Rare disease
CASE REPORT
Pseudoaneurysm: an unusual cause of post-traumatic hand swelling Sonali Shah, Sarah Powell-Brett, Andrew Garnham New Cross Hospital, Wolverhampton, UK Correspondence to Sonali Shah, [email protected] Accepted 3 February 2015
SUMMARY Pseudoaneurysms of the hand are a rare presentation with potentially devastating consequences. We present a case of a hand pseudoaneurysm following a single episode of blunt trauma that was effectively managed by simply suspending the patient’s warfarin therapy. BACKGROUND Few cases of hand pseudoaneurysm are reported in the literature with the majority arising secondary to a penetrating injury to the hand or repetitive microtrauma.1 Early diagnosis and management is imperative to avoid complications such as distal embolism with drastic sequelae such as gangrene or ischaemia of the fingers, spontaneous rupture, bone erosion or peripheral nerve dysfunction. We present a case of an 89-year-old man with a post-traumatic pseudoaneurysm in the left dorsal first webspace following a fall on an outstretched hand. Of emphasis in this report is the importance of considering pseudoaneurysm as a cause of posttraumatic hand swelling and the efficacy of suspending anticoagulants and therefore avoiding operative management.
CASE PRESENTATION An 89-year-old man presented with pain and swelling between the thumb and index finger of the left hand following a fall on an outstretched hand. Examination findings revealed a warm and wellperfused left hand, with intact sensation and range of movement albeit stiffness in the wrist and small joints.
Figure 1 Ultrasound image of the left hand showing a large (3 cm in diameter) false aneurysm in the left first web space. Chaotic flow more proximally around the wrist but with no clear aneurysm neck identifiable. were considered. Forty-eight hours later, with some symptomatic improvement and no further intervention, a repeat ultrasound scan was performed showing thrombosis of the pseudoaneurysm (figure 2). No further imaging or surgical intervention was required and the patient was discharged for outpatient follow-up and physiotherapy. The patient was restarted on warfarin therapy 3 weeks later following confirmed thrombosis of the pseudoaneurysm.
OUTCOME AND FOLLOW-UP On follow-up via a telephone call 6 weeks later, the patient reported a significant reduction in pain and swelling with his only symptom being residual
INVESTIGATIONS
To cite: Shah S, PowellBrett S, Garnham A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208750
Initial results of X-ray imaging of the hand revealed a lucent line over the radial styloid and articular surface potentially representing a fracture. A further X-ray taken 8 weeks later noted a soft tissue swelling seen over the dorsal aspect of the carpus and thumb as well as light vascular calcification. This resulted in the diagnosis of soft tissue injury. Following continuation of symptoms of swelling, stiffness and pain a further outpatient ultrasound scan was requested revealing the underlying pathology of a large (almost 3 cm in diameter) post-traumatic false aneurysm in the left dorsal first web space (figure 1).
TREATMENT Having identified the true cause of swelling, the patient’s warfarin ( prescribed for atrial fibrillation) was stopped while further imaging and treatment
Figure 2 Ultrasound image of the left hand taken 2 days later demonstrating thrombosis of pseudoaneurysm.
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
1
Rare disease stiffness on flexion in his thumb and index finger, most noticeable on making a fist. However, he stated that this range of movement had markedly improved since being discharged and he believes it will continue to do so.
DISCUSSION Pseudoaneurysms, also known as false aneurysms, occur when all three layers of the arterial wall are disrupted, leading to extravasation of blood around the vessel wall, which communicates with the vessel lumen. The false sac inner lining is formed by adventitia and over time the haematoma is replaced by fibrous scar tissue resulting in a false aneurysm. This compares to a true aneurysm in which there is dilation of all layers of the vessel wall.2 3 The false aneurysm can continue to expand into adjacent structures resulting in imminent rupture. Traumatic false aneurysms are rare and the majority are as a result of penetrating injuries or due to repetitive microtrauma, also known as hammer hand syndrome, reported in the case of a baseball player.1 In the few documented cases in the literature, the presentation involves a tender pulsatile palmar swelling.4 This distinctive clinical picture was not present in this case albeit some stiffness and pain in the small joints of the left hand causing a delayed diagnosis. Surgery is the gold standard for large aneurysms with a high risk of complications such as distal embolisation or rupture.5 The technique involves resection of the aneurysm followed by end-to-end anastomosis in order to restore blood flow. Radiological techniques such as endovascular embolisation can also be employed as used successfully to treat a superficial palmar arch aneurysm following carpel tunnel decompression.6 Surgical intervention is often favoured in order to avoid significant complications, as aforementioned, but also, particularly in children, to prevent growth retardation.7 However, the place for conservative management in children and adults is still of significance and often underestimated. This is the only documented case, to the best of our knowledge, where alteration of warfarin therapy alone facilitated thrombosis of the aneurysm. The decision to stop the patient’s warfarin was based on balancing the risk of systemic embolisation against the perioperative and anaesthetic risks involved in surgical management, given the patients’ age and comorbidities. Using the CHA2DS2-VASc scoring system we calculated the patient’s risk of stroke or other thromboembolic event to be 3.2% per annum.8 This gave an increased risk of 0.18% over the 3 weeks the warfarin therapy was suspended and we therefore concluded this to be the more suitable lower risk approach. Other conservative options include compression bandaging, which has successfully been used in a few other cases of pseudoaneurysms of the hand 9–11 and is a routine management option for femoral artery false aneurysms. In conclusion, conservative management of traumatic aneurysms by temporarily suspending anticoagulation therapy is a plausible option, as demonstrated by this case. This offers a
2
simple, non-invasive and cost-effective management option, particularly in elderly patients already on anticoagulation therapy and who may have several comorbidities rendering surgical intervention less desirable. This case also identifies a need to consider pseudoaneurysm as a cause of post-traumatic swelling, despite it being a rare condition.
Learning points ▸ Pseudoaneurysms are a rare yet important differential for post-traumatic hand swelling. ▸ Delayed diagnosis can have potential devastating consequences. ▸ There is the potential for successful conservative management with alteration of anticoagulation therapy. ▸ When considering suspending warfarin therapy it is important to calculate the patient’s risk of systemic embolisation using the CHA2DS2-VASc score and to weigh this against the risks involved in surgical management.
Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3 4 5 6
7 8
9
10 11
Miyamoto W, Yamamoto S, Inoue T, et al. False aneurysm of a proper digital artery caused by repetitive microtrauma in a 16-year-old baseball player. Arch Orthop Trauma Surg 2009;129:61–4. Sakamoto A, Arai K. False aneurysm of the superficial palmar arch in a child: a case report. Cases J 2009;2:7985. Franck D, Christophe S, Michel P. False aneurysm of the palmar arch in a child. J Pediatr Surg 2004;39:117–19. Hughes CD, Binette C, Babigian A. Pseudoaneurysm in the hand of a three-year-old boy: a case report. J Emerg Med 2012;42:e87–9. Mazzaccaro D, Malacrida G, Stegher S, et al. Ulnar artery aneurysm: case report and review of the literature. G Chir 2012;33:110–13. Gull S, Spence RA, Loan W. Superficial palmar arch aneurysm after carpal tunnel decompression, a rare complication: a case report. Case Rep Med 2011;2011:595120. Sarkar R, Coran AG, Cilley RE, et al. Arterial aneurysms in children: clinicopathologic classification. J Vasc Surg 1991;13:47–56. Lip GY, Frison L, Halperin JL, et al. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke 2010;41:2731–8. Fields JM, Chandra S, Au AK, et al. Images in emergency medicine. Child with painful palmar mass. Superficial palmar arch pseudoaneurysm. Ann Emerg Med 2013;62:569–77. Cozzi DA, Morini F, Casati A, et al. Radial artery pseudoaneurysm successfully treated by compression bandage. Arch Dis Child 2003;88:165–6. Ceccanti S, Frediani S, Andreoli GM, et al. Effective compression bandage for repair of a complicated radial artery pseudoaneurysm. Ann Vasc Surg 2014;28:1319.e9–12.
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
Rare disease Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
3
CASE REPORT
Pseudoaneurysm: an unusual cause of post-traumatic hand swelling Sonali Shah, Sarah Powell-Brett, Andrew Garnham New Cross Hospital, Wolverhampton, UK Correspondence to Sonali Shah, [email protected] Accepted 3 February 2015
SUMMARY Pseudoaneurysms of the hand are a rare presentation with potentially devastating consequences. We present a case of a hand pseudoaneurysm following a single episode of blunt trauma that was effectively managed by simply suspending the patient’s warfarin therapy. BACKGROUND Few cases of hand pseudoaneurysm are reported in the literature with the majority arising secondary to a penetrating injury to the hand or repetitive microtrauma.1 Early diagnosis and management is imperative to avoid complications such as distal embolism with drastic sequelae such as gangrene or ischaemia of the fingers, spontaneous rupture, bone erosion or peripheral nerve dysfunction. We present a case of an 89-year-old man with a post-traumatic pseudoaneurysm in the left dorsal first webspace following a fall on an outstretched hand. Of emphasis in this report is the importance of considering pseudoaneurysm as a cause of posttraumatic hand swelling and the efficacy of suspending anticoagulants and therefore avoiding operative management.
CASE PRESENTATION An 89-year-old man presented with pain and swelling between the thumb and index finger of the left hand following a fall on an outstretched hand. Examination findings revealed a warm and wellperfused left hand, with intact sensation and range of movement albeit stiffness in the wrist and small joints.
Figure 1 Ultrasound image of the left hand showing a large (3 cm in diameter) false aneurysm in the left first web space. Chaotic flow more proximally around the wrist but with no clear aneurysm neck identifiable. were considered. Forty-eight hours later, with some symptomatic improvement and no further intervention, a repeat ultrasound scan was performed showing thrombosis of the pseudoaneurysm (figure 2). No further imaging or surgical intervention was required and the patient was discharged for outpatient follow-up and physiotherapy. The patient was restarted on warfarin therapy 3 weeks later following confirmed thrombosis of the pseudoaneurysm.
OUTCOME AND FOLLOW-UP On follow-up via a telephone call 6 weeks later, the patient reported a significant reduction in pain and swelling with his only symptom being residual
INVESTIGATIONS
To cite: Shah S, PowellBrett S, Garnham A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208750
Initial results of X-ray imaging of the hand revealed a lucent line over the radial styloid and articular surface potentially representing a fracture. A further X-ray taken 8 weeks later noted a soft tissue swelling seen over the dorsal aspect of the carpus and thumb as well as light vascular calcification. This resulted in the diagnosis of soft tissue injury. Following continuation of symptoms of swelling, stiffness and pain a further outpatient ultrasound scan was requested revealing the underlying pathology of a large (almost 3 cm in diameter) post-traumatic false aneurysm in the left dorsal first web space (figure 1).
TREATMENT Having identified the true cause of swelling, the patient’s warfarin ( prescribed for atrial fibrillation) was stopped while further imaging and treatment
Figure 2 Ultrasound image of the left hand taken 2 days later demonstrating thrombosis of pseudoaneurysm.
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
1
Rare disease stiffness on flexion in his thumb and index finger, most noticeable on making a fist. However, he stated that this range of movement had markedly improved since being discharged and he believes it will continue to do so.
DISCUSSION Pseudoaneurysms, also known as false aneurysms, occur when all three layers of the arterial wall are disrupted, leading to extravasation of blood around the vessel wall, which communicates with the vessel lumen. The false sac inner lining is formed by adventitia and over time the haematoma is replaced by fibrous scar tissue resulting in a false aneurysm. This compares to a true aneurysm in which there is dilation of all layers of the vessel wall.2 3 The false aneurysm can continue to expand into adjacent structures resulting in imminent rupture. Traumatic false aneurysms are rare and the majority are as a result of penetrating injuries or due to repetitive microtrauma, also known as hammer hand syndrome, reported in the case of a baseball player.1 In the few documented cases in the literature, the presentation involves a tender pulsatile palmar swelling.4 This distinctive clinical picture was not present in this case albeit some stiffness and pain in the small joints of the left hand causing a delayed diagnosis. Surgery is the gold standard for large aneurysms with a high risk of complications such as distal embolisation or rupture.5 The technique involves resection of the aneurysm followed by end-to-end anastomosis in order to restore blood flow. Radiological techniques such as endovascular embolisation can also be employed as used successfully to treat a superficial palmar arch aneurysm following carpel tunnel decompression.6 Surgical intervention is often favoured in order to avoid significant complications, as aforementioned, but also, particularly in children, to prevent growth retardation.7 However, the place for conservative management in children and adults is still of significance and often underestimated. This is the only documented case, to the best of our knowledge, where alteration of warfarin therapy alone facilitated thrombosis of the aneurysm. The decision to stop the patient’s warfarin was based on balancing the risk of systemic embolisation against the perioperative and anaesthetic risks involved in surgical management, given the patients’ age and comorbidities. Using the CHA2DS2-VASc scoring system we calculated the patient’s risk of stroke or other thromboembolic event to be 3.2% per annum.8 This gave an increased risk of 0.18% over the 3 weeks the warfarin therapy was suspended and we therefore concluded this to be the more suitable lower risk approach. Other conservative options include compression bandaging, which has successfully been used in a few other cases of pseudoaneurysms of the hand 9–11 and is a routine management option for femoral artery false aneurysms. In conclusion, conservative management of traumatic aneurysms by temporarily suspending anticoagulation therapy is a plausible option, as demonstrated by this case. This offers a
2
simple, non-invasive and cost-effective management option, particularly in elderly patients already on anticoagulation therapy and who may have several comorbidities rendering surgical intervention less desirable. This case also identifies a need to consider pseudoaneurysm as a cause of post-traumatic swelling, despite it being a rare condition.
Learning points ▸ Pseudoaneurysms are a rare yet important differential for post-traumatic hand swelling. ▸ Delayed diagnosis can have potential devastating consequences. ▸ There is the potential for successful conservative management with alteration of anticoagulation therapy. ▸ When considering suspending warfarin therapy it is important to calculate the patient’s risk of systemic embolisation using the CHA2DS2-VASc score and to weigh this against the risks involved in surgical management.
Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3 4 5 6
7 8
9
10 11
Miyamoto W, Yamamoto S, Inoue T, et al. False aneurysm of a proper digital artery caused by repetitive microtrauma in a 16-year-old baseball player. Arch Orthop Trauma Surg 2009;129:61–4. Sakamoto A, Arai K. False aneurysm of the superficial palmar arch in a child: a case report. Cases J 2009;2:7985. Franck D, Christophe S, Michel P. False aneurysm of the palmar arch in a child. J Pediatr Surg 2004;39:117–19. Hughes CD, Binette C, Babigian A. Pseudoaneurysm in the hand of a three-year-old boy: a case report. J Emerg Med 2012;42:e87–9. Mazzaccaro D, Malacrida G, Stegher S, et al. Ulnar artery aneurysm: case report and review of the literature. G Chir 2012;33:110–13. Gull S, Spence RA, Loan W. Superficial palmar arch aneurysm after carpal tunnel decompression, a rare complication: a case report. Case Rep Med 2011;2011:595120. Sarkar R, Coran AG, Cilley RE, et al. Arterial aneurysms in children: clinicopathologic classification. J Vasc Surg 1991;13:47–56. Lip GY, Frison L, Halperin JL, et al. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke 2010;41:2731–8. Fields JM, Chandra S, Au AK, et al. Images in emergency medicine. Child with painful palmar mass. Superficial palmar arch pseudoaneurysm. Ann Emerg Med 2013;62:569–77. Cozzi DA, Morini F, Casati A, et al. Radial artery pseudoaneurysm successfully treated by compression bandage. Arch Dis Child 2003;88:165–6. Ceccanti S, Frediani S, Andreoli GM, et al. Effective compression bandage for repair of a complicated radial artery pseudoaneurysm. Ann Vasc Surg 2014;28:1319.e9–12.
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
Rare disease Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Shah S, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208750
3
