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G03 vascular injury

  1. 1. Principles for Evaluation and Treatment of Patients with Vascular Injury Timothy McHenry, MD
  2. 2. Overview • Epidemiology • Types of Injury • Evaluation • Treatment
  3. 3. Mechanisms of Vascular Injury in the Extremities • Gunshot wound – 54% • Stab wound – 15% • Shotgun wound – 12% • Blunt trauma – 15% • Iatrogenic – 3%
  4. 4. Types of Injuries Active Hemorrhage • Laceration • Partial transection • Complete Transection
  5. 5. Types of Injury Potentially non-occlusive • Contusion with: – Segmental Spasm – Thrombosis – True Aneurysm
  6. 6. Types of Injury Potentially non-occlusive • Pseudoaneurysm • Arteriovenous Fistula • Intimal Flap
  7. 7. Presentation of Vascular Injury • First priority is hemorrhage control followed by appropriate diagnostic work- up
  8. 8. Presentation of Vascular Injury • Dislocations and displaced or angulated fractures: realigned immediately if vascularity is compromised
  9. 9. Evaluation for Vascular Injury • Physical Examination • Doppler Flowmeter • Duplex Ultrasonography • Arteriogram • Local wound exploration should not be done in an uncontrolled setting • Close coordination with a general or vascular surgeon recommended
  10. 10. Physical Examination Hard Signs • Absent or diminished distal pulses • Active hemorrhage • Large, expanding or pulsatile hematoma • Bruit or thrill • Distal ischemia (pain, pallor, paralysis, paresthesias, coolness)
  11. 11. Physical Examination Soft Signs • Small, stable hematoma • Injury to anatomically related nerve • Unexplained hypotension • History of hemorrhage no longer present • Proximity of injury to major vessel
  12. 12. Doppler Examination • Non-invasive adjunct to physical examination • Small, hand-held (non-directional) Doppler flowmeter provides for subjective interpretation of audible signal • Useful as modality for determining the Ankle-Brachial Index (ABI)
  13. 13. Doppler • Normal arterial signals are triphasic or biphasic
  14. 14. Doppler • Flow distal to a transection may be absent or monophasic and low-pitched due to collateral circulation
  15. 15. Determination of Ankle-Brachial Index • Appropriate sized blood pressure cuff is placed above the ankle or wrist • Doppler derived opening pressure of distal artery • Calculate by dividing ankle pressure by brachial pressure • Measure injured/ uninjured sides • Normal ABI is 1.00 or greater
  16. 16. ABI Criteria • ABI > 0.9 – Advantages • Strong negative predictor for major vascular injury • Objective noninvasive evidence of vascular competence – Disadvantages • Does not exclude all injuries • Not useful in presence of vascular disease
  17. 17. Duplex (B-mode) Ultrasonography • Direction-sensing Duplex (B-mode) ultrasound allows for visual waveform analysis • Highly operator dependent • 96-98% accurate in experienced hands • Generally not available during peak trauma times
  18. 18. Arteriography • Gold standard for evaluation of peripheral vascular injuries • Formal arteriograms done in radiology may cause critical delays in diagnosis or intervention • Single-shot arteriograms done in the emergency room or operating room should be considered in cases where arteriography is indicated.
  19. 19. Indications for Arteriography • Multiple potential sites of injury (shotgun wounds) • Missile track parallels vessel over long distance • Blunt trauma with signs of vascular trauma • Chronic vascular disease • Extensive bone or soft tissue injury • Thoracic outlet wounds • Evaluation of equivocal results from non-invasive tests • Proximity (gsw, knife wound) (controversial) • ABI < .9
  20. 20. Single-shot Arteriogram • 21 or 20 gauge angiocatheter ( at least 2” long) or single lumen central line or a- line kit • 3 way stop-cock • 30 cc syringes (x2) • Iodinated contrast (full strength) • Heparinized saline (1,000 IU/liter) • IV extension tubing • Consider inflow and/or outflow occlusion
  21. 21. Single-shot Arteriogram in the Emergency or Operating Room
  22. 22. Summary of Evaluation • Initial priority is to control hemorrhage – Direct Pressure – Pressure Points – Tourniquet • If penetrating injury with one or more hard signs of vascular injury then immediate surgical exploration is usually warranted • If hard signs present with blunt mechanism or multi-site penetrating mechanism then an arteriogram may be warranted • If soft signs present, consider further diagnostic modalities (usually initially non-invasive)
  23. 23. Treatment Operative Repair Indications: • injuries with hard signs of vascular injury OR • arteriogram showing occlusion or extravasation
  24. 24. Treatment Non-operative Observation • Certain non-occlusive injuries without hard signs (often occult injuries) can be managed conservatively • Criteria: – Low-velocity injury – Minimal arterial wall disruption – Intact distal circulation – No active hemorrhage • Serial arteriography or duplex scanning recommended • Close coordination with a vascular or general surgeon is recommended
  25. 25. Non-operative Management • Intimal injuries and segmental narrowing are most amenable to conservative care and may resolve over time • Small pseudoaneurysms sometimes enlarge, become symptomatic and require operative repair • Asymptomatic acute AV fistulas may be less certain to resolve and should be followed closely
  26. 26. Sequelae of Missed Arterial Injuries • Deterioration of arterial injury can lead to: – Intimal dissection with resulting occlusion – Arteriovenous fistula – Thromboemboli – Stenosis • These can cause distal ischemia with significant morbidity: – Pain – Gangrene – Amputation
  27. 27. Penetrating Arterial Injury Limb Salvage Rates • World War II (Debakey and Simeone, 1946) – 2,471 cases – 51% salvage for ligation – 64.2% salvage for repair • Viet Nam War (Rich et al, 1970) – 1000 cases – 28.5% with concomitant fractures – 87% overall salvage • Recent civilian (Trooskin et al, 1993) – 50 arterial and 17 venous injuries in 51 patients – 22% with concomitant fractures – 100% salvage – Other recent civilian studies approach a 100% salvage rate as well
  28. 28. Blunt Arterial Injury Salvage Rates • Have a high amputation rate due to associated soft-tissue and nerve injuries (the mangled extremity) • These injuries may result in a non-functional limb in spite of a successful revascularization
  29. 29. Mangled Extremity • Indications for Primary Amputation – Anatomically complete disruption of sciatic or posterior tibial nerves in adult even if vascular injury is repairable – Prolonged warm ischemia time – Life threatening sequelae • rhabdomyolysis
  30. 30. Mangled Extremity • Relative Indications for Primary Amputation – Serious associated polytrauma – Severe ipsilateral foot trauma • loss of plantar skin/weight bearing surface – Anticipated protracted course to obtain soft- tissue coverage and skeletal reconstruction
  31. 31. Variables in Consideration of Limb Viability • Skin/Muscle Injury • Bone Injury • Ischemia (time, degree) • Type of Vascular Injury • Shock • Age • Infection • Associated injuries (pulmonary, abdominal, head, etc.) • Comorbid Disease (peripheral vascular disease, diabetes mellitus, etc.)
  32. 32. Classification Systems • Mangled Extremity Syndrome Index (MESI) – 10 variables • Predictive Salvage Index (PSI) – 4 variables • Mangled Extremity Severity Score (MESS) – 4 variables • Limb Salvage Index (LSI) – 7 variables • NISSSA scoring system – 5 variables
  33. 33. Mangled Extremity Scoring System Factor Score Skeletal/soft-tissue injury Low energy (stab, fracture, civilian gunshot wound) 1 Medium energy (open or multiple fracture) 2 High energy (shotgun or military gunshot wound, crush) 3 Very high energy (above plus gross contamination) 4 Limb Ischemia (double score for ischemia > 6 hours) Pulse reduced or absent but perfusion normal 1 Pulseless, diminished capillary refill 2 Patient is cool, paralyzed, insensate, numb 3 Shock Systolic blood pressure always >90 mm Hg 0 Systolic blood pressure transiently <90 mm Hg 1 Systolic blood pressure persistently <90 mm Hg 2 Age, yr <30 0 30-50 1 >50 2
  34. 34. Mangled Extremity Severity Score • All information for classification available at time of ER presentation • Simplest to apply of all scoring systems • Most thoroughly studied • A score of less than 7 is supposed to predict limb salvageability
  35. 35. LEAP Data • 556 lower extremity injuries • prospectively scored—MESS, PSI, LSI, NISSSA, HFS-97 • High specificity (84-98%) • LOW SENSITIVITY (33-51%) • Not a substitute for clinical judgment and experience for salvage vs amputation decision making Bosse et al, JBJS, 83-A, 2001
  36. 36. Mangled Extremity Management • Involves a determination of both the feasibility (restoring viability) and advisability (restoring function) of salvaging the limb • Should be a coordinated effort of the orthopaedic, vascular and plastic surgeons starting at the initial evaluation of the patient
  37. 37. Fasciotomies • Prophylactic fasciotomies after vascular repair have been credited as being a major reason for increased limb salvage rates in recent years • Fasciotomies after prolonged ischemia prevent compartment syndrome that may result from reperfusion injury – The reperfusion injury is delayed and may manifest after the patient leaves the operating room
  38. 38. Indications for Fasciotomies • No absolute clinical indications for fasciotomy exist • Subjective criteria – Extensive soft-tissue or bony injury – Progression of swelling – Compartment tightness • Objective criteria – Ischemia time greater than 6 hours – Compartment pressure within 20 mm Hg of diastolic blood pressure
  39. 39. Morbidity of Fasciotomies • Increased risk of infection – Exposure of injured or ischemic muscle • Decreased fracture healing – Potentially converting a closed to an open fracture • Iatrogenic injury – Neuroma – Chronic venous insufficiency
  40. 40. Pharmacologic Treatment of Reperfusion Injury • Following reperfusion, byproducts of anaerobic metabolism may be released causing local and systemic effects • Administration before reperfusion – Mannitol • Free radical scavenging – Heparin • Anti-coagulant • Anti-inflammatory • May be contraindicated in acute trauma
  41. 41. Issues Concerning Surgical Order • The order of surgical repair in penetrating injuries requiring both vascular repair and orthopaedic fixation is controversial: – Delayed revascularization until after orthopaedic stabilization may adversely effect limb salvage – Fractures instability or subsequent orthopaedic stabilization may disrupt a vascular repair
  42. 42. Surgical Order • In general, revascularization takes precedence over definitive orthopaedic fixation • In cases with gross fracture instability • a temporary vascular shunt can be placed and vascular repair deferred until after orthopaedic fixation • If the ischemia time is short, consideration can be given to application of a provisional unilateral external fixator prior to revascularization
  43. 43. Temporary Vascular Shunt
  44. 44. Definitive Vascular Repair
  45. 45. Definitive Fixation • Definitive orthopaedic fixation should be internal in most cases • Consider external fixation for: – Pediatric fractures – Extensive soft-tissue injuries – Contaminated wounds – Hemodynamically unstable patients
  46. 46. Penetrating Superficial Femoral Artery Injury with Femur Fracture
  47. 47. Summary • The treatment of fractures or dislocations with vascular injury requires close coordination between the orthopaedic surgeon and the vascular or general surgeon to facilitate optimal limb outcome. Return to General Index

Editor's Notes

  • Feliciano DV, Herskowitz K, O’Gormon RB, et al: Management of vascular injuries to the lower extremities. J Trauma 28: 319-328, 1988.
    Furthermore, 38% of fractures associated with gunshot wounds have arterial injuries. (Gahtan et al., Am Surg 60: 123-127, 1994)
  • Potentially non-occlusive injuries present with varying degrees of occlusion that may or may not be clinically significant. The injuries that do not cause clinically significant ischemia can potentially be managed by close observation. Late progression of these lesions, however, may cause delayed ischemia requiring surgical intervention. These injuries do not typically present with active hemorrhage.
  • Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998.
    “Frequently nonocclusive arterial injuries are surrounded by a contained hematoma. If the hematoma is disrupted, exigent hemorrhage may ensue. Local wound exploration is therefore ill advised.”
  • The presence of one or more hard signs is an indication for immediate surgical exploration.
    Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surgical Clinics of North America 75: 207-223, 1995.
  • In general, soft signs may indicate the need for further evaluation. Their significance is controversial and their presence alone do not constitute an indication for surgical intervention.
    Proximity refers to penetrating wounds less than 1 cm to a major vessel. Proximity is very controversial. Some centers now rely on non-invasive methods to initially evaluate injuries less than 1 cm from a major vessel.
    Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998.
    “Recent studies have demonstrated that in the absence of objective clinical findings (e.g., fracture, hematoma, nerve injury), arteriograms performed for proximity alone demonstrate an arterial injury in only 6 to 9% of patients. More significantly, the injuries that are clinically occult but detected only by arteriography are invariably insignificant and do not require surgical repair.”
    Frykberg ER, Crump JM, Vines FS, McLellan GL, Dennis JW, Brunner RG, Alexander RH. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study. J Trauma, 29: 1041-50, 1989.
    152 injuries from penetrating proximity extremity trauma were studied by either immediate or delayed arteriography. 27 radiographic abnormalities found with 16 in major vessels. 1 acute AV fistula was immediately repaired. The remaining 15 were observed (7 cases of segmental narrowing, 6 intimal flaps and two small pseudoaneurysms). One pseudoaneurysm enlarged and underwent repair at 10 weeks. The remaining 14 were successfully managed non-operatively (9 resolved, 2 improved and 3 unchanged) over an average of 2.7 months. Conclusions: 1. The natural history of clinically occult arterial injuries was predominantly benign, 2. Arteriogram could be safely delayed up to 24 hours, 3. “soft” signs were not clinically useful predictors of vascular injury, 4. Arteriography not a cost-effective modality for screening proximity injuries (a possible exception is shotgun wounds because this mechanism was found to have the greatest risk of significant injury).
  • Rutherford RB (ed.) Vascular Surgery (3rd ed.). W.B. Sanders Co., 1989.
  • For triphasic flow the first sound corresponds to high frequency flow during systole. The second sound corresponds to reverse flow in early diastole. The third sound corresponds to a smaller, low velocity flow in late diastole.
  • Other authors have found that an ABI of 1.0 has a higher sensitivity for excluding major arterial injury:
    Schwartz MR, Weaver FA, Bauer M, Siegel A, Yellin AE. Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis. J Vasc Surg 17: 116-22, 1993.
    ABI Sensitivity SpecificityPPVNPV
    &amp;lt;1.00 96301299
    &amp;lt;0.95 79471387
    &amp;lt;0.9063661694
  • Formal departmental arteriograms may not be readily available during peak trauma times and may significantly prolong the time to intervention while not changing management when compared to operating room arteriograms.
    In most cases of penetrating trauma with hard signs of vascular injury, delaying surgical exploration in order to get an arteriogram could potentially compromise limb salvage. The delay of 1 to 3 hours is unwarranted in most instances.
    Itani KM, Burch JM, Spjut-Patrinely V, Richardson R, Martin RR, Mattox KL. J Trauma, 1992. Reviewed 1,882 emergency center arteriograms. These arteriograms had a sensitivity of 95.5% and specificity of 97.7% for vascular injury. 196 of 305 injuries required operative intervention. These results approach the results of formal, departmental arteriograms in detecting vascular injuries. (Proximity was the only indication for arteriogram in 91% of the patients)
  • Other indications for arteriography that do not apply to acute presentation are: intraoperative arteriogram (completion of repair), delayed diagnosis, follow-up of nonoperatively managed arterial injuries.
    The reason patients with chronic vascular disease might warrant arteriogram is that they may have longstanding pulse deficits that predispose them to false-positive non-invasive evaluation.
    The reason that extensive bone or soft tissue injury may warrant an arteriogram is that the extent of the injury may cause hard signs without vascular injury.
    Thoracic outlet wounds sometimes benefit from an arteriogram in order to plan the surgical approach which varies with the exact site of the injury.
  • Arrows mark bullet entrance and exit sites.
    Inflow occlusion can be done manually above the catheter insertion site.
    Outlflow occlusion can be done with a blood pressure cuff. It facilitates retrograde arteriograms to evaluate the brachial artery or proximal contralateral superficial femoral artery.
  • Single-shot arteriogram showing complete transection of the popliteal artery.
  • There are not well established guidelines for serial follow-up studies.
    Stain et al. (Stain JC, Yellin AE, Weaver FA, Penecost MJ. Selective management of non-occlusive arterial injuries. Arch Surg: 124(10): 1136-40, 1989.) in a study of patients with nonocclusive arterial injuries typically restudied the patients by arteriography at 3 to 7 days and again at 1 to 2 months after injury.
  • Stain SC, Yellin AE, Weaver FA, Pentecost MJ. Selective management of nonocclusive arterial injuries. Archives of Surgery, 124: 1136-40, 1989.
    61 nonocclusive arterial injuries (19 intimal defects, 4 intimal flaps, 26 pseudoaneurysms, 2 arterial stenoses and 10 AV fistulas) without associated ischemia or ongoing hemorrhage. All injuries initially treated nonoperatively. Follow-up arteriography performed on 30 injuries with resolution, improvement or stabilization in 21 (87%). 3 injuries progressed, one subsequently required operative repair with no sequelae. All injuries followed without repeat arteriography were successfully managed nonoperatively. The conclusion of this study was that “The overwhelming majority of small arterial injuries or intimal fractures do not lead to vascular complications if managed non-operatively.”
    Frykberg ER, Crump JM, Dennis JW, Vines FS, Alexander RH. Nonoperative observation of clinically occult arterial injuries: a prospective evaluation. Surgery, 109: 85-96, 1991.
    50 clinically occult injuries of major arteries were studied (22 intimal flaps, 21 segmental arterial narrowing, 6 pseudoaneurysms, 1 acute AV fistula). One patient died of unrelated causes and three injuries underwent immediate surgical repair. Of the remaining 46 injuries, 39 underwent serial arteriography and 7 were followed by clinical examination. 29 injuries (63%) completely resolved, 3 improved, 9 remained unchanged and 5 worsened. All 5 were small pseudoaneurysms that enlarged necessitating surgical repair, none with sequelae from the delay. Overall 89% of injuries did not require surgery.
  • It is clear that enthusiasm for non-operative management of select non-occlusion lesions must be tempered in consideration that progression can result in significant morbidity. Frykberg et al., Stain et al. and others have shown that occult, non-occlusive lesions can be selectively managed conservatively. Their studies, however, involved small numbers of patients with limited follow-up.
    An earlier study, (Shumacker HB, Wayson EE. Am J Surg 79: 532-44, 1950) found that the chance of spontaneous resolution of a pseudoaneurysm was approximately 6% and an AV fistula 2%. These involved various sizes of lesions, however.
  • Debakey ME, Simeone FA. Battle injuries of the arteries in World War II: An analysis of 2,471 cases. Ann Surg 123: 534, 1946.
    Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 10: 359, 1970.
    Trooskin SZ, Sclafani S, Winfield J, Ducan AO, Scalea T, Vieux E, Atweh N, Gertler J. The management of vascular injuries of the extremity associated with civilian firearms. Surgery, Gynecology and Obstetrics 176: 350-354, 1993.
  • Harrell DJ, Spain DA, Bergamini TM, Miller FB and Richardson JD. Blunt popliteal artery trauma: a challenging injury. Am Surg, 63: 228-232, 1997.
    14 of 38 limbs (36%) amputated.
    Moniz MP, Ombrellaro MP, Stevens SL, Freeman MB, Diamond DL and Goldman MG. Concomitant orthopedic and vascular injuries as predictors for limb loss in blunt lower extremity trauma. Am Surg, 63: 24-28, 1997.
  • Dirschl Dr, Dahners LE. The mangled extremity: when should it be amputated? JAAOS 4: 182-190, 1996.
  • Dirschl Dr, Dahners LE. The mangled extremity: when should it be amputated? JAAOS 4: 182-190, 1996.
  • Dirschl Dr, Dahners LE. The mangled extremity: when should it be amputated? JAAOS 4: 182-190, 1996.
  • Tornetta P, Olson SA. Amputation versus limb salvage. Orthopaedic Instructional Course Lectures vol 46, 511-8, 1997.
  • Tornetta P, Olson SA. Amputation versus limb salvage. Orthopaedic Instructional Course Lectures vol 46, 511-8, 1997.
  • Dirschl Dr, Dahners LE. The mangled extremity: when should it be amputated? JAAOS 4: 182-190, 1996.
  • Sensitivity and specificity scores are as computed for all gr III tibia fractures
    Sensitivity was defined as the probability that limbs requiring amputation will have scores at or above the score threshold (e.g. MESS of 7 or greater).
    Specificity was defined as the probability that salvaged limbs will have scores below the threshold
    Bosse et al, “A prospective evaluation of the clinical utility of the Lower-extremity injury-severity scores” JBJS, 83-A, 2001
  • Sanders R, Swiontkowski M, Nunley J, Spiegel P. The management of fractures with soft-tissue disruption. JBJS 75-A: 778-789, 1993.
  • Gute DC, Ishida T, Yarimizu K, Korthuis RJ. Inflammatory responses to ischemia and reperfusion in skeletal muscle. Molecular and Cellular Biochemistry 179: 169-187,1998.
    Reperfusion injury occurs in a previously ischemic limb due to interstitial edema. This edema results from damage caused by oxygen free radicals that are formed when oxygen is reintroduced into a previously ischemic environment. Xanthine oxidase (converted from xanthine dehydrogenase during the ischemic period) reacts with oxygen (along with superoxide dismutase) to crease these radicals. Endothelial damage occurs and neutrophils adhere and pass through the endothelium into the tissue (neutrophil rolling). The process is intensified by subsequent production of pro-inflammatory cytokines and chemoattractant agents. The edema that results compromises capillary flow and this in turn produces secondary ischemia (the no-reflow phenomenon).
  • Trooskin SZ, Winfield J, Duncan AO, Scalea T, Vieux E, Atweh N, Gertler J. The management of vascular injuries of the extremity associated with civilian firearms. Surgery, Gynecology and Obstetrics 176: 350-354, 1993.
  • Infection:
    Blaisdell WF. &amp;lt;Discussion of&amp;gt; Rollings DL, Bernhard VM, Towne JH. Fasciotomy: An appraisal of controversial issues. Arch Surg, 116: 1474-1481, 1981.
    Makes the point the fasciotomy for trauma exposes injured muscle (ischemic, necrotic) that has “no intrinsic defense against infection.” He uses fasciotomy for revascularization sparingly.
    Rush DS, Frame, SB, Bell RM, Berg EE, Kerstein MD and Hayes JL. Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischemia and revascularization? J Vasc Surg, 10: 343-350, 1989.
    “Open fasciotomy for compartment syndrome after acute lower extremity is ischemia and revascularization was associated with an increased risk of minor wound morbidity.”
    However, “Fasciotomy remains an effective procedure to maximize postischemic tissue viability and function in the presence of compartment hypertension.”
    Fracture healing:
    Lindsey RW. &amp;lt;Personal communication&amp;gt;
    Other references:
    Feliciano DV, Cruse PA, Spjut-Patrinely V, Burch JM and Mattox KL. Fasciotomy after trauma to the extremities. Am J Surg, 156: 533-536, 1988.
    Vitale GC, Richardson JD, George SM, Miller FB. Fasciotomy for severe, blunt and penetrating trauma of the extremity. Surgery, Gynecology and Obstetrics 166: 397-401, 1988.
  • Hobson RW 2d, Neville R, Watanabe B, Canady J, Wright JG, Belkin M. Role of heparin in reducing skeletal muscle infarction in ischemia-reperfusion. Microcirculation, endothelium and lymphatics 5: 259-76, 1989.
    Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America 16: 129-144, 1998.
  • Starr AJ, Hunt JL, Reinert CM. Treatment of femur fracture with associated vascular injury. J Trauma 40: 17-21, 1996.
  • References:
    Ashworth EM, Dalsing MC, Glover JL, Reilly MK. Lower extremity vascular trauma: a comprehensive aggressive approach. J Trauma 28, 329-336, 1988.
    Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America 16: 129-144, 1998.
    Johansen K, Bandyk BF, Thiele BL, Hansen ST. Use of temporary intraluminal shunt: Resolution of a management dilemma in complex vascular injuries. J Trauma 22: 395-398, 1982.
    Zinman C., Norman D., Hamoud K., Reis ND. External fixation for severe open fractures of the humerus caused by missiles. J Ortho Trauma 11: 536-539,1997.
  • Starr AJ, Hunt JL, Reinert CM. Treatment of femur fracture with associated vascular injury. J Trauma 40: 17-21, 1996
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