Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management

Management algorithm of external fixation in lower leg arterial injury for limb salvages

Purpose

The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation.

Methods

Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery.

Results

Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant.

Conclusion

For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life.

Level of evidence

Retrospective cohort, level IV.

The success rate of the lower leg salvage is high, reach the percentage of 91.8% (90/98).

External fixation is less invasive, with achieving adequate stability to repair the arterial injury timely, can lower the ischemic time, and beneficial for the following bone or soft tissue repair.

Treating the patients with external fixators timely is beneficial to the following vascular anticoagulation, bone defect and vein graft, as a result, the protection of lower limb can be improved.

Medial approach for the treatment of femur fractures in association with vascular injury

INTRODUCTION

To highlight an alternative method of treatment for femoral fractures associated with vascular injury, allowing both fracture fixation and vascular repair from the same surgical approach.

DESIGN

Retrospective case series.

METHODS

Twelve patients with arterial injury as a consequence of femoral fracture were treated by internal fixation. There were five femoral diaphysis, seven distal femoral including supracondylar and intercondylar fractures. Four patients had injury to the popliteal artery, whereas eight to the superficial femoral artery. Seven patients had a nerve injury. Medial femoral approach was used both for the fixation of the fracture and vascular repair. Fracture fixation was done by plate-screw in all patients, whereas vascular injuries were treated using saphenous vein interposition graft in ten patients and end-to-end repair in two patients. Nerve injuries were not dealt by exploration during the vascular repair.

RESULTS

All of the limbs were ultimately survived. Clinical and radiological union was observed in all patients at the last follow-up radiographs. Of the 4 total sciatic nerve palsies, 2 had developed total, one had tibial nerve recovery. One patient had no motor recovery. Of the 3 peroneal nerve palsies, 1 patient had recovery, 2 patients had no motor improvement.

CONCLUSIONS

A midlateral approach is traditionally used for fractures of femur when plates and screws are used for fixation. In association with vascular injury, this procedure requires two separate incisions. The added soft tissue disruption associated with open reduction and internal fixation by lateral incision can be reduced with the use of single medial approach, which allows bony stabilization under direct visualization of the repaired vessels.

Do Antiplatelet and Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries?

Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.

Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons

In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.

Concomitant Vascular War Trauma Saturating a French Forward Surgical Team Deployed to Support the Victims of the Syrian War (2013). Interest of the Vascular Damage Control

Vascular injuries from war require an emergency treatment whose objective is to quickly obtain hemostasis and the restoration of arterial flow. In this context of heavy trauma and limited means, damage control surgery is recommended and is based on the use of temporary vascular shunts (TVSs). We report the management of the simultaneous arrival of 2 vascular injuries of war in a field hospital. Patient 1 presented a ballistic trauma of the elbow with a section of the humeral artery (Gustillo IIIC). A TVS was set up during the external fixation of the elbow. Final revascularization was carried out and aponevrotomies of the forearm were performed. Patient 2 had a riddled knee with an open fracture of the femur, an avulsion of the popliteal artery, and a hemorrhagic shock. A strategy of damage control surgery was carried out with placing an arterial and venous shunt. Aponevrotomies of the leg were carried out before casting. For the traumatisms of the arteries of the members, the use of shunts is reserved for the lesions of the proximal vessels. Many vascular shunts available have the same performances to restore the arterial flow and prevent secondary thrombosis. The time before the final revascularization depends on the clinical condition of the patient. The value of anticoagulation in these cases was not shown.

Compartment syndrome resulting from undetected ulnar artery injury in the absence of a forearm fracture

A 6-year-old boy presented following a transient crush injury to his forearm. He displayed mild abrasions but no laceration or associated fractures. The injury resulted in traumatic rupture of the ulnar artery, which caused a large forearm haematoma and an acute forearm compartment syndrome. Prompt clinical diagnosis and operative intervention were required to prevent disastrous consequences.

Prolonged indwelling time of temporary vascular shunts is associated with increased endothelial injury in the porcine mesenteric artery

BACKGROUND

Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity.

METHOD

After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4).

RESULTS

Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58).

CONCLUSION

When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.

Temporary Intravascular Shunts: When Are We Really Using Them According to the NTDB?

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = –7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period ( P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.

Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: collective review

In this systemic review, we summarise the types, configurations, durations, indications and complications of the temporary intravascular shunts used as an adjunct of damage control surgery (DCS) in severe vascular injuries. We conclude that temporary intravascular shunts can be used without systemic anticoagulation for a prolonged time to maintain distal perfusion in combined orthopaedic and vascular injuries, in the setting of DCS and transferring.

Vascular trauma in an Irish regional hospital

BACKGROUND

Vascular trauma is a common cause of mortality and morbidity worldwide. There are few accurate quantitative data available presently on the nature and outcome of these injuries. The aim of this study was to determine the incidence, aetiology, management and outcome of vascular injuries which required surgical intervention at a regional vascular unit.

METHODS

All patients who suffered a vascular injury requiring surgical intervention between January 1992 and December 2005 were included.

RESULTS

A total of 35 patients who underwent operative intervention for vascular trauma were reviewed. There were 26 men and 9 women with a median age of 26 years (range 3-80 years). Road traffic accidents accounted for 15 (43%) of all cases and 16 patients (47%) had an associated fracture. The brachial artery was most frequently injured, constituting 36% of all cases. Interposition grafting using the autogenous long saphenous vein was the most common procedure performed (11 patients). Eleven patients required a secondary procedure while the overall limb amputation rate was 8.5%. There was one mortality following an IVC injury. Seventy-four per cent of the cohort was asymptomatic at last follow-up.

CONCLUSION

While vascular trauma is relatively uncommon in our catchment area it can be successfully managed. Most of the cases occur in young fit patients.

Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life-threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum-assisted closure (VAC) therapy for an average of 22 days (range 3-46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split-thickness skin grafts were used to cover granulation tissue in most of the cases (66% -- 24 cases), and then local flaps (13% -- five cases) or direct sutures (8% -- three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC therapy were observed other than one case of severe pain in an amputated stump. The average follow-up duration was 265 days (range 33-874 days). No further tegumentary reconstruction was required. VAC therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.

RA, Diniz CAM, Perozin IS, Gonçalves JP, Diniz JAM. Pseudo-aneurisma de artéria tibial posterior pós-tratamento de fratura de perna com fixador externo: relato de caso e revisão da literatura

Este trabalho descreve um caso de pseudo-aneurisma da artéria tibial posterior devido ao uso de fixador externo para tratamento de fratura dos ossos da perna (técnica de Ilizarov), bem como as técnicas utilizadas para seu tratamento. A compressão guiada por ultra-som e a injeção de trombina guiada por ultra-som foram realizadas, sem sucesso. O tratamento definitivo do pseudo-aneurisma e reconstrução arterial foi conseguido através do tratamento cirúrgico clássico, usando enxerto interposto de veia safena magna homóloga invertida. As indicações, vantagens e desvantagens das técnicas de tratamento não invasivo (compressão guiada por ultra-som e injeção de trombina guiada por ultra-som) e as possíveis causas de sua incapacidade na obliteração do pseudo-aneurisma são discutidas. Também foi realizada a revisão de casos de pseudo-aneurisma da artéria tibial posterior na literatura médica, encontrando-se apenas um caso semelhante, entre 24 publicados.

Management of Combat Related Vascular Injuries in a Zonal Hospital

BACKGROUND

The extremity gunshot wound (GSW) and penetrating splinter injuries from mine blast present a surgical challenge in the treatment of arterial trauma especially at non-vascular surgery centre. Adherence to specific principles of management is required for optimal limb salvage.

METHODS

Fourteen vascular injuries in patients of GSW and mine explosions were managed at a zonal military hospital with successful outcome in two years. The diagnosis of arterial injury was done clinically.

RESULTS

The commonest site of vascular injury was femoral. The methods of choice for repair were autogenous vein interposition or end-to-end anastomosis. All except for two patients retained a functional limb.

CONCLUSION

All surgeons in peripheral hospitals should be trained in vascular injury repair to save life and limb. Our series shows that right timing and prompt treatment of vascular injuries in a peripheral hospital, can give satisfactory results.

Unusual arterial injury following a fracture of the forearm bones: A case report

The author describes a case of a 10-year-old boy with fracture of both forearm bones and a concomitant partial rupture of the ulnar artery. The damage to the ulnar artery was repaired at the time of fasciotomy with a good functional outcome.

Vascular injuries of the limbs: a fifteen-year Georgian experience

OBJECTIVES

to analyse the causes of injury, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs in patients with vascular injuries operated on over a period between 1981 and 1995.

PATIENTS

in 157 patients, the injuries were penetrating in 136 cases and blunt in 21. Isolated vascular trauma was present in 92 (58.6%) patients, 65 cases (41.4%) were aggrevated by concomitant bone fractures, severe nerve and soft tissue damage. The most frequently injured vessels were the superficial femoral (20. 6%) and brachial (19.1%) arteries.

RESULTS

saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene grafts were used in three cases, end-to-end anastomoses in 42 cases, venous bypasses in five cases, and venous patches in seven cases. Seventeen patients underwent arterial repair and nine, venous repair. Fasciotomy was used in 18 cases, and vessels were ligated in 14 cases. Blood flow was restored in 91 patients (58.0%), and collaterals compensated in 31 cases (19.7%). Fourteen primary and nine secondary amputations were performed. Twelve patients died. The limb salvage rate was 77.7% (84.1% among surviving patients).

CONCLUSIONS

most vascular injuries associated with limb trauma can be managed successfully unless associated by severe concomitant damage to bones, nerves and soft tissues.

Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma

BACKGROUND

Combined vascular and skeletal injuries are associated with a high limb loss rate. One of the major factors resulting in amputation is frequently because the allowable warm ischemia time for skeletal muscle is exceeded before adequate revascularization.

METHODS

Temporary vascular shunting has been used in selected patients with complete ischemia to minimize the ischemic time of the injured limb, allowing identification of vital structures, thorough debridement, and rigid internal fixation before definitive vascular repair.

RESULTS

Five male and two female patients with a median age of 46 years (range, 27-76 years) admitted with combined orthopedic and vascular injuries of the upper limbs in four and the lower limbs in three patients underwent primary vascular shunting. The median ischemic time for all patients was 180 minutes (range, 120-210 minutes). Shunt insertion was accomplished in all cases within 30 minutes. Median dwell time for the shunt was 185 minutes (range, 90-390 minutes). No shunt-related complications or limb loss occurred. During follow-up ranging from 2 to 24 months, all vascular repairs remained patent. All fractures healed primarily, except for one patient in whom a necrosis of the humeral head occurred. Five patients had an excellent and two patients a good result.

CONCLUSION

Initial temporary vascular shunting in selected patients with combined skeletal and vascular injury of the upper or lower limb may reduce the complications resulting from prolonged ischemia and permits an unhurried and reasonable sequence of treatment.

A ten year audit of surgery for vascular trauma in a British teaching hospital

Vascular trauma is uncommon in the U.K. with the exception of Northern Ireland. In marked contrast to North America, gunshot wounds are rare and stabbings are infrequent. A 10 year audit was carried out in a regional vascular referral unit to determine the mechanisms, treatment and outcome of vascular injuries. Forty-seven patients were operated on during the period. The median age was 26 years (range 7-85 years); two-thirds were men. Road traffic accidents accounted for 21 (45%) of injuries, other accidents 15 (32%) and stabbings 11 (23%). There were no gunshot wounds. Most injuries were penetrating with no associated fracture. Commonly injured vessels were the brachial (30%) and superficial femoral (15%) arteries. Fifty-three primary operations were performed, 10 were vein interpositions and 21 were bypass grafts. There were three primary amputations (6%). Eleven patients suffered a complication including one death. One graft occluded requiring a further bypass. Two patients required fasciotomy as a secondary procedure. Median follow-up was 6 months. Eighty-one percent of patients were symptom free at last follow-up. There were no late vascular complications. Our experience is likely to represent that of other vascular units in countries with strict gun control legislation, little civil violence and modest levels of road traffic accidents.