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”
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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
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•
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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
Reduce, stabilize, resuscitate
No pulses
Asymmetric pulses
Doppler
Multilevel
injury ?
Injury
obvious
Normal exam
ABI <0.9
Angiography
or duplex
ABI >0.9
Observation
Surgery
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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