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 fractureIrreducible dislocationsVascular injuryAmputationCompartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injury

Potential Orthopedic Emergencies

Open fractureIrreducible dislocationsVascular injuryAmputationCompartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal 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 arteryShoulder fx/dislocation axillary arterySupracondylar humerus fx brachial arteryElbow dislocation brachial arteryPelvic fracture gluteal arteriesFemoral shaft fx femoral arteryDistal femur fracture popliteal arteryKnee dislocation popliteal arteryTibial 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

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Duplex scanning

• Requires technician and scanner availability

• Not all surgeons will operate based on duplex information

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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

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