Extremity Vascular Injuries, Fractures, and

Compartment Syndromes

Patients with injured extremities often require a

multidisciplinary approach with involvement of trauma,
orthopedic, and plastic surgeons to address vascular
injuries, fractures, soft tissue injuries, and compartment
syndromes. Immediate stabilization of fractures or
unstable joints is done in the ED using Hare traction, knee
immobilizers, or plaster splints. In patients with open
fractures the wound should be covered with
povidoneiodine (Betadine)-soaked gauze and antibiotics
administered. Options for fracture fixation include external
fixation or open reduction and internal fixation with plates
or intramedullary nails. Vascular injuries, either isolated or
in combination with fractures, require emergent repair.
Common combined injuries include clavicle/first rib
fractures and subclavian artery injuries, dislocated
shoulder/proximal humeral fractures and axillary artery
injuries, supracondylar fractures/elbow dislocations and
brachial artery injuries, femur fracture and superficial
femoral artery injuries, and knee dislocation and popliteal
vessel injuries. On-table angiography in the OR facilitates
rapid intervention and is warranted in patients with
evidence of limb threat at ED arrival. Arterial access for
on-table lower extremity angiography can be obtained
percutaneously at the femoral vessels with a standard
arterial catheter, via femoral vessel exposure and direct
cannulation, or with superficial femoral artery (SFA)
exposure just above the medial knee. Controversy exists
regarding which should be done first, fracture fixation or
arterial repair. The authors prefer placement of temporary
intravascular shunts first with arterial occlusions to
minimize ischemia during fracture treatment, with
definitive vascular repair following. Rarely, immediate
amputation may be considered due to the severity of
orthopedic and neurovascular injuries. This is particularly
true if primary nerve transection is present in addition to
fracture and arterial injury.126 Collaborative decision
making by the trauma, orthopedic, and
plastic/reconstructive team is essential.
Operative intervention for vascular injuries should follow
standard principles of repair (see Vascular Repair

Techniques). For subclavian or axillary artery repairs, 6mm PTFE graft and RSVG are used. Because associated
injuries of the brachial plexus are common, a thorough
neurologic examination of the extremity is mandated
before operative intervention. Operative approach for a
brachial artery injury is via a medial upper extremity
longitudinal incision; proximal control may be obtained at
the axillary artery, and an S-shaped extension through the
antecubital fossa provides access to the distal brachial
artery. The injured vessel segment is excised, and an endto-end interposition RSVG graft is performed. Upper
extremity fasciotomy is rarely required unless the patient
manifests preoperative neurologic changes or diminished
pulse upon revascularization, or the time to operative
intervention is extended. For SFA injuries, external fixation
of the femur typically is performed, followed by end-to-end
RSVG of the injured SFA segment. Close monitoring for calf
compartment syndrome is mandatory. Preferred access to
the popliteal space for an acute injury is the medial oneincision approach with detachment of the semitendinosus,
semimembranosus, and gracilis muscles (Fig. 7-71).
Another option is a medial approach with two incisions
using a longer RSVG, but this requires interval ligation of
the popliteal artery and geniculate branches. Rarely, with
open wounds a straight posterior approach with an Sshaped incision can be used. If the patient has an
associated popliteal vein injury, this should be repaired
first with a PTFE interposition graft while the artery is
shunted. For an isolated popliteal artery injury, RSVG is
performed with an end-to-end anastomosis. Compartment
syndrome is common, and presumptive four-compartment
fasciotomies are warranted in patients with combined
arterial and venous injury. Once the vessel is repaired and
restoration of arterial flow documented, completion
angiography should be done in the OR if there is no
palpable distal pulse. Vasoparalysis with verapamil,
nitroglycerin, and papaverine may be used to treat
vasoconstriction (Table 7-11).
Compartment syndromes, which can occur anywhere in
the extremities, involve an acute increase in pressure

inside a closed space, which impairs blood flow to the

structures within. Causes of compartment syndrome
include arterial hemorrhage into a compartment, venous
ligation or thrombosis, crush injuries, and reperfusion
injury. In conscious patients, pain is the prominent
symptom, and active or passive motion of muscles in the
involved compartment increases the pain. Paresthesias
may also be described. In the lower extremity, numbness
between the first and second toes is the hallmark of early
compartment syndrome in the exquisitely sensitive
anterior compartment and its enveloped deep peroneal
nerve. Progression to paralysis can occur, and loss of
pulses is a late sign. In comatose or obtunded patients,
the diagnosis is more difficult to secure. In patients with a
compatible history and a tense extremity, compartment
pressures should be measured with a hand-held Stryker
device. Fasciotomy is indicated in patients with a gradient
of <35 mm Hg (gradient = diastolic pressure
compartment pressure), ischemic periods of >6 hours, or
combined arterial and venous injuries. The lower extremity
is most frequently involved, and compartment release is
performed using a two-incision, four-compartment
fasciotomy (Fig. 7-72). Of note, the soleus muscle must be
detached from the tibia to decompress the deep flexor
compartment.
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