Evaluation and Treatment of

Vascular Injury
Heather Vallier, MD


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


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

Blood loss
Progressive ischemia
Compartment syndrome
Tissue necrosis
Irreversible damage after 6 hours
Vascular injury
Increased incidence with:
Proximity of vessels to bone
Tethering of vessels at joints
Superficial location of vessels
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
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%)
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
Types of vascular injuries
Spasm
Intimal flaps
Subintimal hematoma
Laceration
Transection
Thrombosis/Occlusion
A-V fistula
Some require treatment, some do not
Consequences of vascular injury
Blood loss
Ischemia
Compartment syndrome
Tissue necrosis
Amputation
Death
Prognostic factors
Level and type of vascular injury
Collateral circulation
Shock/hypotension
Tissue damage (crush injury)
Warm ischemia time
Patient factors/medical
conditions
Speed is crucial
Rapid resuscitation
Complete, rapid
evaluation
Urgent surgical
treatment
PROTOCOL IS ESSENTIAL !
Immediate treatment
Control bleeding
Replace volume loss
Cover wounds
Reduce
fractures/dislocations
Splint
Re-evaluate


Diagnosis
Physical exam
Doppler pressure (Ankle/brachial
systolic pressure index (ABI))
Duplex scanning
Arteriogram
Exploration
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 !
Physical exam
Major hemorrhage/hypotension
Arterial bleeding
Expanding hematoma
Altered distal pulses
Pallor
Temperature differential between extremities
Injury to anatomically-related nerve
Asymmetric pulses warrant doppler
examination (determine ABI)

Absent pulses warrant emergent
vascular consultation/surgical
exploration
Doppler Ultrasound
Determine presence/absence of arterial supply
Assess adequacy of flow
PRESENCE OF SIGNAL DOES NOT
EXCLUDE ARTERIAL INJURY !
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
Duplex Scanning
Noninvasive
Safe
Rapid
Reliable for
Injury to arteries and veins
A-V fistulas
Pseudoaneurysms

Duplex vs Arteriography in Evaluating
Iatrogenic Arterial Injuries in Dogs
Duplex scanning
Requires technician and scanner availability

Not all surgeons will operate based on duplex
information alone
Click image to zoom out

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

Angiography
Identify and control
(i.e. embolization)
bleeding from pelvic
fractures
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
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
Operative angiography
Single view in operating
room
Rapid
Excellent for detecting
site of injury
Surgical exploration
Immediate exploration is
indicated for:
Obvious arterial injury on
exam
No doppler signal
Site of injury is apparent
Prolonged warm ischemia
time
No pulses Asymmetric pulses Normal exam
Reduce, stabilize, resuscitate
Injury
obvious
Multilevel
injury ?
Doppler
ABI >0.9 ABI <0.9
Angiography
or duplex
Surgery
Observation
Modified from Brandyk, CORR 2005
Continued evaluation
Vascular injuries are dynamic

Evaluation should continue after the initial injury
or surgery

Additional debridement and/or fixation
undertaken after successful revascularization
Continued evaluation
Circulation
Neurologic function
Compartment pressures

Surgical considerations
Who goes first?
Temporary shunts
Fracture stabilization
Salvage vs amputation
Fasciotomies
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
Conclusions
Potential exists with every orthopedic injury
Uncommon
Be aware of injuries associated
Understand signs and symptoms of arterial injury
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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