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 EmergenciesOpen fractureIrreducible dislocationsVascular injuryAmputationCompartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injuryDisplaced femoral neck and talar neck fractures

Potential Orthopedic EmergenciesOpen 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

Increased incidence with:

• 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 arteries

iliac arteriesFemoral shaft fx femoral arteryDistal femur fracture popliteal arteryKnee dislocation popliteal arteryTibial shaft fx tibial arteries

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%)

Mechanism of Injury• Penetrating trauma

– GSW

– Stab

• Blunt trauma– High energy

– Low energy

• IatrogenicBlunt trauma with 27% amputation rate vs 9% for

penetrating in Natl Trauma Database, Mullenix PS, et al. J Vasc Surg 2006

Types of vascular injuries• Spasm

• Intimal flaps

• Subintimal hematoma

• Laceration

• Transection

• Thrombosis/Occlusion

• 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 (ABI))

• Duplex scanning

• Arteriogram

• Exploration

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 !

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 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

Duplex Scanning• Noninvasive• Safe• Rapid• Reliable for

– Injury to arteries and veins– A-V fistulas– Pseudoaneurysms

Duplex vs Arteriography in Evaluating Iatrogenic Arterial Injuries in Dogs

Duplex scanning

• Requires technician and scanner availability

• Not all surgeons will operate based on duplex information alone

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 (i.e. embolization) bleeding from pelvic fractures

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

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

Operative angiography

• Single view in operating room

• Rapid

• Excellent for detecting site of injury

Surgical explorationImmediate 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 2005

Continued evaluation• Vascular injuries are dynamic

• Evaluation should continue after the initial injury or surgery

• Additional debridement and/or fixation undertaken after successful revascularization

Continued evaluation

• Circulation

• Neurologic function

• Compartment pressures

Surgical considerations

• Who goes first?

• Temporary shunts

• Fracture stabilization

• Salvage vs amputation

• Fasciotomies

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

Conclusions

• Potential exists with every orthopedic injury

• Uncommon

• Be aware of injuries associated

• Understand signs and symptoms of arterial injury

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

Return to General/Principles

Index

E-mail OTA about

Questions/Comments

If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org