Evaluation and Treatment of Vascular Injury

1. Evaluation and Treatment of
Vascular Injury
Hope University
Department of medicine
Orthopedic lecture

2. Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury

3. Potential Orthopedic Emergencies
Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury

4. Vascular injury
“the clock starts ticking”
• Blood loss
• Progressive ischemia
• Compartment syndrome
• Tissue necrosis
Irreversible damage after 6 hours

5. Vascular injury
Potentially frequent incidence
• Proximity of vessels to bone
• Tethering of vessels at joints
• Superficial location of vessels

6. 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
Femoral shaft fx femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fx tibial arteries

7. Incidence
Overall uncommon
• 3% of long bone fractures
Specific circumstances
• Fractures with GSW (up to 38%)
• Knee dislocations (16-40%)

8. Mechanism of Injury
• Penetrating trauma
– GSW
– Stab
• Blunt trauma
– High energy
– Low energy
• iatrogenic

9. Types of vascular injuries
• Spasm
• Intimal flaps
• Subintimal hematoma
• Laceration
• Transection
• A-V fistula
Some require treatment, some do not

10. Consequences of vascular injury
• Blood loss
• Ischemia
• Compartment syndrome
• Tissue necrosis
• Amputation
• Death

11. Prognostic factors
• Level and type of vascular injury
• Collateral circulation
• Shock/hypotension
• Tissue damage (crush injury)
• Warm ischemia time
• Patient factors/medical conditions

12. Speed is crucial
• Rapid resuscitation
• Complete, rapid
evaluation
• Urgent surgical
treatment
PROTOCOL IS ESSENTIAL !

13. Immediate treatment
• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce
fractures/dislocations
• Splint
• Re-evaluate

14. Diagnosis
• Physical exam
• Doppler pressure (Ankle/brachial
systolic pressure index)
• Duplex scanning
• Arteriogram
• Exploration

15. Diagnosis
• Physical exam
• Doppler pressure (Ankle/brachial
systolic pressure index)
• Duplex scanning
• Arteriogram
• Exploration Careful physical exam and
high index of suspicion are
most important !

16. Physical exam
• Major hemorrhage/hypotension
• Arterial bleeding
• Expanding hematoma
• Altered distal pulses
• Pallor
• Temperature differential between extremities
• Injury to anatomically-related nerve

17. • Asymmetric pulses warrant doppler
examination (determine ABI)
• Absent pulses warrant emergent
vascular consultation/surgical
exploration

18. Doppler ultrasound
• Determine presence/absence of arterial supply
• Assess adequacy of flow
PRESENCE OF SIGNAL DOES NOT
EXCLUDE ARTERIAL INJURY !

19. Doppler ultrasound
• Normal > 0.95
• Abnormal < 0.90
• Does not define extent or level of injury
• Abnormal values warrant further evaluation
Mills, et al. J. Trauma 2004

20. Duplex scanning
• Noninvasive
• Safe
• Rapid
• Reliable for
– Injury to arteries and veins
– A-V fistulas
– Pseudoaneurysms

21. Duplex scanning
• Requires technician and scanner availability
• Not all surgeons will operate based on duplex
information

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

23. Angiography
Identify and control
bleeding from pelvic
fractures

24. Angiography
• Expensive
• Time-consuming
• Difficult to monitor/treat patient
• Procedural risks
– Renal burden from dye
– Possibility of anaphylaxis
– Injury to proximal vessels

25. Operative angiography
• Single view in operating
room
• Rapid
• Excellent for detecting
site of injury

26. Surgical exploration
Immediate exploration is indicated
for:
• Obvious arterial injury on exam
• No doppler signal
• Site of injury is apparent
• Prolonged warm ischemia time

27. No pulses Asymmetric pulses Normal exam
Reduce, stabilize, resuscitate
Injury
obvious
Multilevel
injury ?
Doppler
ABI >0.9ABI <0.9
Angiography
or duplex
Surgery
Observation
Modified from Brandyk, CORR 1005

28. Continued evaluation
• Vascular injuries are dynamic
• Evaluation should continue after the initial
injury or surgery

29. Continued evaluation
• Circulation
• Neurologic function
• Compartment pressures

30. Surgical considerations
• Who goes first?
• Temporary shunts
• Fracture stabilization techniques
• Salvage vs amputation
• Fasciotomies

31. Conclusions
• Potential exists with every orthopedic injury
• Uncommon
• Be aware of injuries associated
• Understand signs and symptoms of arterial injury

32. Conclusions
• Time is crucial
• Most important 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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