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Evaluation and Treatment of Vascular Injury
Heather Vallier, MD
Original Author: Timothy McHenry, MD; March 2004New 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
• IatrogenicBlunt 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 < 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
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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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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
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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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