Spontaneous Radial Hemi-Amputation of the Le[t Hand. Case Report--A. H. Bashir
SPONTANEOUS RADIAL
HEMI-AMPUTATION CASE R E P O R T
OF THE L E F T H A N D
A. H. B A S H I R , Basrah, Iraq Spontaneous amputation is rarely encountered, but m a y occur in patients suffering f r o m arterial insufficiency followed by dry gangrene and separation (Stack, 1966). Because of the free intercommunication between the ulnar and radial arteries in the hand, most surgeons do not usually repair an injured radial or ulnar artery if the other one is intact. Our purpose in reporting this case is to show that the radial or ulnar part of the hand m a y be entirely dependent on the corresponding artery for blood supply. CASE REPORT A forty-five year old policeman enjoyed good health until the 20th September, 1975, when he suddenly lost consciousness for a few minutes. When he recovered he experienced severe continuous pain in the left hand for a few hours, which subsided gradually without treatment. Three weeks later, he consulted a local doctor because of the black discolouration of the thumb and index finger of the
Fig. 1. Left hand, anterior view showing level of spontaneous amputation of the thumb and index finger after complete occlusion of the radial artery by an embolus. Fig. 2. Dorsal view. A. H. Bashir, F.R.C.S.(Ed.), Dept. of Plastic Surgery, College of Medicine, University of Basrah, Basrah, Iraq. The Hand--Vol. 9
No. 1
1977
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Spontaneous Radial Hemi-Amputation of the Le[t Hand. Case Report--A. H. Bashir
left hand. He was treated conservatively for a week, and then had a minor operation for removal of the already almost fully separated t h u m b and index finger. Two weeks later, he was referred and admitted to our department. He gave no history of arterial insufficiency. On examination arterial pulsations were present and of good volume in all limbs except the left upper limb where the brachial and ulnar pulses were weak and the radial one was absent. The heart beat was regular and of normal dual rhythm. The pulse rate was 72/min., blood pressure 150/85 and blood and urine examination results within normal limits. In the left hand, the thumb was lost at the level of the metacarpophalangeal joint, the head of the first metacarpal being exposed and surrounded by gangrenous skin. The index finger showed spontaneous amputation at the middle of the shaft of the second metacarpal which was exposed in the wound, as was the metacarpophalangeal joint of the middle finger (Figs 1 and 2). On clinical grounds, a diagnosis was made of thrombosis of the left subclavian artery with showers of emboli reaching the cerebral circulation giving rise to loss of consciousness and also affecting the brachial and radial arteries leading to a partial occlusion of the former and complete occlusion of the latter. Arteriography confirmed the diagnosis. E m b o l e c t o m y of the brachial artery under local anaesthesia failed to restore blood flow in the radial artery. COMMENT
Although gross vascular anomalies in the hand are not common, there is a real risk of neglecting or forgetting this possibility. It is known that arterial embolism in the hand m a y be followed by a spasm of the artery distal to the embolus which may endanger the survival of the tissue supplied by the artery, but in our limited experience of two such patients, the spasm did not last longer than one hour, and in neither of them resulted in gangrene. Although it is possible that the vascular anastomoses in the hand were affected by the extension of the embolic process, it seems reasonable to think that in the patient described some anomaly in the anatomical pattern of the arterial supply to the hand may have rendered the radial part of the hand completely dependent on the radial artery or one of its branches (Coleman, 1961; Edwards, 1960; Murakami, 1969). REFERENCES
COLEMAN, S. S. and ANSON, B. J. (1961) Arterial Patterns In The Hand Based Upon A Study Of 650 Specimens. Surgery, Gynecology and Obstetrics, 113: 408~424. EDWARDS, E. A. (1960) Organization of the Small Arteries of the Hand and Digits. American Journal of Surgery, 99: 837-846. MURAKAMI, T., TAKAYA, K. and OUTI, H. (1969) The origin, course and distribution of arteries of the thumb. Okajima Folia Anatomica Japonica, 46: 123-137. STACK, H. G. (1966) Amputations in Clinical Surgery (The Hand), p. 308-318. Ed." R. Guy Pulvertaft, General Editorship of C. Rob and R. Smith. London--Butterworths.
66
The Hand--Vol, 9
No. 1
1977
SPONTANEOUS RADIAL
HEMI-AMPUTATION CASE R E P O R T
OF THE L E F T H A N D
A. H. B A S H I R , Basrah, Iraq Spontaneous amputation is rarely encountered, but m a y occur in patients suffering f r o m arterial insufficiency followed by dry gangrene and separation (Stack, 1966). Because of the free intercommunication between the ulnar and radial arteries in the hand, most surgeons do not usually repair an injured radial or ulnar artery if the other one is intact. Our purpose in reporting this case is to show that the radial or ulnar part of the hand m a y be entirely dependent on the corresponding artery for blood supply. CASE REPORT A forty-five year old policeman enjoyed good health until the 20th September, 1975, when he suddenly lost consciousness for a few minutes. When he recovered he experienced severe continuous pain in the left hand for a few hours, which subsided gradually without treatment. Three weeks later, he consulted a local doctor because of the black discolouration of the thumb and index finger of the
Fig. 1. Left hand, anterior view showing level of spontaneous amputation of the thumb and index finger after complete occlusion of the radial artery by an embolus. Fig. 2. Dorsal view. A. H. Bashir, F.R.C.S.(Ed.), Dept. of Plastic Surgery, College of Medicine, University of Basrah, Basrah, Iraq. The Hand--Vol. 9
No. 1
1977
65
Spontaneous Radial Hemi-Amputation of the Le[t Hand. Case Report--A. H. Bashir
left hand. He was treated conservatively for a week, and then had a minor operation for removal of the already almost fully separated t h u m b and index finger. Two weeks later, he was referred and admitted to our department. He gave no history of arterial insufficiency. On examination arterial pulsations were present and of good volume in all limbs except the left upper limb where the brachial and ulnar pulses were weak and the radial one was absent. The heart beat was regular and of normal dual rhythm. The pulse rate was 72/min., blood pressure 150/85 and blood and urine examination results within normal limits. In the left hand, the thumb was lost at the level of the metacarpophalangeal joint, the head of the first metacarpal being exposed and surrounded by gangrenous skin. The index finger showed spontaneous amputation at the middle of the shaft of the second metacarpal which was exposed in the wound, as was the metacarpophalangeal joint of the middle finger (Figs 1 and 2). On clinical grounds, a diagnosis was made of thrombosis of the left subclavian artery with showers of emboli reaching the cerebral circulation giving rise to loss of consciousness and also affecting the brachial and radial arteries leading to a partial occlusion of the former and complete occlusion of the latter. Arteriography confirmed the diagnosis. E m b o l e c t o m y of the brachial artery under local anaesthesia failed to restore blood flow in the radial artery. COMMENT
Although gross vascular anomalies in the hand are not common, there is a real risk of neglecting or forgetting this possibility. It is known that arterial embolism in the hand m a y be followed by a spasm of the artery distal to the embolus which may endanger the survival of the tissue supplied by the artery, but in our limited experience of two such patients, the spasm did not last longer than one hour, and in neither of them resulted in gangrene. Although it is possible that the vascular anastomoses in the hand were affected by the extension of the embolic process, it seems reasonable to think that in the patient described some anomaly in the anatomical pattern of the arterial supply to the hand may have rendered the radial part of the hand completely dependent on the radial artery or one of its branches (Coleman, 1961; Edwards, 1960; Murakami, 1969). REFERENCES
COLEMAN, S. S. and ANSON, B. J. (1961) Arterial Patterns In The Hand Based Upon A Study Of 650 Specimens. Surgery, Gynecology and Obstetrics, 113: 408~424. EDWARDS, E. A. (1960) Organization of the Small Arteries of the Hand and Digits. American Journal of Surgery, 99: 837-846. MURAKAMI, T., TAKAYA, K. and OUTI, H. (1969) The origin, course and distribution of arteries of the thumb. Okajima Folia Anatomica Japonica, 46: 123-137. STACK, H. G. (1966) Amputations in Clinical Surgery (The Hand), p. 308-318. Ed." R. Guy Pulvertaft, General Editorship of C. Rob and R. Smith. London--Butterworths.
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No. 1
1977
