side of the little finger were exposed through midlateral incisions with a zig-zag at the basal digital flexion crease. The ulnar artery and the radial artery with its dorsal branch were approached through separate incisions at the wrist level. Using the operating microscope, circumferential stripping of the adventitia of the common digital arteries was completed over a distance of 2 cm., taking care to preserve all the small arterial branches (Fig. 2). This dissection was extended to include 1 cm. of the proper THE JOURNAL
OF HAND
SURGERY
DIGITAL PERIARTERIAL SYMPATHECTOMY
digital arteries. The same procedure was repeated along a 2 cm. distance on the ulnar artery as well as the radial artery and its dorsal branch. Case reports Case I
Fig. 1
Y-shaped incisions between the distal palmar and the proximal finger flexion creases facilitate exoosure of the common and prgper digital arteries. /
1
A 62-year-old right-handed nurse presented with pain in the tips of her right index and middle fingers. The pain was continuous and had been present for three weeks. She had a one-year history of Raynaud’s symptoms on exposure to cold. The right index and middle fingers were purplish in colour and cooler on palpation than the other fingers. There was a haemorrhagic ulcerated area on the radial aspect of the nail-bed of the index finger. Allen’s test indicated that the ulnar artery was not patent. Using a constant wave Doppler, signals were present in the ulnar artery down to a point 2 cm. proximal to the wrist flexion crease. Sympathectomy was performed on the digital arteries to the medial four fingers and on the radial artery and its dorsal branch. Ten days after the operation, the patient reported relief of pain and cold intolerance, but she had persistent oedema of all digits. One month after the operation, the oedema of the hand had completely resolved and the ulcer of the index finger had almost healed, leaving a small eschar which was slowly separating at the base. After eight months, the right hand appeared normal. One year after the operation, she started to complain of increasing pain and coldness in her left index and middle fingers (i.e. in the other hand) and ulceration over the ulnar aspect of the nail-bed of the middle finger nailbed. Pressure over the ulcer caused a discharge of pus. At operation, the nail was elevated and the ulcer debrided to a bleeding surface. The radial digital artery of the middle finger was found to be thrombosed. Digital sympathectomy was again performed on the digital arteries to the medial four fingers as well as the radial artery and its dorsal branch. Ten days after the second operation, the patient had no complaints but there was moderate oedema of the hand, particularly in the palm. The index and middle fingers were pink but cooler to touch than the ring and little fingers. Two months later, the symptoms had resolved and the ulcer was completely healed. Case 2
Fig. 2
Recommended levels for periarterial sympathectomies. The insert illustrates dissection of the adventitia. A: proper digital artery. B: common digital artery. C : deep palmar arch. D: superficial palmar arch. E : ulnar artery. F : radial artery. G : dorsal branch of the radial artery.
VOL. 16B No. 4 NOVEMBER 1991
A 17-year-old male presented one week after blunt trauma to the right wrist which resulted in right ulnar artery thrombosis confirmed by angiography. He was placed on Nefidipine (Procardia) and Oxpentifylline (Trental), with subsequent improvement in digital perfusion. However, he attended again three months later with persistent pain and coldness in his right index finger 383
T. A. EL-GAMMAL
and progressive ulceration on the radial aspect of the pulp of the same finger. The ulcer was infected and draining. Debridement of the finger pulp and periarterial sympathectomy of the digital arteries on the radial and ulnar aspects of the index finger were performed. Ten days later, there was still pain in the tip of the index finger but less than before. The ulcer had a clean granulating base and appeared to be healing well. Three months after operation, the patient had no pain or cold intolerance and the ulcer had healed. Case 3
A 37-year-old woman had suffered from the C.R.E.S.T. variant of scleroderma for 17 years. The medial four fingers of the left hand and the distal part of the middle finger of the right hand had been amputated for recurrent ulceration, infection and gangrene. She was referred because of pain in the tip of the right thumb and recurrent subungual drainage. Sympathectomy of the radial artery and the ulnar digital artery of the thumb was performed. Ten days after the operation, she reported marked relief of pain and cessation of the discharge. Three months later, she presented again with pain and superficial epidermal ulceration of the right ring and little fingers, for which sympathectomy of the ulnar artery and the digital arteries on both sides of the ring and little fingers and on the ulnar side of the middle finger was performed. Two weeks afterwards, she reported no pain and the skin on the finger-tips was healing with minimal desquama-
AND W. F. BLAIR
tion. The area of the ulnar incision was red and tender but not discharging. Culture of the wound was reported negative. Antibiotic therapy was started and the wound healed in another two weeks. One year later, she presented with severe pain in the right index finger and progressive atrophic changes. Sympathectomy of the radial artery and its dorsal branch and the common digital artery in the second web space and its branch to the ulnar side of the index finger was performed. The digital artery to the radial side of the index finger was absent. The operation resulted in marked relief of pain. However, one month later, a splinter entered her right index finger which became infected and very painful, so the distal part of the index finger had to be amputated. Discussion
The anatomical basis for digital periarterial sympathectomy of the hand was established by Pick (1970), who pointed out that the brachial plexus does not receive its rami communicantes exclusively from the cervicosympathetic trunk. The sino-vertebral nerve, carotid plexus, nerve of Kuntz and the intermediary sympathetic ganglia in the spinal nerve roots by-pass the sympathetic trunk. These alternative pathways may account for the residual sympathetic activity in the upper extremity after cervico-thoracic sympathectomy. The sympathetic fibres travel along the peripheral nerves. Pick (1970) has pointed out that the distal third of the radial artery is innervated by one filament from
Table l-Summary of the procedures,pre- and post-operativefindings Case
1
Age 62
Diagnosis
Raynaud’s disease
Follow-up (month)
14
Digit
Pre-operative pain
Pre-operative ulcer
+ -
Right index middle
-
Operated arteries
Post-operative Post-operative pain ulcer
All digital arteries and radial artery and its dorsal branch
-
-
_ -
_ -
Left index middle ring little
+, infected -
All digital arteries and radial artery and its dorsal branch
+ , infected
Digital arteries on both sides of index
_
-
2
17
Traumatic thrombosis of ulnar artery
3
Right index
3
37
C.R.E.S.T. syndrome
16
Right thumb
+
Recurrent subungual discharge
Radial artery and ulnar digital artery of thumb
_
_
Right ring little
+ +
Superficial epidermal ulceration
Ulnar artery and digital arteries on both sides and little and ulnar side of middle
_ _
_ -
Common digital artery in second web space and its branch to ulnar side of index
_
_
Right index
384
-
THE JOURNAL OF HAND SURGERY
DIGITAL
PERIARTERIAL
the superficial branch of the radial nerve and by eight additional twigs from the lateral cutaneous nerve of the forearm. The distal third of the ulnar artery receives three direct branches from the ulnar nerve and a branch from the medial cutaneous nerve of the forearm which usually travels on the volar surface of the ulnar artery and can be visualised at the wrist level. The deep palmar arch receives two branches from the deep branch of the ulnar nerve and one from the median nerve. The superficial palmar arch receives approximately 12 branches from the common digital nerves. The digital arteries themselves receive three to 12 twigs from the proper digital nerves. Mitchell (1953) pointed out that sympathetic fibres branch in the adventitia. Morgan et al. (1967) studied the relationship between the sympathetic nerves and the arteries in the human hand, using dark field microscopy of sections immersed in glyoxylic acid to excite fluorescence of catecholamine-containing nervous tissue. Their findings confirmed that sympathetic axons travel with the peripheral nerves and send frequent branches to the arteries along their course. The sympathetic axons are located around the external perimeter of the nerves within the epineurium. They also observed that, in the arteries, sympathetic fibres are contained only within the adventitia and do not penetrate the media, and that sympathetic innervation to the arteries is greater in the median nerve distribution than in the ulnar nerve distribution. These anatomical concepts form the conceptual and technical basis of the digital periarterial sympathectomy. The technique of digital periarterial sympathectomy, as originally described by Flatt (1980), consisted of circumferential stripping of the adventitia from the proper digital arteries over 3 to 4 mm. We have employed a more extensive adventitial stripping which includes the distal 2 cm. of the common digital artery and extends past the bifurcation to include 1 cm. of the proper digital arteries. At the wrist level, sympathectomy of the ulnar artery and/or the radial artery and its dorsal branch was also performed. Since all the adventitia may not be removed by stripping at one level, the addition of adventitial stripping of the main ulnar and radial arteries at the wrist increases the likelihood of complete interruption of sympathetic supply to the digital arteries. The indication for the operation in our series was to relieve pain and enhance healing of the digital ulcers. Flatt (1980), Wilgis et al. (1981) and Egloff et al. (1982) reported relief of pain and healing of ulcers in all patients, except those with crush injuries (Flatt, 1980). Reisman (1984) reported similar results in 96% of cases. Clinical results in our series correlate well with the results of
VOL.
16B No. 4 NOVEMBER
1991
SYMPATHECTOMY
previous authors. Pain relief occurred in all patients. It was complete in two patients and partial in the patient with traumatic ulnar artery thrombosis. All ulcers, including the infected ones, had healed at an average of three months. The chronic subungual discharge, in one patient, had completely resolved within ten days. Measurements of the digital temperature or pulse volume were not routinely done. Hypoaesthesia of the pulp and delayed healing of the surgical wound were reported as complications by Egloff et al. (1982) and Reisman (1984). Delayed healing of the surgical incision did occur in one of our patients on chronic steroid therapy; other complications included persistent oedema of the hand which gradually resolved over one month, and recurrent ulceration and infection in the patient with C.R.E.S.T. syndrome caused by a splinter and requiring partial amputation. Although not reported, perforation of the digital artery while stripping the adventitia could occur. The use of an operating microscope should help to prevent this complication and should also improve the quality of the sympathectomy while preserving the important small arterial branches. Conclusion
This study supports the concept that periarterial digital sympathectomy is beneficial in the treatment of ischaemic digital pain and ulcers. It also has a favourable effect on chronic digital infection and drainage which is secondary to digital ischaemia. We recommend that sympathectomy include the ulnar artery and the radial artery with its dorsal branch at the wrist level, to ensure more complete interruption of sympathetic supply to the digital arteries. References BARCROFT, H. and WALKER, A. J. (1949). Return of the tone in bloodvessels of the upper limb after sympathectomy. Lancet, 1: 1035-1039. EGLOFF, D. V., MIFSUD, R. P. and VERDAN, C. (1982). Superselective digital sympathectomy in Raynaud’s phenomenon. The Hand, 15: 1: 1 I& 114. FLATT, A. E. (1980). Digital artery sympathectomy. Journal of Hand Surgery, 5: 6: SSCk556. MITCHELL, G. A. G. Anatomy of the Autonomic Nervous System. Edinburgh, E. S. Livingstone. 1953. MORGAN,k. F.,‘REISMAN, N. R. and WILGIS, E. F. S. (1967). Anatomic localization of sympathetic nerves in the hand. Journal of Hand Surgery, 8: 3: 283-288. PICK, J. The Autonomic Nervous System. Philadephia, J. 8. Lippincott, 1970. REISMAN, N. R. (1984). Surgical management of Raynaud’s phenomenon. Texas Medicine, 80: 44-49. WILGIS, E. F. S. (1981). Evaluation and Treatment of Chronic Digital Ischemia. Annals of Surgery, 193: 6: 693-698.
Accepted: 5 March 1991 William F. Blair, M.D., Division of Hand Clinics, Iowa City, IA 52242, U.S.A. 0 1991 The British
Society
for Surgery
and Microsurgery,
University
of Iowa Hospitals
and
of the Hand
385
SYMPATHECTOMY FOR PAIN AND ULCERS and W. F. BLAIR
From the Division of Hand and Microsurgery, Department of Orthopaedics, University of Iowa Hospitals and Clinics, U.S.A.
Digital periarterial sympathectomy was performed on 11 digits in three patients with chronic digital ischaemia which was a manifestation of either Raynaud’s disease, C.R.E.S.T. syndrome or traumatic ulnar artery thrombosis. Before operation, all patients had pain in the affected fingers and five digits had ulcers, two of which were infected. Using the operating microscope, the adventitia was stripped circmuferentially over the distal 2 cm. of the common digital arteries, the bifurcation and the proximal 1 cm. of the proper digital arteries distal to the bifurcation. The same procedure was repeated, at the wrist level, for the ulnar artery and/or the radial artery and its dorsal branch. Follow-up ranged from three to 16 months. After two weeks, all patients reported relief of pain and the ulcers were progressively healing. By three months, all ulcers had healed. Journal of Hand Surgery (British Volume, 1991) 16B: 382-38.5
Barcroft and Walker (1949) found that, following cervicothoracic sympathectomy, the blood flow increases in normal hands by a factor of six. However, the long-term results of cervico-thoracic sympathectomy for ischaemia of the fingers have been generally discouraging (Flatt, 1980). Pick (1970) pointed out that, in contrast to the lower extremity, relapse after sympathectomy of the upper extremity is very frequent and is attributed to incomplete denervation, regeneration of autonomic nerve fibres and reorganisation and activation of alternative pathways. He also pointed out that sympathectomy is relatively more successful for the relief of hyperhydrosis than for alleviation of vascular disease. The concept of digital sympathectomy was first introduced by Flatt (1980) with the premise that the more distally the operation interrupts the sympathetic fibres, the more effective the results will be. The operation consisted of stripping the adventitia over a length of 3 to 4 mm. from the proper digital arteries, distal to the junction of the distal perforating artery with the common digital artery. His series included eight patients operated upon for digital vascular insufficiency due to frostbite, crush injury, scleroderma and Raynaud’s disease. Followup ranged from one to 17 years. Ulcers healed, pain improved (although not markedly in the crushed fingers) and skin temperature increased by 1 to 3°F. Wilgis et al. (1981) performed adventitial stripping in addition to isolation and division of the sympathetic branches arising distally from the digital nerves. The procedure was done on 18 digits in ten patients with chronic digital ischaemia. All these patients responded before the operation to digital block, with measured increase in digital perfusion. All but one patient experienced improvement in digital circulation, as manifested by pulse volume recordings and radioisotope studies after the operation. Pain was relieved almost immediately after the operation and ulcers healed within two weeks. Egloff et al. (1982) reported improvement of symptoms in all 13 patients with Raynaud’s disease 382
followed for three to 13 months post-operatively; the only reported complication was hypoaesthesia in the pulp of the operated finger. Reisman (1984) reported on 51 digital sympathectomies in 42 patients (including those operated upon by Wilgis et al.). The average follow-up was 26 months. 49 digits (96%) had complete recovery subjectively and the ulcers healed within three weeks. Pulse volume recording and radionuclide scans demonstrated a marked increase in digital blood flow. The temperature of the operated digits often increased as much as 6°C. within one or two days after operation. There were no complications except delayed healing in patients taking steroids and in patients with scleroderma. There was no recurrence of symptoms. He pointed out that patients who do not have an increase in pulse volume recording after digital nerve block should not undergo digital sympathectomy. We report our experience with periarterial digital sympathectomy in 11 digits in three patients with chronic digital ischaemia due to Raynaud’s disease, C.R.E.S.T. syndrome and traumatic ulnar artery thrombosis. The indications for the operation in our series were to relieve pain and induce healing of the digital ulcers. Operative technique The digital arteries were exposed through a Y-shaped incision in the distal palm, overlying the bifurcation of the common digital artery (Fig. 1). The digital arteries to the radial side of the index and the ulnar side of the little finger were exposed through midlateral incisions with a zig-zag at the basal digital flexion crease. The ulnar artery and the radial artery with its dorsal branch were approached through separate incisions at the wrist level. Using the operating microscope, circumferential stripping of the adventitia of the common digital arteries was completed over a distance of 2 cm., taking care to preserve all the small arterial branches (Fig. 2). This dissection was extended to include 1 cm. of the proper THE JOURNAL
OF HAND
SURGERY
DIGITAL PERIARTERIAL SYMPATHECTOMY
digital arteries. The same procedure was repeated along a 2 cm. distance on the ulnar artery as well as the radial artery and its dorsal branch. Case reports Case I
Fig. 1
Y-shaped incisions between the distal palmar and the proximal finger flexion creases facilitate exoosure of the common and prgper digital arteries. /
1
A 62-year-old right-handed nurse presented with pain in the tips of her right index and middle fingers. The pain was continuous and had been present for three weeks. She had a one-year history of Raynaud’s symptoms on exposure to cold. The right index and middle fingers were purplish in colour and cooler on palpation than the other fingers. There was a haemorrhagic ulcerated area on the radial aspect of the nail-bed of the index finger. Allen’s test indicated that the ulnar artery was not patent. Using a constant wave Doppler, signals were present in the ulnar artery down to a point 2 cm. proximal to the wrist flexion crease. Sympathectomy was performed on the digital arteries to the medial four fingers and on the radial artery and its dorsal branch. Ten days after the operation, the patient reported relief of pain and cold intolerance, but she had persistent oedema of all digits. One month after the operation, the oedema of the hand had completely resolved and the ulcer of the index finger had almost healed, leaving a small eschar which was slowly separating at the base. After eight months, the right hand appeared normal. One year after the operation, she started to complain of increasing pain and coldness in her left index and middle fingers (i.e. in the other hand) and ulceration over the ulnar aspect of the nail-bed of the middle finger nailbed. Pressure over the ulcer caused a discharge of pus. At operation, the nail was elevated and the ulcer debrided to a bleeding surface. The radial digital artery of the middle finger was found to be thrombosed. Digital sympathectomy was again performed on the digital arteries to the medial four fingers as well as the radial artery and its dorsal branch. Ten days after the second operation, the patient had no complaints but there was moderate oedema of the hand, particularly in the palm. The index and middle fingers were pink but cooler to touch than the ring and little fingers. Two months later, the symptoms had resolved and the ulcer was completely healed. Case 2
Fig. 2
Recommended levels for periarterial sympathectomies. The insert illustrates dissection of the adventitia. A: proper digital artery. B: common digital artery. C : deep palmar arch. D: superficial palmar arch. E : ulnar artery. F : radial artery. G : dorsal branch of the radial artery.
VOL. 16B No. 4 NOVEMBER 1991
A 17-year-old male presented one week after blunt trauma to the right wrist which resulted in right ulnar artery thrombosis confirmed by angiography. He was placed on Nefidipine (Procardia) and Oxpentifylline (Trental), with subsequent improvement in digital perfusion. However, he attended again three months later with persistent pain and coldness in his right index finger 383
T. A. EL-GAMMAL
and progressive ulceration on the radial aspect of the pulp of the same finger. The ulcer was infected and draining. Debridement of the finger pulp and periarterial sympathectomy of the digital arteries on the radial and ulnar aspects of the index finger were performed. Ten days later, there was still pain in the tip of the index finger but less than before. The ulcer had a clean granulating base and appeared to be healing well. Three months after operation, the patient had no pain or cold intolerance and the ulcer had healed. Case 3
A 37-year-old woman had suffered from the C.R.E.S.T. variant of scleroderma for 17 years. The medial four fingers of the left hand and the distal part of the middle finger of the right hand had been amputated for recurrent ulceration, infection and gangrene. She was referred because of pain in the tip of the right thumb and recurrent subungual drainage. Sympathectomy of the radial artery and the ulnar digital artery of the thumb was performed. Ten days after the operation, she reported marked relief of pain and cessation of the discharge. Three months later, she presented again with pain and superficial epidermal ulceration of the right ring and little fingers, for which sympathectomy of the ulnar artery and the digital arteries on both sides of the ring and little fingers and on the ulnar side of the middle finger was performed. Two weeks afterwards, she reported no pain and the skin on the finger-tips was healing with minimal desquama-
AND W. F. BLAIR
tion. The area of the ulnar incision was red and tender but not discharging. Culture of the wound was reported negative. Antibiotic therapy was started and the wound healed in another two weeks. One year later, she presented with severe pain in the right index finger and progressive atrophic changes. Sympathectomy of the radial artery and its dorsal branch and the common digital artery in the second web space and its branch to the ulnar side of the index finger was performed. The digital artery to the radial side of the index finger was absent. The operation resulted in marked relief of pain. However, one month later, a splinter entered her right index finger which became infected and very painful, so the distal part of the index finger had to be amputated. Discussion
The anatomical basis for digital periarterial sympathectomy of the hand was established by Pick (1970), who pointed out that the brachial plexus does not receive its rami communicantes exclusively from the cervicosympathetic trunk. The sino-vertebral nerve, carotid plexus, nerve of Kuntz and the intermediary sympathetic ganglia in the spinal nerve roots by-pass the sympathetic trunk. These alternative pathways may account for the residual sympathetic activity in the upper extremity after cervico-thoracic sympathectomy. The sympathetic fibres travel along the peripheral nerves. Pick (1970) has pointed out that the distal third of the radial artery is innervated by one filament from
Table l-Summary of the procedures,pre- and post-operativefindings Case
1
Age 62
Diagnosis
Raynaud’s disease
Follow-up (month)
14
Digit
Pre-operative pain
Pre-operative ulcer
+ -
Right index middle
-
Operated arteries
Post-operative Post-operative pain ulcer
All digital arteries and radial artery and its dorsal branch
-
-
_ -
_ -
Left index middle ring little
+, infected -
All digital arteries and radial artery and its dorsal branch
+ , infected
Digital arteries on both sides of index
_
-
2
17
Traumatic thrombosis of ulnar artery
3
Right index
3
37
C.R.E.S.T. syndrome
16
Right thumb
+
Recurrent subungual discharge
Radial artery and ulnar digital artery of thumb
_
_
Right ring little
+ +
Superficial epidermal ulceration
Ulnar artery and digital arteries on both sides and little and ulnar side of middle
_ _
_ -
Common digital artery in second web space and its branch to ulnar side of index
_
_
Right index
384
-
THE JOURNAL OF HAND SURGERY
DIGITAL
PERIARTERIAL
the superficial branch of the radial nerve and by eight additional twigs from the lateral cutaneous nerve of the forearm. The distal third of the ulnar artery receives three direct branches from the ulnar nerve and a branch from the medial cutaneous nerve of the forearm which usually travels on the volar surface of the ulnar artery and can be visualised at the wrist level. The deep palmar arch receives two branches from the deep branch of the ulnar nerve and one from the median nerve. The superficial palmar arch receives approximately 12 branches from the common digital nerves. The digital arteries themselves receive three to 12 twigs from the proper digital nerves. Mitchell (1953) pointed out that sympathetic fibres branch in the adventitia. Morgan et al. (1967) studied the relationship between the sympathetic nerves and the arteries in the human hand, using dark field microscopy of sections immersed in glyoxylic acid to excite fluorescence of catecholamine-containing nervous tissue. Their findings confirmed that sympathetic axons travel with the peripheral nerves and send frequent branches to the arteries along their course. The sympathetic axons are located around the external perimeter of the nerves within the epineurium. They also observed that, in the arteries, sympathetic fibres are contained only within the adventitia and do not penetrate the media, and that sympathetic innervation to the arteries is greater in the median nerve distribution than in the ulnar nerve distribution. These anatomical concepts form the conceptual and technical basis of the digital periarterial sympathectomy. The technique of digital periarterial sympathectomy, as originally described by Flatt (1980), consisted of circumferential stripping of the adventitia from the proper digital arteries over 3 to 4 mm. We have employed a more extensive adventitial stripping which includes the distal 2 cm. of the common digital artery and extends past the bifurcation to include 1 cm. of the proper digital arteries. At the wrist level, sympathectomy of the ulnar artery and/or the radial artery and its dorsal branch was also performed. Since all the adventitia may not be removed by stripping at one level, the addition of adventitial stripping of the main ulnar and radial arteries at the wrist increases the likelihood of complete interruption of sympathetic supply to the digital arteries. The indication for the operation in our series was to relieve pain and enhance healing of the digital ulcers. Flatt (1980), Wilgis et al. (1981) and Egloff et al. (1982) reported relief of pain and healing of ulcers in all patients, except those with crush injuries (Flatt, 1980). Reisman (1984) reported similar results in 96% of cases. Clinical results in our series correlate well with the results of
VOL.
16B No. 4 NOVEMBER
1991
SYMPATHECTOMY
previous authors. Pain relief occurred in all patients. It was complete in two patients and partial in the patient with traumatic ulnar artery thrombosis. All ulcers, including the infected ones, had healed at an average of three months. The chronic subungual discharge, in one patient, had completely resolved within ten days. Measurements of the digital temperature or pulse volume were not routinely done. Hypoaesthesia of the pulp and delayed healing of the surgical wound were reported as complications by Egloff et al. (1982) and Reisman (1984). Delayed healing of the surgical incision did occur in one of our patients on chronic steroid therapy; other complications included persistent oedema of the hand which gradually resolved over one month, and recurrent ulceration and infection in the patient with C.R.E.S.T. syndrome caused by a splinter and requiring partial amputation. Although not reported, perforation of the digital artery while stripping the adventitia could occur. The use of an operating microscope should help to prevent this complication and should also improve the quality of the sympathectomy while preserving the important small arterial branches. Conclusion
This study supports the concept that periarterial digital sympathectomy is beneficial in the treatment of ischaemic digital pain and ulcers. It also has a favourable effect on chronic digital infection and drainage which is secondary to digital ischaemia. We recommend that sympathectomy include the ulnar artery and the radial artery with its dorsal branch at the wrist level, to ensure more complete interruption of sympathetic supply to the digital arteries. References BARCROFT, H. and WALKER, A. J. (1949). Return of the tone in bloodvessels of the upper limb after sympathectomy. Lancet, 1: 1035-1039. EGLOFF, D. V., MIFSUD, R. P. and VERDAN, C. (1982). Superselective digital sympathectomy in Raynaud’s phenomenon. The Hand, 15: 1: 1 I& 114. FLATT, A. E. (1980). Digital artery sympathectomy. Journal of Hand Surgery, 5: 6: SSCk556. MITCHELL, G. A. G. Anatomy of the Autonomic Nervous System. Edinburgh, E. S. Livingstone. 1953. MORGAN,k. F.,‘REISMAN, N. R. and WILGIS, E. F. S. (1967). Anatomic localization of sympathetic nerves in the hand. Journal of Hand Surgery, 8: 3: 283-288. PICK, J. The Autonomic Nervous System. Philadephia, J. 8. Lippincott, 1970. REISMAN, N. R. (1984). Surgical management of Raynaud’s phenomenon. Texas Medicine, 80: 44-49. WILGIS, E. F. S. (1981). Evaluation and Treatment of Chronic Digital Ischemia. Annals of Surgery, 193: 6: 693-698.
Accepted: 5 March 1991 William F. Blair, M.D., Division of Hand Clinics, Iowa City, IA 52242, U.S.A. 0 1991 The British
Society
for Surgery
and Microsurgery,
University
of Iowa Hospitals
and
of the Hand
385