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Arterial injuries of the legs associated with fractures and dislocations
Arterial Injuries of the Legs Associated With Fractures and Dislocations
Fred J. Wolma, MD, Galveston, Albert0
Texas
J. Larrieu,
MD, Galveston, Texas George C. Alsop, MD, Galveston, Texas
Experience with the management of vascular injuries associated with fractures and dislocations of the leg is limited due to the infrequent combination of orthopedic and vascular injuries [1,2]. This report is based on a retrospective review of the charts of 29 patients who were seen and treated between January 1960 and July 1979 at The University of Texas Medical Branch in Galveston, Texas, for arterial injuries of the leg associated with fractures and dislocations.
Clinical Material The 29 patients in this review (26 men and 3 women) were aged 13 to 67 years (mean 28). Blunt trauma was responsible for the arterial injuries in 21 patients and gunshot woundswere responsible in 8. Sixteen patients were operated on more than 6 hours and 13 patients less than 6 hours after injury. Arteriography was performed in all patients but one. The fractures and dislocations most commonly involved are listed in Table I. Fractures of the femur, simple or compound, were the most common, occurring in 12 patients; 9 patients had tibia-fibular fractures, 5 patients dislocations of the knee, and 3 patients pelvic fractures. There were seven compound fractures. All patients had clinical signs of arterial ischemia and absence of peripheral pulses. The vessels most commonly injured were the popliteal artery (11 patients) and the superficial femoral artery (9 patients) (Table II). The vessels were either contused and thrombosed or lacerated by bone fragments or other penetrating injuries in all patients except one in whom a traumatic arteriovenous fistula developed 4 days after a motor vehicle accident. In another patient injury to a popliteal vein was repaired in association with repair of the popliteal artery injury. Vascular reconFrom the Department of Surgery, The University of Texas Medical Branch, Galveston, Texas. Requests for reprints should be addressed to Fred J. Wolma, MD. Department of Surgery, The University of Texas Medical Branch, Galveston, Texas 7’1550. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-8, 1980.
808
struction was performed in 23 patients, while primary amputation was carried out in 2 (Table III). The method of fixation was internal in 10 patients, with the use of a plating technique in 6 and intramedullary rods in 4, and external in the remaining 19 patients. Two patients (6.9 percent) died, both from associated multiple injuries. Overall, 20 limbs (69 percent) were saved, while 9 patients (31 percent) underwent amputation. Seven of the nine patients who required amputation had undergone a previous revascularizing procedure. Eight of the nine patients who underwent amputation were operated on more than 6 hours after injury (88.9 percent). Only 1 of the 13 patients operated on less than 6 hours after injury required amputation (8.33 percent), whereas 8 of the 16 patients operated on more than 6 hours after injury required amputation (50 percent). The patients with popliteal artery injuries had an amputation rate of 36.4 percent and those with trifurcation injuries a rate of 50 percent. The profunda femoris was ligated in two patients without complication; observation was carried out in two others. Only 4 of 17 patients with injuries to the knee or femur required amputation (23.5 percent), whereas 5 of 9 patients with tibia-fibula fractures required amputation (55.5 percent). Fasciotomy was performed in nine patients, six of whom presented more than 6 hours after injury. One patient who underwent internal fixation developed osteomyelitis of the femur but has retained functional use of his leg. One patient who was observed after a gunshot blast to the upper tibia-fibula region has a significant peroneal nerve injury and a cool but viable and painless leg.
Comments The improvement in the results of repair of acute arterial injuries during the Korean conflict [3] over those of ligation during World War II 141 provided the impetus for the development of reconstructive arterial procedures for vascular trauma. In spite of rapid developments in vascular surgery, the incidence of limb loss in patients with arterial injuries associated with orthopedic trauma remains
The American Journal of Surgery
Arterial Injuries of the Legs
relatively high, as evidenced by the 31 percent rate of limb loss in our study as well as by other studies [1,5-71. This high rate is almost directly related to the failure to recognize associated vascular injury in patients with orthopedic trauma to the leg and the consequent delay in treatment. Burnett et al [6] reported that six of their seven amputations were associated with fractures. Although arterial injuries are usually obvious because of the well-known signs of ischemia associated with absent pulses, recognition of vascular injury in patients with fractures or dislocations is impaired because evidence of limb ischemia is usually attributed to vascular spasm, Actually, limb ischemia is rarely due to arterial spasm [6]; therefore arterial injury must be ruled out as the cause of limb ischemia in patients with fractures and dislocations of the leg. The arbitrary safe lag period of 6 hours used in our study and advocated by Miller and Welch [8] shows a limb loss rate of less than 10 percent in patients treated within this period versus an unacceptable 50 percent rate for patients treated more than 6 hours after injury. Similar findings have been reported by others [4,6]. While this time limit is not absolute, since the adequacy of collateral circulation may provide a longer, safer interval, it serves as a guide and an important reminder to act expediently. It should be noted that this lag period was exceeded in eight of our patients, six (75 percent) of whom underwent successful reconstruction. Similar reports of successful vascular repair after long intervals of ischemia following trauma have been reported before [7]. However, repair should not be withheld merely because an arbitrary time limit has been exceeded. In this series trifurcation and popliteal artery injuries resulted in high amputation rates (50 and 36.4 percent, respectively), which were attributed to delayed diagnosis and treatment (Table II). The high rate of limb loss in popliteal artery injury has been well recognized and is again documented in this study. Only 23.5 percent of patients with injuries above the knee required amputation, compared with 55.5 percent of those with injuries to the tibia and fibula, thus emphasizing the importance of vascular assessment in trauma to the lower leg. The fact that three vessels provide flow to the lower leg appears to impart a false sense of security when fractures of the tibia and fibula occur. Arterial spasm is frequently thought to be the cause of ischemic signs, leading to delay in diagnosis and treatment and a higher amputation rate. Burnett et al [S] made a similar observation, stating that arterial injury below the knee is generally observed until signs of hemorrhage or
Volume140,December1980
TABLE I
Types of Orthopedic InJurIes No. of Patients
Type Dislocation of the knee Open femur Closed femur Gunshot wound, femur Open tibia-fibula Closed tibia-fibula Gunshot wound, tibia-fibula Other Total
Salvage Rate
5 4 4 4 3 2 4 3
5 3 3 3 2 0 2 2
29
TABLE II
0 1 1 1 1 2 2 1
20 (69 %)
9 (31 %)
Arterlal InJuries
Artery
No. of Patients
Common femoral Superficial femoral Profunda femoris Popliteal Trifurcation Lower tibia1 Total
2 9 1 11 4 2 29
TABLE Ill
Amputation Rate
Limbs Salvaged No. % 2 7 1 7 2 1 20
77:6 63:6 50 50 69
Limbs Amputated % No. Q 2 0 4 2 1 9
ii:2 364 50 50 31
Vascular Procedures
Procedure
No. of Patients
Limm Salvyd
Saphenous vein interposition Arteriorrhaphy Femoropopliteal vein bypass Amputation Observation Ligation
16
12
4 3
Total
Limbs ;;putats$
75
4
25
2 2
50 66.7
2 1
50 33.3
2 2 2
0 2 2
...
2 0 0
...
29
20
9
31
. .. 69
... ..
ischemia appear. Our results substantiate such a statement. Because of the high rates of limb loss in patients with lower leg fractures (55.5 percent) and popliteal artery (36.4 percent) and trifurcation injuries (50 percent), we perform routine prompt arteriography in all fractures of the tibia and fibula whenever evidence of ischemia is present. Fasciotomy is not performed routinely but is seriously considered when the safe lag period of 6 hours is exceeded. In our series six of the nine patients who underwent fasciotomy (66.7 percent) were seen more
007
Wolma et al
than 6 hours after injury,
and five of them (83.3 percent) later required amputation. None of the remaining three patients who presented less than 6 hours after injury and underwent fasciotomy required amputation. Four-compartment fasciotomy is usually carried out through limited skin incisions and appears adequate if performed early in the course. Reversed saphenous vein interposition yielded the highest salvage rate in this series (75 percent), followed by femoropopliteal reversed saphenous vein bypass (66.7 percent) and arteriorrhaphy (50 percent) (Table III). Although some workers prefer vascular repair before internal or external fixation is undertaken [1,9-111, others prefer stabilization of a fracture before arterial repair [2,7,12]. Unless impending limb loss is present, we prefer stabilization of the fracture to precede vascular repair since manipulation of fractured bones after vascular reconstruction may cause further damage to the repaired vessels. The question of internal versus external fixation of fractures remains unclear. While a higher infection rate and a slight increase in the amputation rate with internal fixation has been reported by some workers [9,10,13,14], others have reported excellent results with internal fixation in civilian trauma [12,15]. We used both types of fixation successfully in our series. It appears that either type of fixation is adequate, at least in civilian trauma. In summary, arterial injuries of the leg associated with fractures and dislocations still result in a disturbingly high incidence of limb loss (31 percent), which is usually directly related to delayed diagnosis and treatment. Furthermore, the high incidence of limb loss (55.5 percent) in patients with below the knee arterial injuries associated with fractures and dislocations demands prompt recognition. Routine arteriography is recommended in all patients with below the knee fractures who exhibit the slightest signs of ischemia. Prompt fixation and prompt arterial repair with or without fasciotomy will result in a greater rate of limb salvage. Summary Twenty-nine patients with vascular injuries of the leg associated with fractures and dislocations were reviewed. The overall limb salvage rate was 69 percent and the amputation rate 31 percent. These rates are usually directly related to delay in diagnosis and treatment. Routine arteriography is recommended in all patients with the slightest signs of ischemia. Prompt diagnosis followed by prompt vascular repair and fracture fixation will result in greater limb salvage. 808
References 1. O’Donnell TF, Brewster DC, Darling RC, Veen H, Waltman AA. Arterial injuries associated with fractures and/or dislocations of the knee. J Trauma 1977; 17:775-84. 2. Sher MH. Principles in the management of arterial injuries associated with fracture/dislocations. Ann Surg 1975182: 630-4. 3. Hughes CW. Arterial repair during the Korean war. Ann Surg 1958;147:555-61. 4. De&key ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg 1946; 123:534-79. 5. Bole PV, Purdy RT, Munda FIT. Civilian arterial injuries. Ann Sung 1976;183:13-23. 6. Burnett HF, Parnell CL, Williams GD. Campbell GS. Peripheral arterial injuries-a reassessment. Ann Surg 1976;183: 701-g. 7. Kootstra G, Schipper JJ, Boontje AH, Lkasen HJ, Binnendijk B. Femoral shaft fracture with injury of the superficial femoral artery in civilian accidents. Surg Gynecol Obstet 1976; 142:399-403. 8. Miller H, Welch CS. Quantitative studies on time factors in arterial injuries. Ann Surg 1949;130:428-38. 9. Connolly J. Management of fractures associated with arterial injuries. Am J Surg 1970;120:331. 10. Connolly J, Whittaker D, Williams E. Femoral and tibia1fractures combined with injuries to the femoral or popliteal artery. J Bone Joint Surg 1971;53-A:56-8. 11. HardyJD, Raju S, Neely WA, Berry DW. Aortic and other arterial injuries. Ann Surg 1975;181:640-53. 12. Smith RF, Seilaggi E, Elliott JP. Fracture of long bones with arterial injury due to blunt trauma. Arch Surg 1969;99: 315-24. 13. Rich NM, Metz CW. Hutton JE. Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam. J Trauma 197 1; 11:464-73. 14. Rosenthal JJ, Gaspar MR, Gjerorum TC. Vascular injuries associated with fractures of the femur. Arch Surg 1975; 110: 494-9. 15. Pradhan OJ, Juanteguy JM, Wilder RJ, Michelson E. Arterial injuries of the extremities associated with fractures. Arch Surg 1972; 105:582-5.
Discussion Arlo S. Hermreck (Kansas City, KS): In general, I agree with everything the authors say, with a few exceptions. One of these exceptions is that we do not routinely perform preoperative arteriography in all patients with vascular trauma to the leg. We like to stratify the patients. If they come into the emergency room with a suspected vascular injury and have good sensation and motor function, we perform arteriography since time is not so critical. On the other hand, if a patient arrives in the emergency room with obvious leg vascular trauma and loss of motor function or sensation, we perform vascular repair immediately. I was not certain about the reason for amputation in the patients with an ischemic interval in excess of 6 hours. Did the vascular repairs fail because of vascular thrombosis, or were you just revascularizing dead extremities? We have seen a large number of nerve injuries associated with traumatic vascular injuries of the arm and leg. What have been your long-term results in these patients? Prolonged ischemia, failure of vascular repair and infection usually limit the early survival of the extremity, but nerve injuries often are the limiting factor.
The American Journal of Surgery
Arterial Injuries of the Legs
Erich W. Pollak (Kansas City, MO): Delay in the treatment of such lesions may result in irreversible ischemia and necessity for amputation. This is particularly true for vascular lesions accompanying the posterior dislocation of the knee which, according to past reports, is followed by an almost 100 percent incidence of major vascular injury. This is why we systematically explore the artery in such instances, even though once in a while we are not going to find an injury. Everett Tucker (Little Rock, AR): In the patients had arterial injuries at the popliteal level and below, was the incidence of associated venous injury? Was venous injury repaired? Was or could the amputation be related to this associated venous injury?
who what such rate
David E. Hutchison (Denver, CO): I implore the use of intraoperative arteriography when the repairs are being done. We have picked up a couple of additional injuries further down the leg when we perform arteriography on the table. I would like to ask your experience on that. Peter F. Lawrence (Salt Lake City, UT): What are your criteria for determining whether or not there is increased compartmental pressure: that is, do you use pressure measurements? Second, how do you determine in an ischemic limb whether or not the tissue is potentially viable? Fred J. Wolma (closing): to tell how much pain is due fracture has been stabilized emia. Although we are not
Volume 140, December 1990
It is very difficult sometimes to the fracture itself after the and how much is due to ischsuggesting that all patients
should undergo arteriography, certainly one should consider arteriography in these types of injuries. The patients who required amputation were those in whom intravascular thrombosis occurred because of the prolonged period from injury to definitive surgery. Many times it is easy to clean out the major arteries, but the smaller vessels and capillaries are sludged. It is very difficult to restore capillary flow in these instances because of thrombosis. If a patient presents with a dead extremity that is cold and mottled, a tight calf and complete motor loss, we would not attempt to revascularize the extremity. In our patients there were no particular definitive nerve injuries, which is surprising. In regard to patients with multiple injuries and a fracture dislocation and an ischemic limb, we always think in terms of “life before limb.” All efforts would be directed toward resuscitation of the patient, management of the more severe injuries, and then management of the fracture and the peripheral vascular injury. A few venous injuries were encountered. When the large veins are involved we try to perform veinorrhaphy if at all possible. However, below the knee, many times ligation is all that can be done. Intraoperative arteriography is employed whenever indicated. We drape in such a manner that the pedal pulses may be palpated. If they are not palpable at the time circulation is restored, arteriography is carried out. We have not routinely measured compartmental pressures. If the injury is over 6 hours old fasciotomy is done. If a patient presents with a cold and mottled extremity with a tight calf and motor and sensory loss, it is considered nonviable.
809
Fred J. Wolma, MD, Galveston, Albert0
Texas
J. Larrieu,
MD, Galveston, Texas George C. Alsop, MD, Galveston, Texas
Experience with the management of vascular injuries associated with fractures and dislocations of the leg is limited due to the infrequent combination of orthopedic and vascular injuries [1,2]. This report is based on a retrospective review of the charts of 29 patients who were seen and treated between January 1960 and July 1979 at The University of Texas Medical Branch in Galveston, Texas, for arterial injuries of the leg associated with fractures and dislocations.
Clinical Material The 29 patients in this review (26 men and 3 women) were aged 13 to 67 years (mean 28). Blunt trauma was responsible for the arterial injuries in 21 patients and gunshot woundswere responsible in 8. Sixteen patients were operated on more than 6 hours and 13 patients less than 6 hours after injury. Arteriography was performed in all patients but one. The fractures and dislocations most commonly involved are listed in Table I. Fractures of the femur, simple or compound, were the most common, occurring in 12 patients; 9 patients had tibia-fibular fractures, 5 patients dislocations of the knee, and 3 patients pelvic fractures. There were seven compound fractures. All patients had clinical signs of arterial ischemia and absence of peripheral pulses. The vessels most commonly injured were the popliteal artery (11 patients) and the superficial femoral artery (9 patients) (Table II). The vessels were either contused and thrombosed or lacerated by bone fragments or other penetrating injuries in all patients except one in whom a traumatic arteriovenous fistula developed 4 days after a motor vehicle accident. In another patient injury to a popliteal vein was repaired in association with repair of the popliteal artery injury. Vascular reconFrom the Department of Surgery, The University of Texas Medical Branch, Galveston, Texas. Requests for reprints should be addressed to Fred J. Wolma, MD. Department of Surgery, The University of Texas Medical Branch, Galveston, Texas 7’1550. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-8, 1980.
808
struction was performed in 23 patients, while primary amputation was carried out in 2 (Table III). The method of fixation was internal in 10 patients, with the use of a plating technique in 6 and intramedullary rods in 4, and external in the remaining 19 patients. Two patients (6.9 percent) died, both from associated multiple injuries. Overall, 20 limbs (69 percent) were saved, while 9 patients (31 percent) underwent amputation. Seven of the nine patients who required amputation had undergone a previous revascularizing procedure. Eight of the nine patients who underwent amputation were operated on more than 6 hours after injury (88.9 percent). Only 1 of the 13 patients operated on less than 6 hours after injury required amputation (8.33 percent), whereas 8 of the 16 patients operated on more than 6 hours after injury required amputation (50 percent). The patients with popliteal artery injuries had an amputation rate of 36.4 percent and those with trifurcation injuries a rate of 50 percent. The profunda femoris was ligated in two patients without complication; observation was carried out in two others. Only 4 of 17 patients with injuries to the knee or femur required amputation (23.5 percent), whereas 5 of 9 patients with tibia-fibula fractures required amputation (55.5 percent). Fasciotomy was performed in nine patients, six of whom presented more than 6 hours after injury. One patient who underwent internal fixation developed osteomyelitis of the femur but has retained functional use of his leg. One patient who was observed after a gunshot blast to the upper tibia-fibula region has a significant peroneal nerve injury and a cool but viable and painless leg.
Comments The improvement in the results of repair of acute arterial injuries during the Korean conflict [3] over those of ligation during World War II 141 provided the impetus for the development of reconstructive arterial procedures for vascular trauma. In spite of rapid developments in vascular surgery, the incidence of limb loss in patients with arterial injuries associated with orthopedic trauma remains
The American Journal of Surgery
Arterial Injuries of the Legs
relatively high, as evidenced by the 31 percent rate of limb loss in our study as well as by other studies [1,5-71. This high rate is almost directly related to the failure to recognize associated vascular injury in patients with orthopedic trauma to the leg and the consequent delay in treatment. Burnett et al [6] reported that six of their seven amputations were associated with fractures. Although arterial injuries are usually obvious because of the well-known signs of ischemia associated with absent pulses, recognition of vascular injury in patients with fractures or dislocations is impaired because evidence of limb ischemia is usually attributed to vascular spasm, Actually, limb ischemia is rarely due to arterial spasm [6]; therefore arterial injury must be ruled out as the cause of limb ischemia in patients with fractures and dislocations of the leg. The arbitrary safe lag period of 6 hours used in our study and advocated by Miller and Welch [8] shows a limb loss rate of less than 10 percent in patients treated within this period versus an unacceptable 50 percent rate for patients treated more than 6 hours after injury. Similar findings have been reported by others [4,6]. While this time limit is not absolute, since the adequacy of collateral circulation may provide a longer, safer interval, it serves as a guide and an important reminder to act expediently. It should be noted that this lag period was exceeded in eight of our patients, six (75 percent) of whom underwent successful reconstruction. Similar reports of successful vascular repair after long intervals of ischemia following trauma have been reported before [7]. However, repair should not be withheld merely because an arbitrary time limit has been exceeded. In this series trifurcation and popliteal artery injuries resulted in high amputation rates (50 and 36.4 percent, respectively), which were attributed to delayed diagnosis and treatment (Table II). The high rate of limb loss in popliteal artery injury has been well recognized and is again documented in this study. Only 23.5 percent of patients with injuries above the knee required amputation, compared with 55.5 percent of those with injuries to the tibia and fibula, thus emphasizing the importance of vascular assessment in trauma to the lower leg. The fact that three vessels provide flow to the lower leg appears to impart a false sense of security when fractures of the tibia and fibula occur. Arterial spasm is frequently thought to be the cause of ischemic signs, leading to delay in diagnosis and treatment and a higher amputation rate. Burnett et al [S] made a similar observation, stating that arterial injury below the knee is generally observed until signs of hemorrhage or
Volume140,December1980
TABLE I
Types of Orthopedic InJurIes No. of Patients
Type Dislocation of the knee Open femur Closed femur Gunshot wound, femur Open tibia-fibula Closed tibia-fibula Gunshot wound, tibia-fibula Other Total
Salvage Rate
5 4 4 4 3 2 4 3
5 3 3 3 2 0 2 2
29
TABLE II
0 1 1 1 1 2 2 1
20 (69 %)
9 (31 %)
Arterlal InJuries
Artery
No. of Patients
Common femoral Superficial femoral Profunda femoris Popliteal Trifurcation Lower tibia1 Total
2 9 1 11 4 2 29
TABLE Ill
Amputation Rate
Limbs Salvaged No. % 2 7 1 7 2 1 20
77:6 63:6 50 50 69
Limbs Amputated % No. Q 2 0 4 2 1 9
ii:2 364 50 50 31
Vascular Procedures
Procedure
No. of Patients
Limm Salvyd
Saphenous vein interposition Arteriorrhaphy Femoropopliteal vein bypass Amputation Observation Ligation
16
12
4 3
Total
Limbs ;;putats$
75
4
25
2 2
50 66.7
2 1
50 33.3
2 2 2
0 2 2
...
2 0 0
...
29
20
9
31
. .. 69
... ..
ischemia appear. Our results substantiate such a statement. Because of the high rates of limb loss in patients with lower leg fractures (55.5 percent) and popliteal artery (36.4 percent) and trifurcation injuries (50 percent), we perform routine prompt arteriography in all fractures of the tibia and fibula whenever evidence of ischemia is present. Fasciotomy is not performed routinely but is seriously considered when the safe lag period of 6 hours is exceeded. In our series six of the nine patients who underwent fasciotomy (66.7 percent) were seen more
007
Wolma et al
than 6 hours after injury,
and five of them (83.3 percent) later required amputation. None of the remaining three patients who presented less than 6 hours after injury and underwent fasciotomy required amputation. Four-compartment fasciotomy is usually carried out through limited skin incisions and appears adequate if performed early in the course. Reversed saphenous vein interposition yielded the highest salvage rate in this series (75 percent), followed by femoropopliteal reversed saphenous vein bypass (66.7 percent) and arteriorrhaphy (50 percent) (Table III). Although some workers prefer vascular repair before internal or external fixation is undertaken [1,9-111, others prefer stabilization of a fracture before arterial repair [2,7,12]. Unless impending limb loss is present, we prefer stabilization of the fracture to precede vascular repair since manipulation of fractured bones after vascular reconstruction may cause further damage to the repaired vessels. The question of internal versus external fixation of fractures remains unclear. While a higher infection rate and a slight increase in the amputation rate with internal fixation has been reported by some workers [9,10,13,14], others have reported excellent results with internal fixation in civilian trauma [12,15]. We used both types of fixation successfully in our series. It appears that either type of fixation is adequate, at least in civilian trauma. In summary, arterial injuries of the leg associated with fractures and dislocations still result in a disturbingly high incidence of limb loss (31 percent), which is usually directly related to delayed diagnosis and treatment. Furthermore, the high incidence of limb loss (55.5 percent) in patients with below the knee arterial injuries associated with fractures and dislocations demands prompt recognition. Routine arteriography is recommended in all patients with below the knee fractures who exhibit the slightest signs of ischemia. Prompt fixation and prompt arterial repair with or without fasciotomy will result in a greater rate of limb salvage. Summary Twenty-nine patients with vascular injuries of the leg associated with fractures and dislocations were reviewed. The overall limb salvage rate was 69 percent and the amputation rate 31 percent. These rates are usually directly related to delay in diagnosis and treatment. Routine arteriography is recommended in all patients with the slightest signs of ischemia. Prompt diagnosis followed by prompt vascular repair and fracture fixation will result in greater limb salvage. 808
References 1. O’Donnell TF, Brewster DC, Darling RC, Veen H, Waltman AA. Arterial injuries associated with fractures and/or dislocations of the knee. J Trauma 1977; 17:775-84. 2. Sher MH. Principles in the management of arterial injuries associated with fracture/dislocations. Ann Surg 1975182: 630-4. 3. Hughes CW. Arterial repair during the Korean war. Ann Surg 1958;147:555-61. 4. De&key ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg 1946; 123:534-79. 5. Bole PV, Purdy RT, Munda FIT. Civilian arterial injuries. Ann Sung 1976;183:13-23. 6. Burnett HF, Parnell CL, Williams GD. Campbell GS. Peripheral arterial injuries-a reassessment. Ann Surg 1976;183: 701-g. 7. Kootstra G, Schipper JJ, Boontje AH, Lkasen HJ, Binnendijk B. Femoral shaft fracture with injury of the superficial femoral artery in civilian accidents. Surg Gynecol Obstet 1976; 142:399-403. 8. Miller H, Welch CS. Quantitative studies on time factors in arterial injuries. Ann Surg 1949;130:428-38. 9. Connolly J. Management of fractures associated with arterial injuries. Am J Surg 1970;120:331. 10. Connolly J, Whittaker D, Williams E. Femoral and tibia1fractures combined with injuries to the femoral or popliteal artery. J Bone Joint Surg 1971;53-A:56-8. 11. HardyJD, Raju S, Neely WA, Berry DW. Aortic and other arterial injuries. Ann Surg 1975;181:640-53. 12. Smith RF, Seilaggi E, Elliott JP. Fracture of long bones with arterial injury due to blunt trauma. Arch Surg 1969;99: 315-24. 13. Rich NM, Metz CW. Hutton JE. Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam. J Trauma 197 1; 11:464-73. 14. Rosenthal JJ, Gaspar MR, Gjerorum TC. Vascular injuries associated with fractures of the femur. Arch Surg 1975; 110: 494-9. 15. Pradhan OJ, Juanteguy JM, Wilder RJ, Michelson E. Arterial injuries of the extremities associated with fractures. Arch Surg 1972; 105:582-5.
Discussion Arlo S. Hermreck (Kansas City, KS): In general, I agree with everything the authors say, with a few exceptions. One of these exceptions is that we do not routinely perform preoperative arteriography in all patients with vascular trauma to the leg. We like to stratify the patients. If they come into the emergency room with a suspected vascular injury and have good sensation and motor function, we perform arteriography since time is not so critical. On the other hand, if a patient arrives in the emergency room with obvious leg vascular trauma and loss of motor function or sensation, we perform vascular repair immediately. I was not certain about the reason for amputation in the patients with an ischemic interval in excess of 6 hours. Did the vascular repairs fail because of vascular thrombosis, or were you just revascularizing dead extremities? We have seen a large number of nerve injuries associated with traumatic vascular injuries of the arm and leg. What have been your long-term results in these patients? Prolonged ischemia, failure of vascular repair and infection usually limit the early survival of the extremity, but nerve injuries often are the limiting factor.
The American Journal of Surgery
Arterial Injuries of the Legs
Erich W. Pollak (Kansas City, MO): Delay in the treatment of such lesions may result in irreversible ischemia and necessity for amputation. This is particularly true for vascular lesions accompanying the posterior dislocation of the knee which, according to past reports, is followed by an almost 100 percent incidence of major vascular injury. This is why we systematically explore the artery in such instances, even though once in a while we are not going to find an injury. Everett Tucker (Little Rock, AR): In the patients had arterial injuries at the popliteal level and below, was the incidence of associated venous injury? Was venous injury repaired? Was or could the amputation be related to this associated venous injury?
who what such rate
David E. Hutchison (Denver, CO): I implore the use of intraoperative arteriography when the repairs are being done. We have picked up a couple of additional injuries further down the leg when we perform arteriography on the table. I would like to ask your experience on that. Peter F. Lawrence (Salt Lake City, UT): What are your criteria for determining whether or not there is increased compartmental pressure: that is, do you use pressure measurements? Second, how do you determine in an ischemic limb whether or not the tissue is potentially viable? Fred J. Wolma (closing): to tell how much pain is due fracture has been stabilized emia. Although we are not
Volume 140, December 1990
It is very difficult sometimes to the fracture itself after the and how much is due to ischsuggesting that all patients
should undergo arteriography, certainly one should consider arteriography in these types of injuries. The patients who required amputation were those in whom intravascular thrombosis occurred because of the prolonged period from injury to definitive surgery. Many times it is easy to clean out the major arteries, but the smaller vessels and capillaries are sludged. It is very difficult to restore capillary flow in these instances because of thrombosis. If a patient presents with a dead extremity that is cold and mottled, a tight calf and complete motor loss, we would not attempt to revascularize the extremity. In our patients there were no particular definitive nerve injuries, which is surprising. In regard to patients with multiple injuries and a fracture dislocation and an ischemic limb, we always think in terms of “life before limb.” All efforts would be directed toward resuscitation of the patient, management of the more severe injuries, and then management of the fracture and the peripheral vascular injury. A few venous injuries were encountered. When the large veins are involved we try to perform veinorrhaphy if at all possible. However, below the knee, many times ligation is all that can be done. Intraoperative arteriography is employed whenever indicated. We drape in such a manner that the pedal pulses may be palpated. If they are not palpable at the time circulation is restored, arteriography is carried out. We have not routinely measured compartmental pressures. If the injury is over 6 hours old fasciotomy is done. If a patient presents with a cold and mottled extremity with a tight calf and motor and sensory loss, it is considered nonviable.
809