Vascular Injury in Orthopedic Trauma

Abstract

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

Analysis of Consecutive Cases of Vascular Injury in Tertiary Level Hospital in Central Nepal

“…Clinical presentations of vascular injuries are not always straight forward. 14,19,20 The most common injury in the present study was complete wall transection in 62% followed by complete wall defect in 22% of cases, intimal injury in six percent cases, spasm five percent and AVF in five percent cases. Intimal defects and subintimal hematomas with secondary occlusion were most commonly caused by blunt trauma while complete wall defect and transection occurred with penetrating trauma.…”

“…The study showed that blunt vascular injuries in the lower extremities occurred most commonly in the anterioposterior tibial arteries. Mavrogenis et al 14 reviewed vascular injury with orthopedic trauma and highlighted the importance of rapid and accurate diagnosis along with through understanding of the management priorities for successful salvage of the limb. The review demonstrates that around 33% of vascular injuries in the wartime were associated with orthopedic injuries and lower extremities vascular injury occur more than upper extremity injuries in the military setup.…”

Femoral artery entrapment after cerclage wiring of distal femoral shaft fracture: A case report

“…The incidence of femoral artery injury after femoral fracture is rare but could be catastrophic. 2 Noniatrogenic causes of femoral artery injury include segmented or bone spike of displaced fracture fragment, penetrating injury and direct traction force to vessels.…”

“…It is tethered proximally by the adductor hiatus and distally by the soleus arch. 2 The causes of vessel injuries included open fracture, segmented or displaced fracture fragment, penetrating injury and traction force to vessels. Furthermore, iatrogenic injuries caused by instrumentation, reduction tools and screws could damage the vessels.…”

Imaging of Vascular Injuries of the Extremities

“…18 The evaluation and treatment of vascular injuries within the extremities should occur in the context of the Advanced Trauma Life Support (ATLS) protocol. 19 Bleeding from an injured extremity affects the circulation during the primary survey of ATLS and is initially managed with direct pressure, manually or through use of a compressive dressing. In the absence of obvious bleeding, the injured extremity is assessed during the secondary survey of ATLS.…”