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Extremity vascular trauma in civilian population: A 7-year review from North India
Injury, Int. J. Care Injured (2006) 37, 295—298
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LETTER TO THE EDITOR Extremity vascular trauma in civilian population: A 7-year review from North India Dear Sir, I read with interest the article in the March 2005 issue entitled ‘‘Extremity vascular trauma in civilian population: a 7-year review from North India’’ by Menakuru et al.3 The issue was evaluated very well, however, I think that there is still need for additional knowledge about the diagnosis of the vascular injury and which one is the priority for repair: vascular or orthopaedic. Firstly, the authors report that fracture fixation preceded arterial repair in all cases, however, temporary shunts were used to decrease ischaemia time in patients who had a critically ischaemic limb. Vascular repair should be carried out before bone stabilisation in order to decrease duration of ischaemia. However, skeletal fixation first helps during vascular repair in cases with no severe ischaemia and who are admitted promptly. Temporary arterial shunts, also, can be inserted during bone stabilisation in cases with a critically ischaemic limb.5 We prefer to do primary, vascular repair as a priority in stable fractures. We assess damage to the vascular structures after bone fixation, but with an unstable bone fracture, we perform bone fixation prior to vascular repair. In tibial artery injuries, bone fixation was usually performed before vascular repair because of unstable fractures. We did not use temporary shunts in any of our cases.1,4 Furthermore, we have a different approach to the indication and methods for angiography. For the upper limb injuries, we broaden the indication for angiography since the excellent collateral circulation around the shoulder and elbow can often maintain pulses and a good Doppler flow. In upper limb fractures, we perform conventional angiography. For lower limb injuries, classical angiography leads to 1—2 h of wasted time and may aggravate the severity of ischaemia. We performed pre-operative angiography by femoral puncture in the emergency room.1,2,4
References 1. Cakir O, Subasi M, Erdem K, Eren N. Treatment of vascular injuries associated with limb fractures. Ann R Coll Surg Engl 2005;87:348—52. 2. Hirshberg A, Mattox KL. Vascular trauma. In: Asher E, editor. Haimovici’s vascular surgery. Massachusetts: Blackwell Science; 2004. p. 421—37. 3. Menakuru SR, Behera A, Jindal R, et al. Extremity vascular trauma in civilian population: a 7-year review from North India. Injury 2005;36:400—6. 4. Subasi M, Cakir O, Kesemenli C, et al. Popliteal artery injuries associated with fractures and dislocations about the knee. Acta Orthop Belg 2001;67:259—66. 5. Winkelaar GB, Taylor DC. Vascular trauma associated with fractures and dislocations. Semin Vasc Surg 1998;11:261—73.
Mehmet Subasi* Department of Orthopaedics and Trauma, Faculty of Medicine, Dicle University, Diyarbakir, Turkey Omer Cakir Department of Cardiovascular Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey *Corresponding author. Tel.: +90 412 2488111 fax: +90 412 2488111 E-mail address: [email protected] (M. Subasi) doi:10.1016/j.injury.2005.10.034
REPLY TO LETTER TO THE EDITOR Extremity vascular trauma in civilian population: a seven year review from North India [Injury 2005 (36) 400—6] Sir, We thank Drs. Subasi and Cakir for the comments. In response to their query regarding the priority of DOI of original article: 10.1016/j.injury.2005.10.034.
0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.
www.elsevier.com/locate/injury
LETTER TO THE EDITOR Extremity vascular trauma in civilian population: A 7-year review from North India Dear Sir, I read with interest the article in the March 2005 issue entitled ‘‘Extremity vascular trauma in civilian population: a 7-year review from North India’’ by Menakuru et al.3 The issue was evaluated very well, however, I think that there is still need for additional knowledge about the diagnosis of the vascular injury and which one is the priority for repair: vascular or orthopaedic. Firstly, the authors report that fracture fixation preceded arterial repair in all cases, however, temporary shunts were used to decrease ischaemia time in patients who had a critically ischaemic limb. Vascular repair should be carried out before bone stabilisation in order to decrease duration of ischaemia. However, skeletal fixation first helps during vascular repair in cases with no severe ischaemia and who are admitted promptly. Temporary arterial shunts, also, can be inserted during bone stabilisation in cases with a critically ischaemic limb.5 We prefer to do primary, vascular repair as a priority in stable fractures. We assess damage to the vascular structures after bone fixation, but with an unstable bone fracture, we perform bone fixation prior to vascular repair. In tibial artery injuries, bone fixation was usually performed before vascular repair because of unstable fractures. We did not use temporary shunts in any of our cases.1,4 Furthermore, we have a different approach to the indication and methods for angiography. For the upper limb injuries, we broaden the indication for angiography since the excellent collateral circulation around the shoulder and elbow can often maintain pulses and a good Doppler flow. In upper limb fractures, we perform conventional angiography. For lower limb injuries, classical angiography leads to 1—2 h of wasted time and may aggravate the severity of ischaemia. We performed pre-operative angiography by femoral puncture in the emergency room.1,2,4
References 1. Cakir O, Subasi M, Erdem K, Eren N. Treatment of vascular injuries associated with limb fractures. Ann R Coll Surg Engl 2005;87:348—52. 2. Hirshberg A, Mattox KL. Vascular trauma. In: Asher E, editor. Haimovici’s vascular surgery. Massachusetts: Blackwell Science; 2004. p. 421—37. 3. Menakuru SR, Behera A, Jindal R, et al. Extremity vascular trauma in civilian population: a 7-year review from North India. Injury 2005;36:400—6. 4. Subasi M, Cakir O, Kesemenli C, et al. Popliteal artery injuries associated with fractures and dislocations about the knee. Acta Orthop Belg 2001;67:259—66. 5. Winkelaar GB, Taylor DC. Vascular trauma associated with fractures and dislocations. Semin Vasc Surg 1998;11:261—73.
Mehmet Subasi* Department of Orthopaedics and Trauma, Faculty of Medicine, Dicle University, Diyarbakir, Turkey Omer Cakir Department of Cardiovascular Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey *Corresponding author. Tel.: +90 412 2488111 fax: +90 412 2488111 E-mail address: [email protected] (M. Subasi) doi:10.1016/j.injury.2005.10.034
REPLY TO LETTER TO THE EDITOR Extremity vascular trauma in civilian population: a seven year review from North India [Injury 2005 (36) 400—6] Sir, We thank Drs. Subasi and Cakir for the comments. In response to their query regarding the priority of DOI of original article: 10.1016/j.injury.2005.10.034.
0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.