Severe upper extremity injury in the adult patient

INTRODUCTION — Upper extremity trauma is one of the most common types of injuries seen in emergency medicine, ranging from simple fingertip injuries to complex injuries involving multiple tissue structures. Some of the more severe injuries include amputation, brachial plexus injury, and mangled limbs, which require a multidisciplinary approach for successful limb reconstruction. Upper extremity injuries rarely have life-threatening consequences, but failure to manage properly can result in severe dysfunction.

Expedient and early management is the optimal way to maximize extremity function after reconstruction; however, this may not be possible at all times. The general principles of upper extremity trauma management are reviewed. (See "Surgical management of severe upper extremity injury".)

INCIDENCE — Upper extremity injury occurs in 20 to 40 percent of injured patients presenting to the emergency department [1,2]. Among patients presenting to the emergency department with lacerations in the United States from 1992 to 2002, 35 percent involved the upper extremities [1]. In a study from Germany, nearly a fourth of patients with severe injury (Injury Severity Score [ISS] >16) had an associated injury of the upper extremities [2].

The most common upper extremity injuries are fractures and lacerations (29 and 23 percent, respectively) [3]. In one database review, the most common type of fractures involved the wrist, followed by phalangeal and metacarpal fractures (16.2, 12.5, and 8.4 per 10,000 people, respectively) [4].

A review of the National Electronic Injury Surveillance System indicated that 30 percent of all upper injuries were related to work, with injuries to the hands and fingers reported as the most common sites [5]. In addition, 50 percent of the injuries were lacerations, 14 percent were crush or abrasion injuries, 8 percent were fractures, 4 percent were sprains, and 3 percent were burns [5].

INITIAL EVALUATION AND MANAGEMENT — We perform initial resuscitation, diagnostic evaluation, and management of trauma patients based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating head, thoracic, or abdominal trauma is discussed in detail separately. Resuscitation and management of life-threatening thoracoabdominal injuries takes precedence over extremity injury. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)

In these situations, bleeding of the extremities as a potential source of hemorrhagic shock should be controlled. Once the patient is stabilized, a thorough examination of any injuries to the patient's extremities as well as chest, abdomen, and head should be performed. After examination, extremity injuries can be stabilized with splints or external fixation devices.

Control of extremity hemorrhage — For upper extremity hemorrhage that is not adequately controlled with direct pressure, retrospective studies have shown that extremity tourniquets reduce bleeding with a low rate of complications [6-8].

Pneumatic tourniquets (PTs) are commonly used to reduce bleeding during elective upper extremity surgery. They can also be used in the emergency department setting to control extremity hemorrhage to improve patient survival [9,10]. Standard PTs can be used to control hemorrhage in the upper extremity distal to the axilla. The inflation pressure of the PT should be less than 250 mmHg, and the PT cuff should be placed at least 5 cm proximal to the open wound, if possible. The PT should not be inflated continuously for more than two hours to avoid ischemic complications [6-8]. The patient should proceed to the operating room for rapid hemorrhage control.

In the prehospital or military setting, the most commonly used tourniquets are the windless style Combat Application Tourniquet (CAT) or Special Forces Tactical Tourniquet (SOFT-T wide). These can be applied rapidly with one hand, if necessary. In a retrospective study, 94 percent of the service personnel who had applied a CAT to the upper extremity achieved absolute control of hemorrhage, and no deaths were reported [11]. The Tactical Combat Casualty Care Committee of the United States military routinely reviews the performance of commercial tourniquets [12]. For junctional wounds at the axilla, wound packing, ideally with a hemostatic dressing, along with continuous pressure is recommended [13]. There are some junctional tourniquets on the market, but there is insufficient evidence to recommend their use at this time. Also, in the battlefield, application of a specialized tourniquet to the axilla has been reported to control axillary (junctional) hemorrhage [14].

Extremity radiography — Patients with any of the following findings on primary trauma survey should undergo plain radiography.

●Extremity deformity

●Point tenderness

●Ecchymosis

●Laceration deep to the muscle fascia

●Laceration in proximity to a joint

●Joint laxity

Radiographic assessment should focus on the area of extremity abnormality and include the joint above and the joint below the injury. The study should be performed with at least two projections (eg, anterior-posterior, lateral).

Bony injuries, particularly comminuted fractures, increase the risk of concomitant arterial injury (table 1). Susceptible locations include fractures of the proximal humerus, humeral shaft, distal radius, and ulna. The presence of any of these fractures on radiographic survey should prompt full vascular assessment.

Antibiotics — For patients with an open fracture, systemic antibiotics are recommended and should be started at the time of the diagnosis. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend coverage against gram-positive organisms (table 2) as soon as possible after injury, and the addition of gram-negative coverage for Gustilo-Anderson type III (table 3) open fractures [15]. (See "Osteomyelitis associated with open fractures in adults", section on 'Antibiotics after open fracture' and 'Evaluation of bones and joints' below.)

Tetanus prophylaxis — Tetanus prophylaxis should be given according to the Centers for Disease Control (CDC) guidelines [16]. (See "Tetanus-diphtheria toxoid vaccination in adults", section on 'Immunization for patients with injuries'.)

Special situations — Upper extremity trauma that demands specific attention includes traumatic amputation, electrical injury, and crush injury, which are reviewed briefly below.

Traumatic amputation — Replantation can be performed if the amputated extremity is not heavily damaged. Immediate cooling of the amputated part is necessary to slow down tissue metabolism during the ischemic period (picture 1). If replantation is not feasible, a revisional amputation and fitting of an appropriate prosthesis will be needed. Upper extremity amputation is reviewed separately. (See "Upper extremity amputation".)

Electrical injury — Electrical injury to the upper extremities can cause progressive soft tissue damage, including vascular injury [17]. Although peripheral nerves are vulnerable to electricity, demyelination of nerves occurs sporadically [18]. It is often difficult to accurately evaluate the depth of the tissue loss from an electrical injury from an external perspective alone. Soft tissue damage can be extensive with tissue necrosis opposite the site of apparent external injury. Thus, additional imaging or surgical exploration is needed. Clinical or imaging signs of massive soft tissue destruction is usually associated with compartment syndrome. Early fasciotomy at the time of the first debridement is usually performed in patients with high-voltage electrical injury to prevent possible compartment syndrome, which would worsen soft tissue injury [19]. Even with appropriate management of electrical injury, amputation may be necessary if infection or extensive tissue necrosis occurs [20,21]. (See "Electrical injuries and lightning strikes: Evaluation and management".)

Crush injury — Crush injury is caused by an external compression of the extremities, which results in laceration, bony fracture, compression of soft tissues, or ischemia or bleeding distal to the injured site. Severe damage can also result in tissue edema, caused by inhibition of venous return and lymph flow [22]. With prolonged compression of tissues, rhabdomyolysis from muscle necrosis can occur causing myoglobinuria and hyperkalemia, which can lead to life-threatening cardiac dysfunction and kidney failure (ie, crush syndrome). There is also significant risk of compartment syndrome in this situation, which may require fasciotomy. (See "Upper extremity fasciotomy techniques" and "Crush-related acute kidney injury".)

UPPER EXTREMITY EVALUATION — A brief extremity exam is performed during the initial trauma assessment to identify major external hemorrhage (primary survey) but should be repeated in more detail once life-threatening injuries have been addressed and any active external bleeding is controlled. Upper extremity injuries are evaluated and documented based on four functional components: bones and joints, soft tissues, vessels, and nerves (figure 1).

Knowledge of upper extremity anatomy is important for proper upper extremity assessment. (See "Surgical management of severe upper extremity injury", section on 'Upper extremity anatomy'.)

Evaluation of bones and joints — It is important to consider every possible injury to the bones and joints when evaluating the injured upper extremity. Rotation deformities are often overlooked, especially with fractures of the fingers and hands. The presence of blood mixed with oil droplets (indicative of the presence of marrow) from the wound may suggest an open fracture.

Any open fracture sites should initially be cleaned of any foreign debris and dressed with a moist sterile dressing until definitive debridement can be accomplished. (See "Surgical management of severe upper extremity injury", section on 'Fracture management'.)

Open fractures are traditionally graded using the Gustilo-Anderson system (table 3) [23]. While open fracture grading is usually performed intraoperatively, the severity of the orthopedic injury generally can be estimated during the initial evaluation of the extremity. A disadvantage of this scoring system is the low interobserver agreement. The Orthopaedic Trauma Association has proposed a framework for developing a new classification scheme for open fractures [23,24]. This descriptive framework may replace the Gustilo-Anderson system, but it has yet to be validated and correlated with complications and outcomes. While a higher-grade fracture has been correlated with increased risk of infection and with amputation in the lower extremity [25-28], the occurrence of infection with upper extremity fracture is very rare, and furthermore, the rate of amputation does not depend on the fracture grade [25]. In open upper extremity fractures, stabilization of the fracture has been reported to reduce the risk of pyogenic osteomyelitis [29]. The fracture should be immediately stabilized either by temporary fixation using an external fixator or by definitive fixation. Regardless of the grade of the fracture, definitive fixation (image 1) and defect coverage with a soft tissue flap, or a "fix and flap approach," is aggressively performed in upper extremity injuries, rather than relying on injury grade [28]. There is no equivalent replacement for the sensory and prehensile function of the hand. Thus, salvage of even a portion of the hand and upper extremity will provide superior functionality compared with a prosthesis [30]. (See "Surgical management of severe upper extremity injury", section on 'Fracture management'.)

Active movement of the extremity screens for pain, motor function, and range. When no obvious deformity is present or depending on the patient's level of consciousness, passive range of motion can assist with the identification of abnormalities. Splints are placed for temporary fixation if bony or joint abnormalities are clinically diagnosed.

For obvious or suspected fracture of the joint, extremity radiography should be performed. In addition to the location, particular attention must be given to the appearance of the soft tissue surrounding the fracture or dislocation. As examples, the presence of a radiolucent area near the joint suggests the possibility of an open dislocation; a fat pad or sail sign (formed by the effusion of an intra-articular hemorrhage elevating the fat pad) on an elbow radiograph indicates intra-articular injury, such as a distal humerus fracture [31]. Although frequently used, radiography can be unrevealing at times. Radiography early after injury sometimes does not show a clear fracture line, even though the patient may complain of pain or have swelling in the affected area. A common example of when this can happen is with an occult scaphoid fracture. Follow-up radiographic examination can clarify the diagnosis.

Computed tomography (CT) is useful when a cross-sectional or three-dimensional evaluation of the fracture is needed. While magnetic resonance imaging (MRI) is effective for identifying occult fractures and deep soft tissue damage, such as muscle ruptures, triangular fibrocartilage complex (TFCC) injuries, and rotator cuff tears, MRIs are rarely performed during the initial evaluation of extremity injury for practical reasons.

Soft tissue assessment — Any extremity deformity, point tenderness, ecchymosis, deep laceration, laceration near a joint, or joint laxity must be examined carefully because of the possibility of underlying fracture. If the skin defect results in the exposure of soft tissue or bone, a skin graft or flap may be needed for coverage, and a preliminary assessment for possible graft or flap donor sites should also be performed. (See "Surgical management of severe upper extremity injury", section on 'Wound coverage and reconstruction'.)

Tendon and muscle injuries can also be identified during this examination by evaluating the movement of the corresponding tendon during range of motion. As an example, a separate evaluation of the flexor digitorum superficialis and flexor digitorum profundus provides a more thorough and accurate diagnosis of possible flexor injury. A diagnosis of a tendon rupture is usually easy with associated open wounds; however, subcutaneous tendon ruptures are more subtle, and careful examination is needed to exclude the injury and potentially associated nerve damage.

Compartment syndrome must also be considered early and throughout the patient's course to avoid missing the diagnosis. Early fasciotomy can prevent further increases in compartment pressure that can lead to muscle necrosis and neuropathy. Clinical features of compartment syndrome include disproportionate or severe pain, pain induced by passive extension of the muscle, and hardness of the subfascial tissues. Measuring compartment pressure aids the diagnosis. Compartment syndrome of the upper extremity and upper extremity fasciotomy are discussed in detail separately. (See "Acute compartment syndrome of the extremities" and "Upper extremity fasciotomy techniques".)

Vascular assessment — A detailed vascular assessment of the injured upper extremity begins with observing the skin color, temperature, and capillary refill and inflation of the finger pads after compression. A complete pulse examination will identify any asymmetry or the absence of pulses. Blood pressures should be obtained in both upper extremities for comparison, and a wrist-brachial index (ie, injured extremity index [IEI] in trauma patients) calculated. IEI <0.9 is considered abnormal [32]. (See "Noninvasive diagnosis of upper and lower extremity arterial disease", section on 'Wrist-brachial index'.)

Vascular injuries may be apparent from symptoms such as pulsatile bleeding from a visible vessel, or a rapidly expanding hematoma, but signs of distal extremity ischemia, a thrill, or a bruit are not specific. A bruit can be indicative of a partially thrombosed vessel (eg, intimal injury, dissection), or a vessel that is on traction, in spasm, or compressed (eg, compartment syndrome). Differences in systolic blood pressure between the upper extremities should raise concern, particularly in young individuals with no risk factors for underlying vascular disease. In the setting of a shock or the presence of joint dislocation or angulated fracture, the pulse assessment should be repeated after resuscitation and/or reduction of the abnormality.

In addition to clinical findings, vascular imaging aids the diagnosis [33-35]. CT angiography is generally preferred because it is less invasive than catheter-based arteriography and has high sensitivity and specificity. It can also be performed at the same time as head, chest, or abdominal CT, which are frequently needed. Where an appropriately sensitive CT scanner is not immediately available, catheter-based arteriography can be performed to exclude vascular injury, either in a dedicated interventional suite or in the operating room. (See "Surgical and endovascular techniques for aortic arch branch and upper extremity revascularization".)

The American Association for the Surgery of Trauma peripheral vascular injury scale is a classification scheme based on anatomic damage and is one of the criteria for assessing the need for therapeutic intervention in multiple trauma cases involving other organ injuries [36] (table 4). It has been reported that multiple trauma patients with upper extremity injuries have an increased likelihood of thoracoabdominal injury complications [37]. This scale allows for an immediate calculation of the impact of the vascular injury on systemic status for patients suffering from multiple trauma with upper extremity injury. In the upper extremity, vascular injuries distal to the wrist, such as finger or palmar artery injuries, are classified as grade I; radial or ulnar artery injuries as grade II; axillary vein or brachial artery injuries as grade III; and axillary artery injuries as grade V. In multiple trauma cases, higher-grade injuries are more likely to cause death because of hemorrhage and require immediate damage control for the injured vessels, while lower-grade injuries are less of a priority for intervention. The scale is not commonly used in the initial assessment of isolated severe upper extremity injuries and may not be related to the functional prognosis of the patient.

Peripheral nerve assessment — A reliable peripheral nerve assessment may be difficult to obtain immediately following the injury because of pain, concomitant injuries, sedation, or other neurologic injury (spine, head) [15].

Findings that suggest nerve injury include sensory abnormality, motor loss, and loss of perception. The sensory examination of an acutely injured extremity should include two-point discrimination and the distribution of sensory disturbances. The distribution of motor abnormalities is also noted. To evaluate a nerve, the nerve is lightly percussed, which elicits a tingling sensation throughout the innervated area (Tinel sign). In cases of head trauma and shock, the patient's altered state of consciousness reduces the reliability of the neurologic findings. For patients with remote injury, nerve conduction velocity and electromyography may help with the diagnosis of nerve injuries. The Seddon classification classifies nerve injury (table 5) as neurapraxia, axonotmesis, and neurotmesis [38]. (See "Traumatic peripheral neuropathies".)

Neurapraxia and axonotmesis can heal without surgical intervention; however, with neurotmesis, all of the components of the nerve are injured or disconnected, requiring surgical repair. Axonotmesis can be distinguished from neurotmesis by observing the distal progression of the Tinel sign (occurring less than 1 mm a day); however, this can take several weeks. To avoid the consequences of delayed repair, exploration of the nerve can be performed promptly after the injury to determine if repair is needed [39]. (See "Surgical management of severe upper extremity injury", section on 'Nerve exploration and repair'.)

INJURY SEVERITY SCORING

MESS — The Mangled Extremity Severity Score (MESS) is the most widely applied scoring system to categorize the degree of extremity injury [40]. The term "mangled" refers to a limb in which at least three of the four functional components (bone, vessels, nerves, soft tissue) are injured. For the upper extremity, while MESS is not an effective predictor of upper extremity salvage, it may be useful for predicting limb loss [30,41,42]. (See 'Predicting limb loss' below.)

The MESS is calculated by scoring each of the areas listed below (calculator 1).

●Severity of skeletal and/or soft tissue injury

●Severity and duration of limb ischemia

●Severity of shock

●Patient age

Component scores are then added to yield the MESS, which ranges from 2 to 14. "Severity and duration of ischemia" scores are doubled if perfusion has not been restored within six hours of injury. Patients with a truly mangled extremity will typically have MESS scores of 4 or greater.

Predicting limb loss — It is very difficult to estimate the likelihood that an injury to the upper extremity will result in limb loss or salvage. (See "Surgical management of severe upper extremity injury", section on 'Limb salvage versus amputation'.)

The MESS system, along with other scoring systems, is not sufficient in determining the likelihood of limb salvage in upper extremity injuries. Some studies have shown that a score ≥7 was associated with the prediction to amputate [42,43]. However, compared with the its use for lower extremity injuries, several studies suggest that MESS is not a sensitive predictor of amputation in severe injuries of the upper extremity [44,45]. In a study evaluating brachial artery injuries, none of the following were associated with the success rate of limb salvage: ischemia time, the severity of the open fracture, nerve deficits, diminished capillary refill, and MESS [46]. Thus, many recommend that the estimated probability of limb salvage should be based on a combination of injury scoring, but also clinical findings specific to the patient [42,46,47].

The Mangled Upper Extremity Score (MUES), a separate evaluation dedicated to upper extremity injury, has been proposed. The assessment includes age, compression injury, debridement injury, avulsion injury, need for fasciotomy, need for bone fixation, bone loss, repair, and size of skin loss [48]. The MUES has been correlated with the number of hospital complications and length of hospital stay; however, it cannot predict the success of limb salvage attempts [47,48].

MANAGEMENT APPROACH — Once a severe extremity injury has been identified, a customized management plan should be developed taking into consideration the patient's other injuries. Every effort should be made to salvage the upper extremity if there is no clear indication for primary amputation. An attempt to salvage a mangled extremity is reasonable in most instances; however, in a patient with severe multisystem injuries and a mangled extremity, primary amputation may be indicated to save the patient's life. Following every initial limb salvage attempt, the extremity should be reevaluated in the short term for signs of sensorimotor function and tissue viability.

In multiply injured trauma patients, the management plan should be made by one lead surgeon in collaboration with the orthopedic, vascular, and neurosurgery services, as needed. The priority of, timing to, and approach to each injury should be determined in advance. (See "Surgical management of severe upper extremity injury", section on 'Damage control surgery'.)

●Based upon Advanced Trauma Life Support (ATLS) principles, the hemodynamically unstable trauma patient with indications for surgery (eg, positive Focused Assessment with Sonography for Trauma [FAST], obvious signs of vascular injury) should be taken to the operating room to identify and control bleeding. Life-threatening injuries to the head, neck, chest, or abdomen take precedence over the extremity injury. A damage control or staged approach to the injured extremity is warranted once external bleeding from the extremity is controlled (see 'Control of extremity hemorrhage' above). In some cases, the severity of the extremity injury or time constraints due to the need to manage life-threatening injuries will preclude meaningful attempts at limb salvage, and primary amputation may be the best option. If the extremity is the primary (or only) injury, a more definitive approach to repair can be taken at the outset.

●For hemodynamically stable patients, the timing of the management of extremity vascular injury depends upon the degree and duration of ischemia. Patients with obvious vascular injury are taken to the operating room for evaluation and management. Patients with suspected arterial injury with clinical signs (eg, injured extremity index (IEI) <0.9) [32] should be evaluated using computed tomographic (CT) angiography or conventional arteriography depending upon institutional resources [33-35]. With CT angiography, it is difficult to differentiate dissection of the artery from vasospasm or external compression to the artery [35].

Arterial revascularization is fraught with difficulties in the presence of bony instability. Under these circumstances, the most appropriate sequence of care is arterial shunting, if needed, and fracture stabilization followed by definitive vascular repair, once the bones have been stabilized.

●The timing and management of extremity injury when no vascular injury is present depends upon the severity of fracture and the degree of soft tissue loss. Open fracture debridement and fracture stabilization should be performed as soon as is possible depending upon the nature and extent of nonextremity injuries. Multiple debridement procedures are frequently required before definitive fracture fixation and soft tissue coverage can be achieved. (See "Surgical management of severe upper extremity injury", section on 'Surgical management'.)

MORBIDITY AND MORTALITY — Among patients with injuries to the upper extremity, isolated injuries have the lowest mortality rates. However, mortality increases if vascular injury is present. Mortality correlates to the volume of blood lost as a result of the extremity injury, which can be significant with injuries involving the proximal (junctional) vasculature [49]. The highest mortality rates reflect severe, coexistent injuries, and complications. In a review of data from the National Trauma Data Bank in the United States, the mortality rate for arterial injuries that involved the upper extremity was 2.2 percent, which was lower compared with the lower extremity at 7.7 percent [50]. Mortality and complication rates, such as the probability of amputation, were higher for blunt injuries compared with penetrating injuries [50].

Patients with upper extremity injuries have a higher Glasgow Coma Scale (GCS) scores and are less likely to sustain head trauma complications compared with patients without upper extremity injuries [37,51]. This could partially explain the lower mortality in patients with upper extremity injuries in multiple traumas.

The occurrence of venous thromboembolism, which is high following lower extremity injury, is much lower in the upper extremity. However, the incidence increases as the severity of the trauma increases [52]. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Pelvis or extremity injury'.)

Patients with severe injuries to their extremities are subject to other complications, including bone and soft tissue complications (infection, necrosis, nonunion, osteomyelitis), vascular complications (thrombosis), and rhabdomyolysis, any of which can lead to amputation along with other late complications such as heterotopic ossification in the residual limb. Heterotopic ossification in the upper extremity is associated with concurrent brain or spinal cord injuries, leading to prolonged hospitalization [53]. Overall, most of the complications that may occur result in prolonged hospitalization. Wound complications often require additional operative treatments. These complications are discussed in more detail separately. (See "Surgical management of severe upper extremity injury", section on 'Complications'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Extremity compartment syndrome" and "Society guideline links: Severe blunt or penetrating extremity trauma".)

SUMMARY AND RECOMMENDATIONS

●Upper extremity trauma – Trauma to the upper extremities is one of the most common injuries seen in the emergency department. Upper extremity injury occurs in 20 to 40 percent of injured patients presenting to the emergency department, with most injuries occurring in the forearm or wrist. Upper extremity injuries that demand specific attention include traumatic amputation, electrical injury, and crush injury. (See 'Incidence' above and 'Special situations' above.)

●Extremity examination – A brief upper extremity exam is performed during the initial trauma assessment but should be repeated once life-threatening injuries have been addressed. The upper extremity is evaluated and documented based on four functional components: bones and joints, soft tissues, vessels, and nerves (figure 1). Injury to three of these four elements constitutes a "mangled extremity." The upper extremity evaluation is usually conducted by combining the findings on clinical examination and imaging. Surgical exploration is sometimes needed to fully evaluate the severity of nerve injury. (See 'Upper extremity evaluation' above.)

●Extremity radiography – Patients with extremity deformity, point tenderness, ecchymosis, deep laceration, laceration near a joint, or joint laxity should undergo plain radiography to evaluate for possible extremity fracture. Radiographic assessment should focus on the area of extremity abnormality and include the joint above and the joint below the injury. The study should be performed with at least two projections (eg, anterior-posterior, lateral). (See 'Extremity radiography' above.)

●Management approach – Every effort should be made to salvage the upper extremity if there is no clear indication for primary amputation. Following the initial limb salvage attempt, the extremity should be reevaluated for signs of sensorimotor function and tissue viability. (See 'Injury severity scoring' above and 'Management approach' above.)

•Suspected vascular injury – Patients with suspected vascular injury (clinical examination findings, injured extremity index [IEI] <0.90) should undergo vascular imaging. Computed tomographic (CT) angiography is preferred because it is less invasive than catheter-based arteriography and has high sensitivity and specificity. It can also be performed at the same time as head, chest, or abdominal CT, which are frequently needed. Where an appropriately sensitive CT scanner is not immediately available, catheter-based arteriography can be performed to exclude vascular injury either in a dedicated interventional suite or in the operating room. (See 'Vascular assessment' above.)

•Extremity hemorrhage – Patients with obvious upper extremity vascular injury (eg, pulsatile bleeding, an expanding hematoma) are taken directly to the operating room for further examination and management. Direct pressure is usually effective in controlling upper extremity hemorrhage. For hemorrhage that is not adequately controlled with direct pressure, a pneumatic tourniquet can be used. (See 'Control of extremity hemorrhage' above.)

•Unsalvageable limb – In a patient with severe multisystem injuries and a mangled extremity, a primary amputation may be indicated to save the patient's life. Clinical scoring systems are not sufficient in determining the likelihood of amputation in upper extremity injuries. (See 'Injury severity scoring' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges You Jeong Kim, BS, who contributed to an earlier version of this topic review.