Evaluation and Treatment of Vascular Injury

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Evaluation and Treatment of Vascular Injury

• Heather Vallier, MD
• Original Author Timothy McHenry, MD March 2004
• New Author Heather Vallier, MD Revised January
  2006

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

• the clock starts ticking

• Blood loss
• Progressive ischemia
• Compartment syndrome
• Tissue necrosis

Irreversible damage after 6 hours
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Vascular injury

• Increased incidence with
• Proximity of vessels to bone
• Tethering of vessels at joints
• Superficial location of vessels

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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
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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)

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Mechanism of Injury

• Penetrating trauma
• 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
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Types of vascular injuries

• Spasm
• Intimal flaps
• Subintimal hematoma
• Laceration
• Transection
• Thrombosis/Occlusion
• A-V fistula

Some require treatment, some do not
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Consequences of vascular injury

• Blood loss
• Ischemia
• Compartment syndrome
• Tissue necrosis
• Amputation
• Death

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Prognostic factors

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

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Speed is crucial

• Rapid resuscitation
• Complete, rapid evaluation
• Urgent surgical treatment

PROTOCOL IS ESSENTIAL !
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Immediate treatment

• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce fractures/dislocations
• Splint
• Re-evaluate

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Diagnosis

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

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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 !
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Physical exam

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

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

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Doppler Ultrasound

• Determine presence/absence of arterial supply
• Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL
INJURY !
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Doppler Ultrasound for Knee Dislocation

• Abnormal ABI lt 0.90
• Does not define extent or level of injury
• Abnormal values warrant further evaluation
• ABI gt 0.90 can be observed (i.e. no arteriogram)

Mills, et al. J. Trauma 2004
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Duplex Scanning

• Noninvasive
• Safe
• Rapid
• Reliable for
• Injury to arteries and veins
• A-V fistulas
• Pseudoaneurysms

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Duplex vs Arteriography in Evaluating Iatrogenic
Arterial Injuries in Dogs
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Duplex scanning

• Requires technician and scanner availability
• Not all surgeons will operate based on duplex
  information alone

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Click image to zoom out                         
                                                  
                       
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Angiography

• Locates site of injury
• Characterizes injury
• Defines status of vessels proximal and distal
• May afford therapeutic intervention

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Angiography

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

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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

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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
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Operative angiography

• Single view in operating room
• Rapid
• Excellent for detecting site of injury

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Surgical exploration

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

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Reduce, stabilize, resuscitate
No pulses
Asymmetric pulses
Normal exam
Doppler
Injury obvious
Multilevel injury ?
ABI gt0.9
ABI lt0.9
Angiography or duplex
Observation
Surgery
Modified from Brandyk, CORR 2005
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Continued evaluation

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

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Continued evaluation

• Circulation
• Neurologic function
• Compartment pressures

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Surgical considerations

• Who goes first?
• Temporary shunts
• Fracture stabilization
• Salvage vs amputation
• Fasciotomies

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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

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Conclusions

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

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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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