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Evaluation and Treatment of Vascular Injury
Heather Vallier, MD
Original Author: Timothy McHenry, MD; March 2004New Author: Heather Vallier, MD; Revised January 2006
Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury
Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury
Vascular injury
“the clock starts ticking”
• Blood loss
• Progressive ischemia
• Compartment syndrome
• Tissue necrosis
Irreversible damage after 6 hours
Vascular injury
Potentially frequent incidence
• Proximity of vessels to bone
• Tethering of vessels at joints
• Superficial location of vessels
Arterial injuries associated with fractures or dislocations
Clavicle fracture subclavian artery
Shoulder fx/dislocation axillary artery
Supracondylar humerus fx brachial artery
Elbow dislocation brachial artery
Pelvic fracture gluteal arteries
Femoral shaft fx femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fx tibial arteries
Incidence
Overall uncommon
• 3% of long bone fractures
Specific circumstances
• Fractures with GSW (up to 38%)
• Knee dislocations (16-40%)
Mechanism of Injury
• Penetrating trauma
– GSW
– Stab
• Blunt trauma
– High energy
– Low energy
• iatrogenic
Types of vascular injuries
• Spasm
• Intimal flaps
• Subintimal hematoma
• Laceration
• Transection
• A-V fistula
Some require treatment, some do not
Consequences of vascular injury
• Blood loss
• Ischemia
• Compartment syndrome
• Tissue necrosis
• Amputation
• Death
Prognostic factors
• Level and type of vascular injury
• Collateral circulation
• Shock/hypotension
• Tissue damage (crush injury)
• Warm ischemia time
• Patient factors/medical conditions
Speed is crucial
• Rapid resuscitation
• Complete, rapid
evaluation
• Urgent surgical
treatment
PROTOCOL IS ESSENTIAL !
Immediate treatment
• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce
fractures/dislocations
• Splint
• Re-evaluate
Diagnosis
• Physical exam
• Doppler pressure (Ankle/brachial
systolic pressure index)
• Duplex scanning
• Arteriogram
• Exploration
Diagnosis
• Physical exam
• Doppler pressure (Ankle/brachial
systolic pressure index)
• Duplex scanning
• Arteriogram
• Exploration Careful physical exam and high index of suspicion are
most important !
Physical exam
• Major hemorrhage/hypotension
• Arterial bleeding
• Expanding hematoma
• Altered distal pulses
• Pallor
• Temperature differential between extremities
• Injury to anatomically-related nerve
• Asymmetric pulses warrant doppler examination (determine ABI)
• Absent pulses warrant emergent vascular consultation/surgical exploration
Doppler ultrasound
• Determine presence/absence of arterial supply
• Assess adequacy of flow
PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !
Doppler ultrasound
• Normal ABI > 0.95
• Abnormal < 0.90
• Does not define extent or level of injury
• Abnormal values warrant further evaluation
Mills, et al. J. Trauma 2004
Duplex scanning
• Noninvasive• Safe• Rapid• Reliable for
– Injury to arteries and veins– A-V fistulas– Pseudoaneurysms
Click image to zoom out
Duplex scanning
• Requires technician and scanner availability
• Not all surgeons will operate based on duplex information
Click image to zoom out
Angiography
• Locates site of injury
• Characterizes injury
• Defines status of vessels
proximal and distal
• May afford therapeutic
intervention
Angiography
Identify and control bleeding from pelvic fractures
Angiography
• Expensive
• Time-consuming
• Difficult to monitor/treat patient
• Procedural risks
– Renal burden from dye
– Possibility of anaphylaxis
– Injury to proximal vessels
Operative angiography
• Single view in operating
room
• Rapid
• Excellent for detecting
site of injury
Surgical exploration
Immediate exploration is indicated
for:
• Obvious arterial injury on exam
• No doppler signal
• Site of injury is apparent
• Prolonged warm ischemia time
No pulses Asymmetric pulses Normal exam
Reduce, stabilize, resuscitate
Injury obvious
Multilevel injury ?
Doppler
ABI >0.9ABI <0.9
Angiography or duplex
SurgeryObservation
Modified from Brandyk, CORR 1005
Continued evaluation
• Vascular injuries are dynamic
• Evaluation should continue after the initial injury or surgery
Continued evaluation
• Circulation
• Neurologic function
• Compartment pressures
Surgical considerations
• Who goes first?
• Temporary shunts
• Fracture stabilization techniques
• Salvage vs amputation
• Fasciotomies
Conclusions
• Potential exists with every orthopedic injury
• Uncommon
• Be aware of injuries associated
• Understand signs and symptoms of arterial injury
Conclusions
• Time is crucial
• Most important for diagnosis
– High index of suspicion
– Thorough physical exam
• Have a defined protocol/relationship with your
colleagues from vascular and trauma surgery
Return to General/Principles
Index
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Questions/Comments
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