Management of Fractures With Associated Arterial Injury in Combat Casualties

McNamara, James J.; Brief, Donald K.; Stremple, John F.; Wright, J. Kelly

doi:10.1097/00005373-197301000-00003

Cited by 47 publications

(16 citation statements)

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“…Delay in diagnosis of major arterial injuries represents a significant contributor to high amputation rates, although increasingly sophisticated orthopedic and vascular surgical techniques have markedly improved overall outcomes in most modern series. Recent studies [5][6][7] of both military populations and civilian data have demonstrated a marked improvement in limb salvage with early recognition of arterial injury and application of advanced techniques of vascular repair. Early literature 8,9 demonstrated a high rate of association of vascular injuries with blunt lower-extremity trauma and emphasized the importance of rapid diagnosis and aggressive efforts at limb salvage, advocating mandatory arteriogra- phy in all patients irrespective of the results of neurovascular examination on admission.…”

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confidence: 99%

Blunt Lower-Extremity Trauma and Popliteal Artery Injuries

Abou-Sayed

Berger²

2002

Arch Surg

103

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Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage.Design: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months).Setting: Single-institution, academic level I trauma center.Patients: Medical records of patients presenting emergently with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified.Interventions: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone.Main Outcome Measures: Limb salvage rate and necessity for vascular surgical intervention based on an-giographic data in patients with normal neurovascular examination results.Results: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (PϽ.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention.Conclusions: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.

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confidence: 99%

Blunt Lower-Extremity Trauma and Popliteal Artery Injuries

Abou-Sayed

Berger²

2002

Arch Surg

103

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“…8,18,25 In our series, associated fracture also had a significant impact on the amputation rate (p Ͻ 0.05). The order of repair of vascular injury and stabilization of fracture was random in the early years of the study; those who were directly referred to us underwent vascular repair first and those that were referred to us from the orthopedic hospital underwent stabilization of fracture first.…”

Section: Discussionmentioning

confidence: 56%

Popliteal Artery Injuries: The Kashmir Experience

Dar

Ahanger

Wani

et al. 2003

The Journal of Trauma: Injury, Infection, and Critical Care

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“…McNamara [65] reported on the management of arterial injuries associated with fractures in combat casualties. In this study, there were a total of 178 patients that sustained injuries to the brachial, superficial femoral and popliteal arteries; 60 of these patients had accompanying long bone fractures; noting that the presence of associated fractures greatly increased the risk of amputation at all sites with arterial injuries secondary to the massive accompanying soft-tissue injury.…”

Section: Twentieth Century Warsmentioning

confidence: 99%