1. Evaluation and Treatment of Vascular Injury
Heather Vallier, MD
Original Author: Timothy McHenry, MD; March 2004
New Author: Heather Vallier, MD; Revised January 2006

2. Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury
Displaced femoral neck and talar neck fractures

3. Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury

4. “the clock starts ticking”
Vascular injury
“the clock starts ticking”
Blood loss
Progressive ischemia
Compartment syndrome
Tissue necrosis
Irreversible damage after 6 hours

5. Vascular injury Increased incidence with: Proximity of vessels to bone
Tethering of vessels at joints
Superficial location of vessels

6. 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
iliac arteries
Femoral shaft fx femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fx tibial arteries

7. Incidence of Fracture or Dislocation with Vascular Injury
Uncommon
3% of long bone fractures
Specific circumstances
Fractures with GSW
(up to 38%)
Knee dislocations (16-40%)

8. Mechanism of Injury Penetrating trauma Blunt trauma Iatrogenic GSW
Stab
Blunt trauma
High energy
Low energy
Iatrogenic
Blunt trauma with 27% amputation rate vs 9% for penetrating in Natl Trauma Database,
Mullenix PS, et al. J Vasc Surg 2006

9. Types of vascular injuries
Spasm
Intimal flaps
Subintimal hematoma
Laceration
Transection
Thrombosis/Occlusion
A-V fistula
Some require treatment, some do not

10. Consequences of vascular injury
Blood loss
Ischemia
Compartment syndrome
Tissue necrosis
Amputation
Death

11. Prognostic factors Level and type of vascular injury
Collateral circulation
Shock/hypotension
Tissue damage (crush injury)
Warm ischemia time
Patient factors/medical conditions

12. Speed is crucial PROTOCOL IS ESSENTIAL ! Rapid resuscitation
Complete, rapid evaluation
Urgent surgical treatment
PROTOCOL IS ESSENTIAL !

13. Immediate treatment Control bleeding Replace volume loss Cover wounds
Reduce fractures/dislocations
Splint
Re-evaluate

14. Diagnosis Physical exam
Doppler pressure (Ankle/brachial systolic pressure index (ABI))
Duplex scanning
Arteriogram
Exploration

15. Careful physical exam and high index of suspicion are most important !
Diagnosis
Physical exam
Doppler pressure (Ankle/brachial systolic pressure index (ABI))
Duplex scanning
Arteriogram
Exploration
Careful physical exam and high index of suspicion are most important !

16. Physical exam Major hemorrhage/hypotension Arterial bleeding
Expanding hematoma
Altered distal pulses
Pallor
Temperature differential between extremities
Injury to anatomically-related nerve

17. Asymmetric pulses warrant doppler examination (determine ABI)
Absent pulses warrant emergent vascular consultation/surgical exploration

18. PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !
Doppler Ultrasound
Determine presence/absence of arterial supply
Assess adequacy of flow
PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !

19. Doppler Ultrasound for Knee Dislocation
Abnormal ABI < 0.90
Does not define extent or level of injury
Abnormal values warrant further evaluation
ABI > 0.90 can be observed (i.e. no arteriogram)
Mills, et al. J. Trauma 2004

20. Duplex Scanning Noninvasive Safe Rapid Reliable for
Injury to arteries and veins
A-V fistulas
Pseudoaneurysms

21. Duplex vs Arteriography in Evaluating Iatrogenic Arterial Injuries in Dogs

22. Duplex scanning Requires technician and scanner availability
Not all surgeons will operate based on duplex information alone

23. Click image to zoom out
                                                                                                 

24. Angiography Locates site of injury Characterizes injury
Defines status of vessels proximal and distal
May afford therapeutic intervention

25. Angiography
Identify and control (i.e. embolization) bleeding from pelvic fractures

26. Angiography Expensive Time-consuming
Difficult to monitor/treat trauma patient in angiography suite
Procedural risks
Renal burden from dye
Possibility of anaphylaxis
Injury to proximal vessels

27. CT Angiography Alternative to conventional angiography
Good sensitivity and specificity
Costs much more
ANGIOGRAPHY WILL DELAY REVASCULARIZATION. It is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery
Redmond, et al. Orthopedics 2008

28. Operative angiography
Single view in operating room
Rapid
Excellent for detecting site of injury

29. Surgical exploration Immediate exploration is indicated for:
Obvious arterial injury on exam
No doppler signal
Site of injury is apparent
Prolonged warm ischemia time

30. Reduce, stabilize, resuscitate
No pulses
Asymmetric pulses
Normal exam
Doppler
Injury obvious
Multilevel injury ?
ABI <0.9
ABI >0.9
Angiography
or duplex
Observation
Surgery
Modified from Brandyk, CORR 2005

31. Continued evaluation Vascular injuries are dynamic
Evaluation should continue after the initial injury or surgery
Additional debridement and/or fixation undertaken after successful revascularization

32. Continued evaluation Circulation Neurologic function
Compartment pressures

33. Surgical considerations
Who goes first?
Temporary shunts
Fracture stabilization
Salvage vs amputation
Fasciotomies

34. Surgical considerations
Who goes first? Discuss with vascular surgeon
Temporary shunts Will benefit some patients
Fracture stabilization Consider provisional ex fix
Salvage vs amputation Trend toward salvage (LEAP)
Fasciotomies Prophylactic after Ischemia

35. Conclusions Potential exists with every orthopedic injury Uncommon
Be aware of injuries associated
Understand signs and symptoms of arterial injury

36. Conclusions Time is crucial Paramount 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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