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Vascular Injury in Orthopedic Trauma
Andreas F. Mavrogenis, MD; George N. Panagopoulos, MD; Zinon T. Kokkalis, MD;
Panayiotis Koulouvaris, MD; Panayiotis D. Megaloikonomos, MD; Vasilios Igoumenou, MD;
George Mantas, MD; Konstantinos G. Moulakakis, MD; George S. Sfyroeras, MD;
Andreas Lazaris, MD; Panayotis N. Soucacos, MD, FACS
abstract
Vascular injury in orthopedic trauma is challenging. The risk to life and limb can
be high, and clinical signs initially can be subtle. Recognition and management
should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas),
complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal
defects and subintimal hematomas with possible secondary occlusion are most
commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm
can occur after either blunt or penetrating trauma to an extremity and is more
common in young patients. Clinical presentation of vascular injury may not be
straightforward. Physical examination can be misleading or initially unimpressive;
a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within
the context of the overall resuscitation of the patient according to the established
principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the
field, made mostly during times of war, have made limb salvage the rule rather
than the exception. Teamwork, familiarity with the often subtle signs of vascular
injuries, a high index of suspicion, effective communication, appropriate use of
imaging modalities, sound knowledge of relevant technique, and sequence of
surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that
generates significant controversy and confusion among clinicians involved in the
care of trauma patients. [Orthopedics. 2016; 39(4):249-259.]
V
ascular injury associated with orthopedic trauma is a potentially
limb- and life-threatening event
that represents a challenge for every ortho-
JULY/AUGUST 2016 | Volume 39 • Number 4
pedic surgeon and clinician involved in the
primary care of trauma patients. Whether
encountered in the emergency department
or in the elective setting, loss of limb or life
can easily occur if the diagnosis of an associated vascular injury is missed or delayed.
Under these circumstances, a rapid and accurate diagnosis, as well as a thorough understanding of the management priorities
implicated is of paramount importance for
successful salvage of the limb.1
At the beginning of the 20th century,
Alexis Carrel (1873-1944) and Charles C.
Guthrie (1880-1963) at the University of
Chicago were among the first to develop
standard vascular operative techniques,
including repair of the lateral arterial wall,
end-to-end anastomosis, and insertion of
venous interposition grafts.2-4 Since then,
the management of vascular trauma has
evolved mainly through the contribution
of armed conflicts. Ligations and ampuThe authors are from the First Department of
Orthopaedics (AFM, GNP, ZTK, PK, PDM, VI,
PNS) and the Department of Vascular Surgery
(GM, KGM, GSS, AL), National and Kapodistrian
University of Athens, ATTIKON University Hospital, Athens, Greece.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to:
Andreas F. Mavrogenis, MD, First Department of
Orthopaedics, National and Kapodistrian University of Athens, ATTIKON University Hospital,
41 Ventouri St, 15562 Holargos, Athens, Greece
([email protected]).
Received: June 2, 2015; Accepted: November
30, 2015.
doi: 10.3928/01477447-20160610-06
249
n Feature Article
tations remained the rule until the end of
World War II (1939-1945).5-9 A major shift
in this attitude occurred during the Korean
War, with 88% of injuries undergoing an
attempt at primary repair or anastomosis
(60%) or interposition grafting (27%).10-12
In the Vietnam War (1954-1975), the
development of forward surgical teams
(FSTs) and advances in rotary wing casualty evacuation (CASEVAC) made primary arterial reconstruction even more
feasible.13-16 The conflicts in Iraq and Afghanistan (Global War on Terror) brought
significant advances in the management
of vascular injuries in trauma,17 including
redefinition of the concept of damagecontrol resuscitation,18,19 widespread early use of battlefield tourniquets,20,21 routine use of personal protective gear (body
armor),22 frequent application of temporary vascular shunts, refinement of the organization of in-theater levels (echelons)
of care,23,24 development of the Joint Theater Trauma System,23 the implementation of Clinical Practice Guidelines,25 and
the institution of a Joint Theater Trauma
Registry26 for collection and analysis of
data.27 In the past decade, the establishment of the National Trauma Data Bank
by the American College of Surgeons has
allowed detailed descriptive data and adequately powered statistical analysis of a
wide variety of vascular injuries and related trauma.28-31
Epidemiology
The overall incidence of vascular injury following extremity trauma varies
widely by population (military vs civilian),
geographic location (urban vs rural), and
mechanism of injury (penetrating vs blunt
trauma).32,33 In a recent National Trauma
Data Bank analysis, the incidence for vascular injury in orthopedic trauma was 1.6%
for adults and 0.6% for pediatric patients,34
which is significantly lower than the 6% to
12% incidence among combat casualties.35
Patients with extremity vascular injuries
tend to be younger (average age, 30 years)
and predominantly (70%-90%) male,36,37
250
even though this trend tends to change to
elderly patients.38 In the austere environment, high-caliber rounds and explosive
ordinance with shrapnel are the predominant wounding agents.35,39 The force, trajectory, and tissue damage associated with
military injuries are much more devastating than those seen in civilian series.
Because nearly all vascular injuries in
wartime are caused by blast or high-velocity weaponry, approximately 33% of those
with vascular injuries have associated orthopedic injuries, and up to 20% have partial- or full-thickness burns and associated
head or torso injuries.40 Lower-extremity
vascular injuries occur at approximately
double the rate of upper-extremity injuries
in the military setting, reflecting the relative length of axial vessels and the exposed
position of the lower extremity away from
the protection of the torso.41 The superficial
femoral artery is the vessel most commonly injured (33% to 37%), followed by the
popliteal and tibial arteries (25% each).40-42
In urban trauma centers in the United
States, peripheral vascular injuries are
mostly caused by low-velocity missile
wounds from handguns.43 In contrast, stab
wounds account for most of the civilian extremity vascular injuries in countries where
firearms are more difficult to obtain.44 Vascular injuries from blunt orthopedic trauma, such as fractures, dislocations, contusions, crush injuries, and traction, account
for only 5% to 25% of injuries that require
treatment.45,46 The femoral or popliteal arteries are most commonly injured (50%
to 60%), followed by the brachial artery
(30%).43 Whether by blunt or penetrating
mechanism, civilian vascular injuries frequently occur in association with high-risk
behavior such as substance abuse, violence, and late-night hours.47 Rural settings
have a higher proportion of blunt injuries,
but they still comprise less than 45% of the
total rate.47
Vascular injuries associated with long
bone fractures in otherwise healthy young
trauma patients are relatively rare. The reported incidence of injuries to the super-
ficial femoral artery in association with a
fracture of the femur has been less than
1% to 2%.48 Injuries to the popliteal artery, tibioperoneal trunk, or trifurcation
vessels occur in only 1.5% to 2.8% of all
tibial fractures. When open fractures of
the tibia are reviewed separately, the incidence of arterial injury rises to approximately 10%.49 With knee dislocations, the
incidence of injury to the popliteal artery
requiring surgical repair ranges from 16%
to 20%.50
The anatomy of the lower extremity
predisposes the femoral and popliteal vessels to injury at certain locations during
trauma. The popliteal artery runs through
the popliteal fossa and is tethered proximally by the adductor hiatus and distally
by the soleus arch. Therefore, high rates
of vascular injuries are observed with
specific lower-extremity injuries such
as high-energy tibial plateau fractures
(especially Schatzker types IV and VI
fractures), high-energy displaced distal
femoral fractures at the level of the adductor hiatus, open fractures of the femur,
segmental femoral fractures, floating knee
injuries, and posterior knee dislocations
(Table 1).51 When observing any of these
injury patterns, it is necessary to rapidly
begin an evaluation for vascular compromise.51 The association between certain
elective and emergency orthopedic operative procedures and arterial injuries also
has been well documented.
Types of Vascular Injury
From a pathology standpoint, there
are 5 types of vascular injury: (1) intimal
injury (flaps, disruptions, or subintimal
and intramural hematomas), (2) complete wall defects with pseudoaneurysms
or hemorrhage, (3) complete transections
with hemorrhage or occlusion, (4) arteriovenous fistulas, and (5) spasm.52 Intimal defects and subintimal hematomas
with possible secondary occlusion are
associated most commonly with blunt
trauma, whereas wall defects, complete
transections, and arteriovenous fistulas
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usually occur with penetrating trauma.
Spasm can occur after either blunt or
penetrating trauma to an extremity and is
more common in young patients. When
there is an injury to the intima or intima/
media and dilatation of an artery occurs,
this is a traumatic true aneurysm with no
extravasation of blood outside the lumen
of the artery. A full-thickness defect in
the wall of an artery with extravasation
of blood outside the lumen is an acute
pulsatile hematoma immediately after
injury and a traumatic false aneurysm
when the surrounding tissues encapsulate
the blood.8
Diagnosis
Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or
initially unimpressive33; a normal pulse
examination may be present in 5% to
15% of patients with vascular injury.53
Detection and treatment of vascular
injuries should take place within the
context of the overall resuscitation of
the patient according to the established
principles of the Advanced Trauma Life
Support (ATLS) protocols.54 Bleeding
from an injured extremity affects the
“circulation” during the primary survey
of ATLS and should be managed with
direct pressure, a compressive dressing,
or if that is not effective, with tourniquet
application and ongoing resuscitation. In
the absence of bleeding, the injured extremity is assessed during the secondary
survey of ATLS. The secondary survey
should include clinical examination of
the extremities, followed by radiographic
evaluation of the injured ones. Thorough
neurologic and vascular examinations
should be performed on arrival prior to
any intervention (eg, reduction), and they
should be repeated following the patient’s resuscitation.54
Vascular examination should include
assessment of capillary refill and extremity color and temperature, as well as standard documentation of palpable, Doppler-
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Table 1
Vascular Structures at Risk in Orthopedic Trauma
Skeletal Injury
Vessels at Risk
Fractures
Clavicle or first rib
Subclavian vessels, brachial plexus
Humerus neck
Axillary artery and nerve
Humeral diaphysis and supracondylar area
Brachial artery, radial nerve
Acetabulum
External iliac, superior gluteal and femoral
vessels; sciatic nerve
Femoral shaft
Superficial femoral artery
Supracondylar femur
Popliteal vessels
Proximal tibia
Popliteal artery, tibioperoneal trunk, tibial
artery, peroneal artery; peroneal nerve
Distal tibia
Tibial or peroneal artery
Cervical spine
Vertebral artery
Thoracic spine
Descending aorta
Lumbar spine
Abdominal aorta
Dislocations
Shoulder dislocation (anterior)
Axillary artery and nerve
Elbow dislocation
Brachial artery; radial, ulnar, and median
nerves
Hip dislocation
Femoral artery; sciatic nerve
Knee dislocation
Popliteal artery; peroneal and tibial nerves
Ankle dislocation
Posterior tibial artery; posterior tibial nerve
evident, or absent pulses in the affected extremity. Results should be compared with the
contralateral side. For the patient in whom
physical examination findings change after
any manipulation or intervention, further
workup is required to rule out the presence
of an iatrogenic vascular injury. Conversely,
reduction of a fracture or dislocation may
improve vascular status. Should first palpation of distal pulses document a difference
between the injured and a contralateral uninjured extremity in a hemodynamically
stable patient, a fracture or dislocation of a
joint in the injured extremity should be realigned or reduced, respectively.46
Physical examination findings are classified into hard or overt signs and soft signs
of vascular injury (Table 2). Hard signs of
extremity vascular injury include massive
bleeding, a rapidly expanding hematoma,
any of the classic signs of arterial occlu-
sion (ie, pulselessness, pallor, paresthesia,
pain, paralysis, and poikilothermia), a palpable thrill, or an audible bruit.55-57 The
incidence of vascular injuries in patients
with any hard sign is consistently greater
than 90%.58 When hard signs of injury are
present, there is limited need for imaging
diagnostic tests, such as computed tomography (CT) or conventional angiography,
which take extra time and may provide
findings that cloud decision making.24,25,40
In contrast, in these cases, immediate
operation on the injured extremity is necessary,33 generally with exploration of the
injury site with wide exposure to enable
vascular exploration and repair. In the patient with other acute life-threatening injuries, such as an intracranial hematoma
with midline shift, bleeding to the chest,
abdomen, or pelvis, gastrointestinal contamination in the abdomen, and simulta-
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Table 2
Hard and Soft Signs
of Vascular Injury in
Orthopedic Trauma
Hard sign
Pulselessness
Pallor
Paresthesia
Pain
Paralysis
Rapidly expanding hematoma
Massive bleeding
Palpable thrill or audible bruit
Soft sign
History of bleeding in transit
Proximity-related injury
Neurologic findings from nerve
adjacent to a named artery
Hematoma over a named artery
neous trauma in 2 extremities, 1 operative
team should manage the life-threatening
injury elsewhere, and a second team
should control bleeding and reestablish
perfusion, preferably with a temporizing
measure, such as a temporary intravascular shunt.8,59 If a hard sign is present,
except if an expanding hematoma or external bleeding, localization of the defect
is necessary prior to incision. In patients
with fractures at multiple levels or gunshot wounds, a rapid duplex ultrasound
(DUS) study or surgeon-performed arteriogram in the emergency department or
operating room should be obtained.60-62
Soft signs of vascular injury include
a history of arterial bleeding at the scene
or in transit; a proximity-related injury
(proximity of a penetrating wound or
blunt injury to an artery in the extremity);
a small, nonpulsatile hematoma over a
named artery; and a neurologic deficit in
a nerve adjacent to a named artery. These
patients still have a palpable or Dopplerevident peripheral pulse. The incidence of
vascular injuries in such patients ranges
252
from 3% to 25%, depending on which
soft sign or combination of soft signs is
present.63,64 The presence of peripheral
pulses equal to those in the contralateral
uninjured extremity is good evidence of
no or limited arterial injury, such as intimal injury.65
In this setting, in addition to a comprehensive physical examination, an arterial
pressure index (API) or injured extremity
index (IEI) should be performed.66,67 The
API or IEI is similar to the ankle-brachial index (ABI) and is calculated using a
manual blood pressure cuff and a continuous wave Doppler. The first step is to
determine the pressure at which the arterial Doppler signal occludes in the injured
extremity, which is the numerator in the
equation. Next, the cuff and Doppler are
moved to the uninjured extremity, and the
pressure at which the arterial Doppler signal occludes is recorded, which is the denominator in the equation. An IEI greater
than 0.90 is considered normal and has
a high specificity for excluding a vascular injury.67,68 A patient with diminished
peripheral pulses or an API less than 0.9
should undergo an imaging study, typically an arteriography, DUS, or CT angiography (CTA) to document the presence and
location of a possible vascular injury.67,69
Beyond the obvious hard or soft signs
of vascular injury, physical examination
of the injured extremity should include
observation of the position in which the
extremity is held, presence of an obvious deformity of a long bone or joint,
presence or absence of an open wound
or bony crepitus, skin color of the distal
extremity compared with that of the opposite side (in light-skinned individuals),
time required for skin capillary refill in
the distal digits, and a complete motor
and sensory examination. In the lower
extremity, the stability of the knee joint
should be assessed carefully; increased
laxity may suggest spontaneous reduction
of a knee dislocation. Because of the wellknown association of knee dislocation
(especially posterior) with popliteal artery
injury, there should be a low threshold for
obtaining imaging in such an instance.70,71
However, not all surgeons agree with this
approach, advocating that routine imaging
is not necessary after spontaneous or orthopedic reduction of a dislocated knee in
the presence of normal pulses.65
Imaging
Local expertise usually dictates the imaging study to be selected to demonstrate
the presence of a suspected vascular injury in the setting of orthopedic trauma.
Angiography, CTA, and DUS are the
modalities used for this purpose in most
trauma centers.
Conventional catheter-based angiography was developed in the 1970s, allowing for accurate diagnosis of arterial
injury with a less invasive procedure than
open surgical exploration of the area of
the presumed vascular injury.72-75 Conventional angiography options include
conventional film, digital subtraction after
intra-arterial or intravenous injection of a
contrast agent, or surgeon-performed “1or 2-shot” studies, either in the emergency
department or the operating room.62 Three
major disadvantages of arteriography are
the cost of the procedure, the delay, and
the need for a specialized team comprising a physician, angiography technologist,
and nurse.72 Surgeon-performed percutaneous intravascular injection studies in
injured patients have been associated with
a complication rate of 1% to 4% and a
sensitivity/specificity greater than 95%.73
As renal toxicity is a potential issue, adequate fluid resuscitation is mandatory.74
Currently, conventional angiography usually is reserved for intraoperative use.75
Duplex ultrasound is a combination of
real-time B-mode ultrasound imaging and
pulsed Doppler flow detection.76 Numerous studies have shown a good accuracy
of DUS in assessing vascular injury. Sensitivity ranges from 50% to 100%, whereas
specificity and accuracy exceed 95%.77-79
Although inexpensive and noninvasive,
DUS can be time-consuming and signifi-
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cantly operator-dependent; therefore, DUS
has been considered by many surgeons to
be unreliable for the detection of vascular
injuries in extremity trauma, especially in
the setting of the increasing use of CTA.75
Yet, DUS may have a role in the surveillance of known injuries initially selected
for nonoperative management.80
CTA has become the diagnostic modality of choice for the diagnosis and localization of extremity vascular injuries in
trauma.58,81,82 Advantages of CTA include
rapid diagnosis of possible vascular injury
during the initial trauma CT evaluation,
simultaneous imaging of bone and soft
tissues, rapid procedure, no need for an interventional radiology team, and cost-effectiveness.75,82,83 Accuracy is comparable
with that of conventional angiography.8
Disadvantages include the presence of CT
artifacts when missiles or metallic fragments are in the field of study, potential
for renal failure from contrast medium,
and suboptimal study if poor timing of intravenous bolus administration.72,84
Considerations of Management
The first step in the management of extremity vascular injury is control of bleeding, addressed during the circulation step
of the primary survey of ATLS.54 Bleeding
can be controlled by digital compression,
application of a pressure dressing, inflation above the systolic blood pressure of
a proximally placed blood pressure cuff,
or application of a proximal tourniquet.85
In the presence of questionable peripheral
pulses associated with gross deformity
of the limb from fracture or dislocation,
immediate realignment or reduction, respectively, should be performed, and the
neurovascular status should be reassessed
and documented (Figure 1).52 It might
be difficult to assess vascular status in
trauma patients in shock or hypothermia;
such patients should be resuscitated and
rewarmed first and then vascular status
should be reassessed.8
The presence of vascular injury in orthopedic trauma does not always warrant
JULY/AUGUST 2016 | Volume 39 • Number 4
surgical treatment. A single major vessel
occlusion distal to the knee or elbow in
the absence of severe soft tissue damage
or a mangled extremity rarely constitutes
a viability risk for the injured extremity. In
such cases, observation might be a viable
option. Serial imaging surveillance, however, is necessary.75 Nonocclusive arterial
injuries such as spasm, intimal flaps, or
intramural hematomas detected in angiography performed for soft signs of vascular injuries seem to heal without surgery
in 87% to 95% of cases.63,71 Furthermore,
isolated traumatic aneurysms in selected
vessels may be treated by therapeutic
embolization instead of an open vascular operation.52 In addition, certain vascular injuries such as intimal dissections
and flaps or small pseudoaneurysms have
been shown to be amenable to endovascular treatments with stents or stent grafts.86
Open Vascular Repair
In the operating room, an operative
tourniquet can replace the bleeding-control modality used previously. However,
if the injury is too proximal or exsanguinating hemorrhage resumes, a member
of the surgical team should be gloved
and gowned in a sterile fashion, apply
proximal pressure control, and the patient should be prepped and draped with
this team member included in the surgical
field.52
For all locations of peripheral vascular
injury, preparation of the skin and draping should encompass all potential areas
of proximal and distal vascular control,
the area where a distal fasciotomy would
be performed, and one (or the ipsilateral)
lower extremity from the groin to the toenails for possible retrieval of the greater
or lesser saphenous vein from the groin
or the ankle.52,75,87 Often, it is helpful
to drape the hand or foot of the affected
extremity in a sterile plastic bag, so that
color changes can be noted (at least in
light-skinned patients) and distal pulses
can be palpated under sterile conditions
after repair is completed.52
Figure 1: Sagittal computed tomography scan with
3-dimensional reconstruction showing contusion
of the left popliteal artery in a 50-year-old woman
with an open supracondylar femoral fracture. The
pulse returned after reduction of the fracture.
Repair of an injured peripheral vessel
is performed ideally with the surgeon and
assistants wearing magnification loupes
and battery-powered headlamps, or the
operating microscope. Standard vascular
instruments that should be available include appropriate retractors, Metzenbaum
scissors, DeBakey forceps, Gerald forceps, jeweler’s forceps, fine-tipped needle
holders, vessel loops, Fogarty balloon
catheters with stopcocks, intraluminal
shunts, unfractionated heparin solution,
and a contrast agent for a completion angiography.88
Incisions typically are made longitudinally, directly over the target vessel
proximal and distal to the injury to ensure
adequate exposure for proximal and distal vascular control and repair.75 Incisions
should provide comfortable exposure. After vascular control is achieved, the incisions can be extended as needed to expose
the zone of vascular injury. When the area
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A
B
Figure 2: Preoperative photograph showing an intima tear of the right posterior tibial artery in a 52-yearold man with a gunshot open tibial fracture (A). Intraoperative photograph showing surgical repair and
fasciotomies performed through the posterior approach to the leg (B).
A
B
C
Figure 3: Preoperative photograph (A) and anteroposterior radiograph (B) of the ankle joint showing an
open fracture-dislocation of the midtarsal (Chopart) joint of the right foot in a 35-year-old man. Surgical
exploration after reduction and stabilization of the fracture-dislocation with external fixation showed transection of the posterior tibial artery that was repaired with end-to-end anastomosis. Photograph showing
the foot 10 days after closure with a split-thickness skin graft (C).
A
B
Figure 4: Intraoperative photograph showing transection of the right brachial artery in a 6-year-old boy
with a humeral diaphysis fracture; the arrows indicate the proximal and distal parts of the artery (A). Intraoperative photograph showing successful reconstruction of the brachial artery with a reversed saphenous
vein bypass graft (arrows) (B).
of injury is in proximity to a joint, a gently curved (lazy “S”) incision to prevent
a postoperative scar contracture is recommended.55,75,88 Not dissecting far enough
proximally and distally from an area of
injury is a common error. However, if
control of hemorrhage cannot be obtained
254
or an extensive hematoma is overlying the
arterial injury, making it difficult to obtain
control close enough to avoid backbleeding from collaterals, it is not inappropriate to enter the zone of injury directly.55,75
After vascular control is obtained in either
classic or direct fashion, vascular occlu-
sion can be maintained by applying a
small DeBakey clamp, bulldog clamp, or
Silastic (Dow Corning Corporation, Auburn, Michigan) vessel loops.
In general, small lacerations can be
addressed by lateral angiorrhaphy with
5-0 or 6-0 polypropylene sutures applied
transversely (Figure 2). If this leads to
significant narrowing, vein patch angioplasty is a viable alternative. In cases of
complete transection of the injured artery,
debridement back to healthy intima at
both ends is performed, and the feasibility
of an end-to-end anastomosis without tension is assessed (Figure 3)88; this normally is performed using 6-0 or 7-0 polypropylene sutures applied in a continuous or
interrupted technique with 2 stay sutures
180° apart.89
If the anastomosis is sewn under tension, an hourglass appearance will result
at the suture line, which often leads to
thrombosis in the postoperative period;
in this case, the surgeon should opt for
Fogarty embolectomy and either a redo
anastomosis or an interposition graft. If
an end-to-end anastomosis cannot be performed with minimal tension, a substitute
conduit should be inserted. An autogenous reversed saphenous vein graft from
an uninjured lower extremity remains the
conduit of choice for most peripheral vascular injuries (Figure 4).88 Alternatives to
the saphenous vein are use of either the
cephalic or basilic vein, or insertion of a
polytetrafluoroethylene graft. However,
patency with these grafts seems to be significantly less in the long-term.90
A vascular repair should never be left
exposed. A significant soft tissue defect
overlying a conduit or anastomosis will
result in contamination, leading to infection. A decision must be made in conjunction with the plastic surgery service
on whether there is healthy muscle close
enough to be transposed or rotated to
cover the vascular repair.91 If there is not,
an extra-anatomic bypass graft should be
fashioned.92-94 Finally, a completion arteriogram should be performed to confirm
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patency, and identify and address technical issues.88,93,94
Compartment Syndrome
The development of compartment syndrome portends a poor limb outcome.95,96
The classically described diagnostic signs
of the 5 P’s (pain, pallor, paresthesia, passive extension, and pulses intact) represent late signs of compartment syndrome
and are frequently absent or obscured in
trauma patients because of distracting injuries and altered mental status. The key
clinical findings are pain out of proportion
to the associated injury and pain on passive movement of the muscles of the involved compartments.95 The incidence of
clinically relevant compartment syndrome
after extremity vascular injury is unknown
because of the widespread use of prophylactic fasciotomy in the setting of orthopedic or vascular surgery.96 Performance of
a fasciotomy concomitant with or soon after revascularization of the limb is associated with a fourfold reduction in eventual
amputation and other complications.97
Performance of a fasciotomy is most
strongly predicted by the presence of a
fracture or dislocation, a vein or nerve injury, or multiple arterial injuries.97 Early calf
or forearm fasciotomy should be considered in all patients with restoration of distal perfusion after ischemia resulting from
trauma, especially if multiple fractures or
arterial injuries are present. Although fasciotomies complicate wound management
and may require additional operative procedures for wound closure (Figure 5), their
benefits, even when performed prophylactically, outweigh these risks.
Sequence of Repair
The ideal sequence of surgical repair
in combined orthopedic and vascular injuries remains an area of debate.98 Proponents of performing the orthopedic intervention before the vascular repair argue
that skeletal stabilization is required to
protect the vascular repair and that manipulation, reduction, and internal fixation
JULY/AUGUST 2016 | Volume 39 • Number 4
B
A
C
Figure 5: A 20-year-old man presented with a distal femoral diaphysis fracture with transection of the
left popliteal artery and thrombosis of the posterior and anterior tibial veins. Anteroposterior radiograph
of the left femur showing reduction and stabilization of the femoral fracture with external fixation, which
was followed by arterial thrombectomy and fasciotomies of the leg through a medial and lateral incision
to successfully revascularize the limb (A). Postoperative photographs showing the fasciotomy incisions
approximated with vessel loops using a shoelace technique at 7 days postoperatively (B) and completely
closed with interrupted sutures 15 days later (C).
may endanger the repair.99 Decreasing
warm ischemia time remains the primary
argument in support of performing vascular repair first.33 It is difficult to argue
against the statement that reversal of limb
ischemia should take precedence. Even
more confusing is the fact that a recent
meta-analysis failed to demonstrate any
statistically significant difference in overall amputation rate when vascular repair
or orthopedic repair was performed first
(13% vs 11.6%, respectively).98 Temporary versus definitive fracture fixation at
the index procedure also is controversial,
although most studies tend to favor temporary external fixation as a more reasonable, expedited solution.100,101
In general, it is recommended that the
orthopedic procedure is performed first
in (1) patients with neither cold ischemia
(ie, pulseless limb or absent capillary
refill) nor a prolonged period of warm
ischemia (ie, present capillary refill), and
(2) the setting of a very comminuted and
unstable fracture pattern to facilitate subsequent vascular repair. In contrast, a vascular procedure should be performed first
in (1) patients with a cold, pulseless limb
and little or no capillary refill, and (2) pa-
tients who have undergone a prolonged
period of either cold or warm ischemia.
In these patients, restoration of arterial inflow has the highest priority and should be
accomplished first by formal repair or by
the insertion of a temporary intraluminal
vascular shunt (TVS).60
A temporary intraluminal vascular
shunt is an intraluminal plastic conduit
for the temporary maintenance of arterial
inflow/venous outflow.102 First described
by Eger et al103 in Israel in 1971, the use
of vascular shunts significantly increased
in trauma centers for revascularization after trauma.39,104 The primary indications
include need for damage control surgery,
Gustilo-Anderson type IIIC open fractures, and preservation of an amputated
upper extremity at the arm, forearm, or
wrist level before replantation. In general,
the initial use of a TVS to restore flow in
the ischemic limb, followed by external
fixation to stabilize the fracture removes
the sense of urgency from the situation,
allowing for the procedure to be quickly
terminated and for the patient in extremis
to be hemodynamically stabilized to return to the operating room for a formal,
definitive vascular repair.105
255
n Feature Article
foot trauma, (5) anticipated protracted
course for soft tissue coverage, and (6) anticipated need for multiple reconstruction
procedures.108-110 In general, an attempt at
initial limb salvage and early revascularization is recommended, especially when
the decision of limb salvage versus primary amputation does not seem clear.106 One
should keep in mind that a patient’s life
should not be endangered by an injured
limb (Figure 7).
A
Conclusion
B
C
Figure 6: Photograph (A) and anteroposterior radiograph (B) of the right femur showing an open femoral
diaphysis fracture in a 49-year-old man. Intraoperative photograph (C) showing transection of the right
femoral vessels and sciatic nerve. A primary amputation was performed.
A
B
Figure 7: Preoperative anteroposterior radiograph (A) of the right humerus showing an open fracture of
the right humeral diaphysis in a 65-year-old man. Surgical exploration after reduction and stabilization of
the humeral fracture with external fixation showed complete transection of the axillary artery and the ulnar,
median, and radial nerves. The arterial injury was reconstructed with a reverse saphenous vein interposition
graft. Postoperative photograph after 2 days (B) showing the graft failed. An amputation was performed.
Mangled Extremity
A mangled extremity results from
high-energy or crushing trauma that
causes combined injuries to arteries,
bone, soft tissue, tendons, and nerves that
significantly compromise the viability of
the limb.52,106,107 The management is challenging; the dilemma is whether to attempt limb salvage or opt for a primary
amputation (Figure 6). The Mangled Ex-
256
tremity Severity Score (MESS) has been
devised as a treatment decision aid; a
score of 7 or more points usually indicates
the need for primary amputation.107 Other
indications for immediate amputation include: (1) a warm ischemia time of more
than 6 hours in the presence of a crush
injury that disrupts collaterals, (2) injury
of the posterior tibial nerve, (3) associated
severe polytrauma, (4) severe ipsilateral
Vascular injury in orthopedic trauma
is challenging to manage. The risk to life
and limb can be high. Clinical signs can
be subtle initially. In the absence of clear
signs of vascular compromise, these injuries can easily be missed, with potentially
devastating consequences. Therefore,
prompt recognition and management of
vascular injury in orthopedic trauma is of
paramount importance and should be undertaken in an orchestrated fashion with
the overall care of the patient. Tertiary
trauma centers ideally should have a clear
protocol of activation of the appropriate
trauma team including vascular, orthopedic, and plastic surgeons; colleagues
should establish priorities, discuss the
appropriate sequencing, communicate
management decisions with the operating
room personnel and anesthesiologists, and
perform the repairs.
Although a cold limb requires urgent
surgical exploration, resuscitation and
management of associated life-threatening injuries should take priority over any
extremity problems. Damage-control resuscitation with early blood transfusion
is necessary in patients with hemorrhagic
shock. Neurovascular status should be
assessed in every injured extremity as a
priority; findings should be documented
clearly in the medical records as a timed
entry. Active bleeding should be controlled in an expedited manner, either by
tourniquet or a gloved hand compressing
the bleeding site. The time of tourniquet
placement should be carefully recorded.
Copyright © SLACK Incorporated
n Feature Article
Blind clamping or local wound exploration in the trauma bay should be discouraged as potentially detrimental.
A deformed, pulseless extremity
should be realigned and a dislocation reduced; neurovascular status then should
be reassessed as reestablishment of flow
is not infrequent. Imaging should include
DUS, CTA, or on-table angiography;
however, imaging should not delay reperfusion as the injury pattern usually predicts the level of vascular injury in most
cases. Reperfusion delay with prolonged
warm ischemia (>3-6 hours) leads to irreversible tissue damage, with resulting
myoglobinuria and acute renal failure that
may be life-threatening.
Limb salvage is not always the correct decision; in many cases, primary
amputation may be the most reasonable
choice. In any case, the patient and relatives should be made aware of the possible risks of surgery, potential for multiple
procedures, and possibility of immediate
or secondary amputation. Preparation for
surgery should include (1) administration
of broad-spectrum antibiotics, (2) tetanus
toxoid, and (3) a bolus of systemic heparin as well as ensuring the injury is isolated and bleeding is under control.
The key factors in successful management are optimal sequence of the repair,
adequate exposure and vascular control,
debridement of the injured vessel wall to
healthy intima, proximal and distal balloon catheter thrombectomy, tension-free
end-to-end repair or appropriately sized
interposition graft, good soft tissue coverage, stable but expeditious fracture fixation, and adequate fasciotomies. Failure
to perform fasciotomies after revascularization of an acutely ischemic limb is
the most common cause of preventable
limb loss. Incisions for fasciotomies or
vascular control should preserve perforating vessels, taking into account the future
potential need for fashioning flaps for
soft tissue coverage. Finally, a bed in the
intensive care unit ideally should be reserved for early postoperative monitoring.
JULY/AUGUST 2016 | Volume 39 • Number 4
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