Botulinum Toxin A Salvage of Ischemic Hand Trauma

Abstract

Summary: Posttraumatic hand injuries from crush injury, infusion, or iatrogenic vascular cannulation can cause ischemic finger damage that can progress to necrosis and digital amputation. Botulinum toxin type A (Botox) improves blood flow in chronic vasospastic disorders of the hand. Botox’s efficacy in salvaging ischemic loss in digits in acute traumatic and iatrogenic injury has not been previously reported. From February of 2015 to December of 2016, 11 patients at a Level I trauma center (West Virginia University) presented to the hand surgery service with early ischemic injury and vascular compromise to hand and fingers as a result of crush, direct drug injection, or proximal arterial injury from drug injection or catheterization. Before 2015, all patients with vascular compromise were treated with standard protocol. After January of 2016, patients were treated with additional injection of 80 to 100 U of Botox into the palm and wrist. Before administration of Botox, six patients with vascular compromise of one or more fingers were treated with a conservative protocol and 83 percent had amputation of necrotic digits. After January of 2016, five patients with ischemia were treated with Botox into the palm and proximal arteries. All Botox-treated digits were preserved (100 percent salvage). Pain scores were lower in Botox-treated fingers. We conclude that (1) in the acute traumatic vascular hand injury, early Botox injection markedly increases digital salvage; (2) direct nerve effects after Botox injections improve postinjury pain scores; and (3) early use of Botox in finger injuries is our standard approach to impending ischemia in the hand.

Safety and efficacy of botulinum toxin type A in preventing and treating scars in animal models: A systematic review and meta‐analysis

“…Clinicians have achieved good prophylactic results with BTXA injection near the surgical incision after surgery. Laarakker reported that BTXA is used to salvage ischaemic hand injuries to avoid finger or limb amputation 27 . However, some studies show the opposite conclusion with BTXA injection 28,29 .…”

Acral Necrosis in a COVID-19-Infected Man Treated with Botulinum Toxin Type A

“…The toxin cleaves the SNARE proteins and indirectly inhibits neurotransmitter release of acetylcholine, but also glutamate, norepinephrine, substance P, and calcitonin gene-related peptide at the synapses and neuromuscular junction. Each neurotransmitter affects vascular tonus resulting in decreased vascular smooth muscle tone leading to vasodilatation [ 8 ]. The clinical effect of Botox® gradually occurs within 3–10 days and lasts approximately 12 weeks.…”

“…In the Botox group, all digits were preserved. Moreover, cases experienced pain relief and improvement of digital perfusion [ 8 ]. The physiological mechanisms of Botox® are not fully elucidated.…”

Pollicization of Long Finger After Traumatic Amputation of Thumb and Index Finger

“…We routinely acutely use botulinum A toxin injections in severe traumatic or crush injuries of the hand. Laarakker and Borah described dramatic improvements in digital survival in hand and finger injuries with early Botox injections into the affected fingers and adjacent to radial and ulnar arteries [15]. Botox use for vasospastic disease of the hand is well-described by Neumeister in multiple settings [16].…”