LA Kings’ Martinez Sustains Lacerated Artery, Nerves in Wrist: Treatment and Outcome

In a recent NHL game, an awkward collision caused an opponent to slide skate-first into the outstretched arm of Los Angeles Kings defenseman Alec Martinez, slicing his radial artery and two superficial radial nerves. Martinez immediately left the game and underwent successful surgery to repair the damage.

While these injuries can sometimes be career-ending if not treated promptly and properly, Martinez is expected to make a full recovery.

Anatomy of Martinez’ Injury

The radial (thumb) side of the wrist houses many complex structures. One that you may already be familiar with is the radial artery – the artery which runs along the underside of the wrist and is often used to take a pulse. Along with the ulnar artery, which runs along the pinky side of the forearm, the radial artery is responsible for supplying blood flow to the fingers. If this blood flow is stopped or impaired, the hand and digits may not receive the proper amount of blood to stay alive and functioning.

Radial nerves are divided into deep and superficial branches. The former innervates the muscles that bend the wrist backward, while the latter provides sensation to the backside of the hand and fingers. Given that Martinez sliced superficial but not deep nerves, only the sensation on the back of his hand (and not movement) was likely affected by the skate – a fortunate outcome for an athlete that requires extensive use of the hand and wrist.

Causes and Symptoms

Laceration of the radial artery and/or nerves typically comes as a result of a deep cut but is also possible in cases of extreme blunt trauma. In Martinez’ case, both were likely at play.

Symptoms of an arterial injury include uncontrollablebleeding, a pulsing or expanding pool of blood beneath the skin, turbulent blood flow as heard with a stethoscope, a diminished pulse, and inadequate blood supply to the fingers resulting in paralysis, numbness, or tingling.

As intuition might suggest, the primary symptom of a lacerated superficial radial nerve is the loss of sensation on the back of the hand. If a deep nerve was also damaged, movement may also be impaired.

If you experience any of these symptoms, especially following an accident, impact, or injury, medical care should be sought immediately at an urgent care or emergency clinic.

Diagnosis

The medical provider will typically begin with a physical and medical history. Considering that many vascular and nerve injuries of the wrist come as a result of a cut or blunt trauma, the patient may be at risk for multiple, concomitant diagnoses, including fractures and dislocations. While the tests listed below are specific for vascular and nerve damage, the patient should be aware that other testing, such as an x-ray, may be used to confirm or rule-out possibility of other injuries.

Vascular Damage

Aside from evident cues (see symptoms list above) of a vascular injury, a medical provider may perform a modified Allen’s test to confirm the diagnosis. Pressure is applied over each of the wrist’s arteries, and the patient clenches their hand several times until the palm turns pale. Pressure over one artery is then released and the time for color to return to the palm is used to diagnose blood flow issues. A host of other diagnostic modalities are also available, ranging from the simple (blood pressure) to more complex (ultrasound), though arterial injuries may require a degree of urgency that precludes the use of longer tests.

Nerve Damage

For nerve injuries, motor and sensation evaluations will be performed to determine the location and extent of damage. The former will focus on range of motion, functionality, symmetry between limbs, and strength in the muscles that are specifically connected to the nerve in question. For example, a deep radial nerve test would involve isolated movements of the elbow wrist and fingers.

To examine sensation, the provider typically begins with quick, physical assessments, such as a 2-point discrimination test. In this test, the medical provider touches two close points on an area of skin and the patient assesses whether they feel two points, one point, or no points, indicating damage or complete loss of sensation.

Further discernment of nerve damage may require electrodiagnostic techniques, the two most common of which are known as the nerve conduction study and electromyography. These tests induce a current into the body to stimulate nerves and muscle and measure the resulting speed or strength of the conducted signal. Soft tissue imaging methods such as MRI can also be used in certain cases.

Treatment and Recovery

Both vascular and nerve injuries, when they reach the degree of Martinez’, require surgery. Mild versions of the latter – if surgery is not an option – may be partially ameliorated with immobilization and massage to increase blood flow.

Under anesthesia, the surgeon will make incisions along the wrist over the injured area. A lacerated artery can be repaired, allowing for immediately blood flow (Martinez’ outcome), or ligated – cut off completely. However, ligation is typically reserved for smaller blood vessels that won’t confer damage to other structures if cut off. Nerves, on the other hand, are repaired either with a nerve graft – bridging the gap between two ends – or closed together end-to-end. The latter has a better prognosis and is a simpler procedure.

After repair, severed nerves can take months to heal, depending on the amount of damage. While arteries will begin pumping blood again immediately after repair, careful observation needs to be continued to ensure there is proper healing without re-injury.

A major concern of vascular surgery is the risk of blood clot, though this risk usually fades several weeks after surgery. Unfortunately, the procedure also carries the risk of further nerve damage during incisions and repair. As with many surgeries, risks of infection and scarring are present.

Martinez’ Outlook

Despite vascular and nervous injuries sometimes being career threatening, Martinez’ surgery was successful, and the outlook is promising. Assuming no damage was done to deep radial nerves, Martinez will retain full movement of the wrist, only waiting on the return of sensation. He currently has no timeline for recovery, though the slow regeneration of nerves would suggest several months.

Unfortunately for the Kings, Martinez was averaging the second most minutes per game of any team member at 21, meaning there will be a major gap to fill going forward. That said, the team’s dismal place near the bottom of the Western conference standings suggests they have little to play for in terms of a postseason spot, lessening the pressure for a quick return for Martinez.

Citations

1. Gupta, S. (April 30, 2019). Hand Nerve Injury Repair. Retrieved from https://emedicine.medscape.com/article/1287077-overview#a8
2. Panthaki, Z. (April 11, 2019). Vascular Upper Extremity Injury. Retrieved from https://emedicine.medscape.com/article/1287360-overview#showall
3. Wilhelmi, B. (June 29, 2016). Hand Anatomy https://emedicine.medscape.com/article/1285060-overview#showall
4. Gretz, A. (November 26, 2019). Kings’ Martinez undergoes surgery after scary wrist injury. Retrieved from https://nhl.nbcsports.com/2019/11/26/kings-martinez-undergoes-surgery-after-scary-wrist-injury/
5. Kings’ Alec Martinez undergoes surgery for cut on wrist (Nov 26, 2019). Retrieved from https://www.espn.com/nhl/story/_/id/28169190/kings-alec-martinez-undergoes-surgery-cut-wrist

Dr. John Knight

Dr. Knight is a renowned hand, wrist and upper extremity surgeon with over 25 years of experience. Dr. Knight is a Board Certified Orthopedic Surgeon and Fellowship trained. Dr Knight has appeared on CNN, The Doctors TV, Good Morning America, The Wall Street Journal, The Washington Post, Forbes, The Huffington Post, Entrepreneur, Oxygen network and more.