Surgical treatment of hand vascular anomalies: A case report

Abstract

Background. Vascular anomalies in the hand do not occur frequently. Their presence in the metacarpal region can cause different functional disorders. The extent of such disorders directly depends on the localization and size of vascular anomalies, duration and the nature of the anomaly growth as well as on eventual secondary complications such as ulceration or bleeding. The aim of this case report was to show the specifics in the clinical picture, pathogenesis and evolution of such anomalies, applied diagnostic procedures (radiography, ultrasound, magnetic resonance, electromyography) and surgical treatment as well as postoperative functional results. Case report. In the Clinic for Plastic Surgery and Burns, Military Medical Academy Belgrade, two patients were treated surgically for vascular anomalies of the middle palmar region of the hand. The first patient, a 36-year-old male, a former active sportsman (professional handball player) was treated for acute increase in the vascular anomaly of hand in the metacarpal region and proximal phalange of III and IV fingers of his right hand. The anomaly was detected 6 months prior to his hospitalization while two weeks before the hospitalization there was a sudden growth and increase in the change. The second case, a 15-year-old male patient actively pursuing a career in professional basketball was treated for a tumor localized in the metacarpal zone of his left hand. According to the information provided by his parents, the anomaly had been present since his birth. Initially, the anomaly manifested itself as a discoloration of the skin with a marked capillary drawing, gradually increasing throughout the last five years to the present dimension. The growth of the malformation was noticed to coincide in both patients with more active pursuit of their professional sports career. Conclusion. The clinical picture of hand vascular anomalies is dominated by the symptoms of compression of neurovascular structures (paresthesia, intense hand pain, swollen fingers). If it is a chronic progressive process, signs of ischemic intrinsic muscle fibrosis with corresponding functional deficit, as well as tissue defect (usura) of bone and joint structures represent the basic pathological findings. Acute increase is accompanied by compartment syndrome symptoms and ischemic fibrosis of intrinsic hand musculature and development of irreversible dysfunction of the hand. In the presented cases rapid response implies accurate diagnostic methods followed by surgical extirpation in order to treat compartment syndrome.Uvod. Vaskularne anomalije u predelu sake ne javljaju se cesto. Njihovo prisustvo u zoni metakarpusa dovodi do razlicitih funkcionalnih smetnji sake. Obim tih smetnji direktno zavisi od lokalizacije i velicine vaskularne anomalije, trajanja i prirode rasta promene, kao i od eventualnih sekundarnih komplikacija kao sto su ulceracija i krvarenja. Cilj ovog rada bio je da se prikazu specificnosti klinicke slike, patogeneze i ocene tih promena sprovedene dijagnostickim postupcima (radiografija, ultrazvuk, angiografija, magnetna rezonanca, elektromiografija) i nacina hirurskog lecenja, kao i postoperativni funkcionalni rezultati. Prikaz bolesnika. U Klinici za plasticnu hirurgiju i opekotine Vojnomedicinske akademije u Beogradu hirurski su tretirana dva bolesnika sa vaskularnim anomalijama srednjedlanskog regiona sake. Prvi bolesnik, star 36 godina, muskog pola, bivsi aktivni sportista (profesionalni rukometas) lecen je zbog akutnog rasta vaskularne anomalije sake u metakarpalnoj regiji i proksimalnim falangama III i IV prsta desne sake sa palmarne strane. Vaskularna anomalija dijagnostikovana je sest meseci pre hospitalizacije, a nagli rast promene poceo je dve nedelje pre hospitalizacije. Drugi bolesnik, star 15 godina, muskog pola, aktivni profesionalni kosarkas, lecen je zbog tumefakcije lokalizovane u metakarpalnoj regiji leve sake sa palmarne strane. Heteroanamnesticki podaci uzeti od roditelja ukazali su na to da je promena bila prisutna na rodjenju bolesnika i da se manifestovala kao diskoloracija koze u predelu dlana sa kapilarnom sarom, koja je postepeno rasla, a narocito u poslednjih pet godina do aktuelne velicine. Rast opisanih malformacija kod oba bolesnika poklapao se sa povecanjem fizicke aktivnosti tokom njihovih sportskih karijera. Zakljucak. U klinickoj slici vaskularnih anomalija sake dominiraju simptomi kompresije na neurovaskularne strukture, od parestezija pa do intenzivnih bolova sake i otoka prstiju. Ukoliko se radi o hronicnom progredirajucem procesu, znaci ishemicne fibroze intrizicke muskulature sa odgovarajucim funkcionalnim deficitom, kao i uzure na kostanozglobnim strukturama, predstavljaju osnovni patoloski nalaz. U slucaju akutnog rasta prisutni su simptomi kompartment sindroma sa pretecom ishemicnom fibrozom intrizicke muskulature dlana i nastankom ireverzibilne disfunkcije sake. U tim, akutnim slucajevima brzo reagovanje podrazumeva precizne dijagnosticke metode, a nakon toga hirursku ekstirpaciju u cilju lecenja kompartment sindroma.