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Table of Contents
VASCULA
R TRAUMA
1 Objectives
2 Overview
3 Diagnosis
4 Management
5 The decision to amputate
6 Management Algorithm
6.1 1. Resuscitation
6.2 2. Risk factors for amputation
6.3 3. Amputation technique
6.4 4. Hards signs of vascular injury
6.5 5. Investigation
6.6 6. Fasciotomy
6.7 7a. Damage control
6.8 7b. Definitive repair
6.9 8. Vascular shunts
6.10 9. Skeletal stabilization
6.11 10. Exclusion of clinically significant vascular injury
6.12 11. Wound management
6.13 12. Secondary amputation
6.14 13. Limb salvage
7 References
8 Authors & Contributors
Objectives
Overview
Diagnosis
The absence of hard signs excludes major arterial injury with sufficient
accuracy to allow further diagnostic workup to be avoided. Since most
complex extremity trauma does not manifest hard signs, avoiding the
considerable expense of arteriography in this population has substantial
economic advantages.
Superficial femoral
artery injury - intimal
flap
Resolution at 6
weeks
Popliteal artery
injury nonocclusive
Resolution at 1
week
This principle holds true even for the especially high-risk injury of posterior
knee dislocation, in which setting routine arteriography has been advocated
in all cases, due to a substantial risk of popliteal artery disruption and its
associated high rate of limb loss. However, those published studies that
compare the clinical manifestations of patients with posterior knee dislocation
with outcome show no surgically significant arterial injuries in that majority
of patients who have no hard signs (Table 1), confirmed by follow-ups of up
to 2 years. Again, most cases present without hard signs, allowing major
resource savings at no harm to the patient by using only physical findings to
exclude arterial injury. Arteriography is indicated only in that minority of
patients with knee dislocation presenting with hard signs, to exclude the
need for surgery in those 30% of patients who do not have an arterial injury.
Immediate surgery without imaging may be undertaken if the clinical picture
clearly indicates vascular injury(i.e. absent pulse, cold ischemic foot).
No.
KD
Surgery
(%)
Surgery(%)
Kaufman et
al
19
4 (21)
4 (100)
15 (79)
Treiman et
al
115
29 (25)
22 (75)
86 (75)
Dennis et al
38
2 (13)
2 (100)
36 (87)
Kendall et al
37
6 (16)
6 (100)
31 (84)
Miranda et
al
32
8 (25)
6 (75)
24 (75)
Martinez et
al
23
11 (48)
2 (18)
12 (52)
Hollis et al
39
11 (28)
7 (64)
28 (72)
Stannard et
al
134
10 (8)
9 (90)
124 (93)
Total
437
81 (18)
58 (72)
356
(82)
over its accuracy in the presence of severe tissue disruption and large bulky
dressings. Further study is necessary to clarify this. Again, the physical exam
quite clearly answers all questions of management in this setting, as absent
pulses mandates ruling out vascular injury, and present pulses in the absence
of other hard signs reliably excludes vascular injury as well as any imaging
modality. Noninvasives add nothing and may lead the examiner astray, as
Doppler flow signals may be transmitted by collaterals around a completely
occluded or transected vessel, while a pulse can not. Thus, Doppler flow
signals DO NOT exclude a vascular injury. The presence or absence of a pulse
is all that is necessary to decide on the next step in diagnosis.
Management
ER Arteriogram
Completion
arteriogram
Arteriogram
Shunt in place
Elbow fracture-dislocation
Crush injury
Multiple fractures
Severe contamination
Patient preference
Management Algorithm
1. Resuscitation
Resuscitation and management of all life-threatening injuries must take
priority over any extremity problems. Only active extremity hemorrhage
must be controlled at this time by direct pressure, tourniquet, or direct
clamping of visible vessels (in that order of preference) as a life saving
measure. Blind clamping in wounds is discouraged and potentially harmful to
limb salvage.
Once attention is directed to the extremity, neurovascular injury must be
assumed in all injured extremities until definitively excluded as the first
diagnostic priority. Vascular injury must be found and treated within 6 hours
to maximize the chance of limb salvage, as it is the major determinant of
limb salvage.
These factors have been applied over the course of the last two decades in
several scoring systems to predict primary amputation. Although the scoring
systems have validated these factors to be associated with a worse prognosis
for limb salvage, none have adequate prospective reliability to permit a
definitive decision for amputation to be made solely based on a score alone.
3. Amputation technique
If early amputation is deemed necessary, a guillotine-type amputation
should be performed at an appropriate level above the destructive wound.
Marginally viable soft tissue should be preserved and the open wound
copiously irrigated and dbrided of contaminating debris. The amputation
stump should be dressed with a bulky absorbent dressing and protective
splint if amputation is below the knee and/or elbow. Early return to the
operating room for further wound debridement and definitive management
should be anticipated.
If the need for amputation is not clear on initial presentation, limb salvage
should be attempted and the extremity observed carefully for the next 24-48
hours for soft tissue viability, skeletal stability, and sensorimotor function.
Active hemorrhage
5. Investigation
The presence of any one or more hard signs mandates immediate arterial
imaging to confirm or exclude vascular injury. Most hard signs in this setting
(as much as 87%) are NOT due to vascular injury, but rather to soft tissue
and bone bleeding, traction of intact arteries to lose pulses, or compartment
syndrome. When imaging is not possible, immediate surgical exploration of
the vessel at risk must be done. If these measures exclude surgically
significant vascular injury (i.e. no occlusion, extravasation, transection) then
the treatment of soft tissue and skeletal injuries may proceed. *How this
reperfusion is achieved depends on the patients hemodynamic status,
physiologic parameters, skeletal stability, wound characteristics, and resource
availability.
6. Fasciotomy
A 2-incision, 4 compartment fasciotomy of the distal extremity should be
performed liberally in complex extremity trauma at the time of initial
revascularization due to the high risk of compartment syndrome. If it is
elected not to do this immediately, observation must include the frequent
direct measurement of compartment pressures due to the poor sensitivity of
the clinical examination for the presence of compartment syndrome.
Unstable skeleton
wound coverage
Stable skeleton
8. Vascular shunts
Many commercial plastic intraluminal shunts are available. However plastic IV
tubing, or connecting tubing that accompanies many closed suction drains, is
sufficient if irrigated with heparinized saline before use. The ends of the
tubing are placed in the proximal and distal segments of the injured artery,
secured by a silk suture tied around the vessel over the shunt and then also
tied directly on the shunt itself to prevent dislodgement. Alternatively, shunt
clamps are available to clamp the vessel over the shunt. Flow through the
shunt should be monitored regularly by palpating distal arterial pulsation
and/or using a Doppler device to detect flow signals through the shunt or
distal vessel. If flow ceases, the shunt and distal vessel must be
thrombectomized with a Fogarty catheter and reinserted. If not
contraindicated, systemic heparinization may facilitate shunt flow.
9. Skeletal stabilization
Only skeletal stabilization by splint or external fixation should be done after
reperfusion in those settings found in 7a above. Definitive internal fixation of
skeletal extremity injuries should be delayed until conditions in 7b above are
reached, and after definitive vascular repair is performed.
References
1. Howe HR, Poole GV, Hansen KJ, et al: Salvage of lower extremities
following combined orthopedic and vascular trauma: A predictive salvage
index. Am Surg 53:205,1987.
2. McNamara JJ, Brief DK, Stremple JF et al: Management of fractures with
associated arterial injury in combat casualties. J Trauma 13:17,1973.
3. Applebaum R. Yellin AE, Weaver FA et al: Role of routine arteriography in
blunt lower extremity trauma. Am J Surg 160:221,1990.
4. Norman J, Gahtan V, Franz M et al: Occult vascular injuries following
gunshot wounds resulting in long bone fractures of the extremities. Am Surg
61:146,1995.
5. Miranda FE, Dennis JW, Veldenz HC et al: Confirmation of the safety and
accuracy of physical examination in the evaluation of knee dislocation for
popliteal artery injury: A prospective study. J Trauma 49:375,2000.
6. Feliciano DV, Mattox KL, Graham JM et al: Five-year experience with PTFE
2002;347:1924-31.
23. Stannard JP, Sheils TM, Lopez-Ben RR, et al: Vascular injuries in knee
dislocations: the role of physical examination in determining the need for
arteriography. J Bone Joint Surg 2004;86A:910-915.
24. Hollis JD, Daley BJ. 'Knee Dislocations: is arteriography always
necessary? 10-year institutional review.' Abstract EAST January 2004. J
Trauma 2004;56:227