Missile-induced vascular trauma

Injury, 12, 13-30

13

Prinfedin Great Britain

Missile-induced

vascular trauma

Aires A. B. Barros D’Sa, Thomas H. Hassard, Reginald H. Livingston and J. W. Sinclair Irwin Roval Victoria Howital, Belfast, and Department Medicine, The QueenS University of Belfasi Summary

During seven and a half years of serious hostilities amidst the civilian population of Northern Ireland, a wide variety of vascular injuries inflicted by low and high velocity missiles and bomb explosions were observed. One hundred and thirteen patients, 96.5 per cent males of average age 26.8 years, sustained 191 vascular injuries and were treated at the Royal Victoria Hospital. Treatment commenced within one hour in 87 per cent of patients. Reduced limb ischaemia time, early bleeding control and vascular repair with restoration of flow within 6 hours of injury in 94.4 per cent of patients contributed to an excellent result in 85.5 per cent of survivors. Despite rapid admission, the mortality rate within 3 days of injury was 12.4 per cent, these patients sustaining trauma to major vessel trunks and vital organs. Associated nerve injuries (25 per cent) and skeletal injuries (30 per cent) were treated appropriately. A special group of 38 patients were ‘knee-capping’ victims and contributed to the majority of popliteal vessel trauma. A total of 14.9 per cent of primary arterial and 3 per cent of primary venous reconstructions failed due to thrombotic occlusion, but early postoperative revision was successful in every case. The overall amputation rate for lower limb injuries was 6.9 per cent; of these 5 cases, 4 had popliteal vessel injuries, in 2 of which infection (acute clostridial and chronic osteomyelitis) was partly responsible. Significant wound infection was otherwise absent. The pathophysiological aspects pertinent to the range of weaponry and methods of assault are presented. The operative and postoperative management and results are discussed in the light of documented military and civilian experience. INTRODUCTION SIGNIFICANT advances in the treatment

of vascular injuries, as in other fields, have been made in wartime. Vascular experience gained in World War I was followed by some recommendations

of Medical

Statistics,

Faculty of

which stimulated controversy (Makins, 19 19; Matas, 192 l), but the major report from World War II (De Bakey and Simeone, 1946) showed that the results of arterial repair were better than those of ligation. The currently accepted principles and surgical techniques used in the management of acute vascular trauma are largely attributable to military expertise developed in the past 35 years (De Bakey and Simeone, 1946; Jahnke and Seeley, 1953; Hughes, 1958, 1971; Chandler and Knapp, 1967; Gorman, 1968; Cohen et al., 1969; Rich and Hughes, 1969; Rich, Baugh et al., 1969; Rich, Manion et al., 1969; Rich et al., 1970, 1971; Rich and Sullivan, 1972; Rich, Jarstfer et al., 1974; Rich, Hobson et al., 1974; Rich et al., 1975). In the Korean War, vein grafts were used to repair large defects in injured arteries (Jahnke and Seeley, 1953; Hughes, 1954; Spencer and Grewe, 1955) with encouraging results and a significant fall in the amputation rate (Hughes, 1958). Newly learned concepts were extended to civilian practice and contributed greatly to the measure of success achieved as witnessed by several large series (Morris et al., 1960; Patman et al., 1964; Morton et al., 1966; Trieman et al., 1966; Dillard et al., 1968). The Vietnam Vascular Registry established in 1966 at the Walter Reed General Hospital, Washington, to document and analyse vascular injuries proved of immense value in early treatment (Chandler and Knapp, 1967; Gorman, 1968; Cohen et al., 1969; Hewitt and Collins, 1969; Hewitt et al., 1969, 1973; Rich and Hughes, 1969; Rich, Baugh et al., 1969; Rich, Manion et al., 1969; Rich et al., 1970, 1971; Hughes, 1971; McNamara et al., 1973; Rich, Jarstfer et al.,

14

Injury: the British Journal of Accident Surgery Vol. 1~/NO. 1

1974; Rich, Hobson et al., 1974; Rich et al., 1975). Improvements were attributable to two main factors: first, the reduction in the time lag between injury and treatment due to almost routine evacuation by helicopter; secondly, the availability of surgeons experienced in vascular reconstruction. An awareness of the extensive vascular trauma caused by high velocity missiles and of tension at the arterial repair site led to the use of autogenous vein grafts far outnumbering other methods of repair in military and civilian practice (Hewitt et al., 1969; Rich, Manion et al., 1969; Drapanas et al., 1970) with rewarding results. Missle-induced vascular trauma is not relevant to the civilian surgeon working in cities, especially in countries such as the United States. Internecine strife and urban guerilla warfare have become increasingly prevalent around the globe, the participators having access to an arsenal of advanced weaponry and the ability to construct hideously destructive explosive devices. This paper reviews and discusses the special character of missile-induced vascular trauma encountered during civil hostilities in Northern Ireland in the light of previous literature.

Tab/e /. Incidence of vascular injuries related to type of missile

PATIENTS AND METHODS Preoperative data

The patients described were admitted to the Royal Victoria Hospital, Belfast, over a period of seven and a half years (August 1969 to February 1977). Most injuries occurred in the Belfast area, but some were transferred from other hospitals in Northern Ireland. The series included 113 patients, 109 of whom (96.5 per cent) were males. The average age was 26.8 years (range 9-63 years). A total of 45 per cent of these patients were injured during the four summer months from May to August. Deaths from vascular injury before admission are not included. Eight patients had each sustained bomb or bullet injuries on one previous occasion, and one patient was injured again after the period covered in this paper. Although the circumstances are varied, the wounding agents responsible have been of three main types, i.e. low velocity bullets, high velocity bullets and fragments from explosive devices, each producing a characteristic vascular injury. The incidence in each case is shown in Table I.

The leading cause is a low velocity missile from a hand gun and sometimes from a machine gun. This includes ‘knee-cappings’, a loose

Wounding missile

Patients no. %

Bullet Low velocity High velocity Uncertain velocity Fragments from explosions Total

48 28 22 15 113

42.5 24.8 19.5 13.2

popular term describing a form of punishment meted out by paramilitary organizations in which a hand gun of low velocity is usually fired one or more times behind the knee. Vascular injuries were associated with damage to other regions of the body as follows: head and neck 5.3 per cent, thorax 6.2 per cent, abdomen 25.7 per cent and limbs 20.4 per cent. A majority of the head, neck and trunk injuries were inflicted by high velocity weapons, machine guns and bomb explosions, while most lower limb injuries were caused by low velocity weapons. The missiles responsible for popliteal artery and vein injuries in 52 patients (46 per cent) were as follows: low velocity bullets 38, high velocity bullets 7 and explosive fragments 7. The estimated time from injury to admission was as follows: 41 per cent arrived in less than 15 minutes (occasionally within 5 minutes), 72 per cent within 30 minutes and 87 per cent before 1 hour had elapsed. In 9 per cent of patients this interval could not be established. The history was sometimes limited by the patient’s condition or his reluctance to divulge details. The time of injury, type of weapon and a rough estimate of blood lost were usually deduced. The systolic blood pressure was over 120 mmHg in 22.1 per cent of cases, 10 l-l 20 in 2 1.3 per cent, 80-100 in 30.9 per cent, measureable at less than 80 in 14.2 per cent and unrecordable in 11.5 per cent of patients. Early management

A brisk clinical examination was done to locate bleeding internally or from the limbs. Observations made included bleeding: arterial, venous or mixed; haematoma: pulsatile, expanding; thrill or audible bruit; pedal pulses; distal limb pallor, ischaemia, oedema, tenderness; neurological deficit.

Barros D’Sa et al.: Missile-induced

Vascular Trauma

Standard but energetic resuscitatory measures were implemented in the treatment of bleeding and shock. Tracheal intubation was performed after vascular injuries in the head, neck and chest. Pad and pressure bandages were usually adequate to control bleeding from limb vessels, but when ineffectual, a vascular clamp, in preference to a haemostat, ought to be used. Blood, usually warmed and microfiltered, was transfused using group 0 Rhesus negative in emergencies, in addition to clear solutions (mainly Hartmann’s solution). Plasma substitutes and expanders were administered only in cases of shock. Prophylactic tetanus toxoid and a broadspectrum antibiotic were given. Narcotic analgesics were administered on arrival as they decrease vasospasm and are useful as an anaesthetic premeditation. Nasogastric intubation was almost routine. Plain radiographs were used to locate bony injury and foreign bodies, unless patients were shocked or had suffered a grave injury requiring urgent operation. Emergency angiography was used on five occasions, in all cases for popliteal vascular injury. In three of these patients, pedal pulses were present: two had injured both artery and vein and one the artery only. The two remaining patients were admitted from distant hospitals 46 and 72 hours after injury. When a life-endangering injury was not vascular, a limb-threatening vascular injury did not receive first priority.

15

damaged intima or a raised flap. Classic methods of repair were employed for both arteries and veins. Direct anastomosis was sometimes feasible for complete severance of vessels. In most instances, the gap was bridged by a vein graft either in its original form or fabricated into a panel or compilation graft of satisfactory calibre, (Earle et al., 1960; Livingston and Wilson, 1975). Prostheses were used only when absolutely necessary. Prolene was the suture material usually employed. The vessels were covered by neighbouring tissues. When indicated, fasciotomy of the leg was performed by an extension of a popliteal wound down the posterior compartment and subcutaneously through small skin incisions over unexplored compartments. The adjacent nerves were inspected carefully: injuries were documented in terms of contusion and varying degrees of neurotmesis. Internal fixation of fractures caused by high velocity missiles was avoided except in the case of one case of fractured neck of the femur. External fixation either by split plaster casts or temporary skeletal traction was employed. To facilitate early mobilization and discharge, a quadrilateral, ischial-bearing long-leg plaster cast was used for femoral fractures, and a patellar tendon-bearing walking short-leg plaster cast was employed for tibia1 fractures. Haemarthroses of the knee joint were aspirated. Operative

Operative

management

Each wound was treated on its own merits. Wide exploration and thorough wound toilet were considered imperative, especially when the agent was a high velocity bullet. In low velocity popliteal injuries particularly, toilet was limited so as to retain enough skin and tissue to cover nerves and vessels after repair. The incision, often made with some urgency, was usually extended from the excised entry or exit wound and modified according to conventional operative approaches. Devitalized muscle was meticulously trimmed back to where it bled. Where possible, wounds were carefully explored and all foreign bodies and free bony fragments were removed. The wound was copiously irrigated and allowed to drain freely. Vessels were controlled proximally and distally by vascular clamps. Distal thrombectomy by Fogarty balloon was attempted, and local or systemic heparinization undertaken. As a rule, the ends of a transected vessel or the edges of a lacerated vessel were trimmed to remove

data

By the end of the operation a mean of 3.3 1 (range 0.5-9.5 1) of blood had been used and a mean of 2.1 1(range 0.5-7 1)of other liquids. Fifty-two entry wounds, some with a circular burn or powder mark, were located around the knees and only 35 exit wounds were found. In the series of alleged ‘knee-cappings’, the right knee was involved twice as often as the left. In 12 patients both knees were shot, one of which had a vessel injured. The majority (76 per cent) of the entry wounds were clearly posterolateral, and twice as often above as below the popliteal crease. Correspondingly, 70 per cent of the exit wounds were anteromedial. Table II shows the number of patients who sustained injuries of arteries alone, of veins alone or of both vessels. Injuries of small vessels in abdominal and other areas are not considered. Several patients suffered injuries of two or more vessels, making a total number of 19 1. Fig. 1 illustrates the distribution of vessels involved in the arterial and venous groups respectively. The preponderance of lower limb

16

Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 1

Table //, Distribution of patients suffering injuries to arteries or veins or both vessels

Table /I, Type and incidence of presenting vascular injury

Patients Vessels injured

Arteries only Veins only Arteries and veins concomitantly Total

%

24 30

21.2 26.6 52.2

59

Artery

Type of injury

no.

113

Complete severance Defect in vessel wall Laceration Contusion Thrombosis in continuity Arteriovenous fistula Total

51 23 13 2 2 1 92

Vein

31 29 37 -

1 1 99

92

VENOUS

ARTERIAL

Fig. I. Distribution

and extent of arterial and venous trauma.

injuries (63 per cent of all arterial injuries, 59.6 per cent of all venous injuries) is evident. Table III shows the type and incidence of the presenting vascular injury. Exploration was performed with a Fogarty balloon catheter in 33 cases but rarely extracted thrombus, except in late arrivals with poor back bleeding. The distal bed in the leg was infused with heparinized saline in 60 per cent of injuries; in 23 per cent of cases systemic heparin was given. Methods of repair are shown in Table I Y. In 31 cases, the long saphenous vein was taken from the opposite leg and in 20 cases from the same limb at various sites. The donor segment was from the long saphenous vein just above the ankle. Table V shows the methods by which

popliteal vascular injuries were treated. (Injuries to anterior and posterior tibia1 veins and the posterior tibia1 artery were managed by ligation, while two injuries to the anterior tibia1 artery were repaired respectively by lateral suture and by direct anastomosis.) In the leg, subcutaneous and, when skin was still tight, transcutaneous fasciotomy accompanied re-exploration on the of which were for injuries of the popliteal artery, its main branches or the popliteal vein. Eleven one-, 4 two- and 12 three-compartment fasciotomies were performed. In 2 patients delayed fasciotomy accompanied re-exploration on the first and third postoperative days. Vacuum drainage was used in 24 per cent of cases, all but one of which involved lower limb injury. Six

17

Barros D’Sa et al.: Missile-induced Vascular Trauma

Table IV. Technique and incidence of primary repair of vascular injury Technique of repair

Artery

Vein

Lateral suture Vein patch angioplasty End-to-end anastomosis Interposition vein graft Interposition compilation graft Interposition Dacron tube graft Thrombectomy only Flow re-established Ligation Nil (patient succumbed before repair accomplished) Total

:3

38

78 25 12 2

10 3 7 8 -

Tab/e V. Popliteal technique of repair

vessel

injuries: incidence

Technique of repair Lateral suture Vein patch angioplasty End-to-end anastomosis Interposition vein graft Interposition compilation graft Ligation Total

-

1 67 (72.8 %)

and

Artery

Vein

3 5 2 12 8 2 32

13 5 3 : 334

patients died before vascular repair could be completed. Control of bleeding and/or restoration of blood flow was accomplished in the remaining 107 patients, and the median time taken from injury to this point was 3.8 hours. Table VI shows the number of cases in which circulation was restored with each successive hour from injury. Nerve injury accompanied vascular injury in approximately 25 per cent of patients. Apart from one spinal cord injury, Table VII shows the 28 nerves involved. The ratio of injuries caused by low and high velocity bullets and bomb fragments was 15 : 7 : 3 respectively. Seventy per cent of nerve injuries were in the lower limb, and 65 per cent of these followed ‘knee-cappings’. Wounds producing vascular damage were associated with 35 fractures in 34 patients (30 per cent) (Table VIII). Low velocity bullets caused cortical damage, undisplaced or slightly displaced fractures just above and below the knee joint in 17 patients (50 per cent), 13 of

67 (67.7 96)

22

25

3 92

7 99

these being right-sided. In the ‘knee-cappings’ 2 patellas were damaged. Thirty per cent of the 52 patients with popliteal vascular injuries had accompanying fractures with 8 tense haemarthroses. High velocity weapons produced shattering of the femoral shaft, the spine and scapulas and were invariably associated with extensive destruction of vessels. Of the 2 patients with spinal injury, one had associated injury of the cord and died shortly after repair of the aorta, lungs and abdominal viscera, while the other died at laparotomy due to exsanguination from an aorta torn above the renal arteries. In this series fractures were not caused by bomb explosions. Postoperative

management

with multiple injuries were treated in intensive care units. Legs were kept horizontal and at room temperature. In those with venous injuries (22 per cent) the lower limb was elevated. After vascular repair in the lower limb, active movement of hip and knee joints was often omitted for 72 hours, after which graduated physiotherapy began. Postoperative anticoagulation with heparin was avoided if widespread injury had occurred. When given, the dose was 5000 units subcutaneously thrice daily for about 10 days. If all was well 5-7 days after injury, wounds were closed by delayed primary suture (35 cases) or split skin grafting (17 cases). Nerve injuries were evaluated clinically by serial conduction studies. The mean time in hospital was 23 days f 3 (25 s.e.m.). In all, 14 per cent of surviving patients were serving soldiers who were transferred from the Royal Victoria Hospital for follow-up in hospitals throughout the United Kingdom. Patients

18

Injury: the British Journal of Accident Surgery Vol. 1 Z/No.

Tab/e V/, Speed of revascularization who survived repair Time of injury to vascular repair (hr) 1 2 3 4 5 6 7-80

in the 107

patients

Tab/e VU. List of nerve injuries associated with vascular trauma Nerves

Vascular repair effected In specified time By specified time No. % No. % 4 15 26 36 12 8 6

3.7 14.0 24.4 33.7 1 I.2 7.4 5.6

4 1: 81 93 101 107

1

Brachial plexus Median Ulnar Sciatic Internal popliteal External popliteal Sural Anterior tibia1 Posterior tibia1 Total

3.7 17.7 42.1 75.8 87.0 94.4 100.0

No. 3 3 1 6 8 3 2 1 1 28

Tab/e V/M List of skeletal injuries associated with vascular trauma

Bone fractured

Incidence related to missile Low High Bomb velocity velocity fragment

Spine Scapula Ulna Pelvis Femur Neck Shaft Condyle and supracondylar region Patella Tibia, condyle and upper shaft Fibula Total

Results and late management

Of the 16 patients (14 per cent) who died, 14 (12-4 per cent) did so within 3 days. Table IX analyses these cases. Six patients with injury of major vascular trunks and critical organs died despite rapid resuscitatory and operative treatment. Eight survived operation but died within 3 days from non-vascular causes. Two later deaths at 24 and 84 days were due to complications of the initial injury. Thrombosis at the site of reconstruction in IO popliteal arteries and 2 popliteal veins necessitated re-exploration involving Fogarty balloon thrombectomy and distal heparin infusion. It was not clear why this complication had occurred within vein grafts, 7 of which were in arteries and 2 in veins. Specific causes were recognizable, however, in some arterial reconstructions: one vein graft was too long and

1 2 -

1

9 2 5 1 21

2 2 1 3

-

3

-

3

-

-

-

1

‘-

1 10

Total

1 4

2 2 4

9 2 7 4 35

worked well after it was shortened; another, which was too narrow, was revised successfully; in another, inadequately excised damaged intima was trimmed and a fresh vein graft functioned well. Two patients, each with thrombosed vein grafts of the popliteal artery and vein in one leg, were treated successfully, in one case by replacement with compilation grafts and in the other by simple thrombectomy of the two vessels. Two vein patch angioplasties of arteries thrombosed: one was revised and the other was replaced by an interposition vein graft. One artery repaired by end-to-end anastomosis, which thrombosed due to insufficient initial trimming, re-thrombosed after vein graft replacement and required a third operation to restore flow. A total of 14.9 per cent (10 out of 67) of all primary arterial and 3 per cent (2 out of 67) of all primary vein reconstructions

Barros D’Sa et al.: Missile-induced Vascular Trauma

19

Table/X. Analysis of mortality

No.

Missile causing injury

Additional regions of organ injury

Vessels injured

Timing and circums tances of death

?LV HV HV (multiple) ?HV

5

LV

6

LV

7

HV

8

HV

9

HV

10

?LV

11

?LV

12

Abdominal aorta, inferior vena cava Common iliac artery and vein Brachial artery and basilic vein Common carotid and vertebral arteries, internal jugular vein Inferior vena cava Inferior vena cava, both renal veins Abdominal aorta, inferior mesenteric artery Splenic artery and vein

Thorax, abdomen Abdomen

On table before control established

-

Head, abdomen, leg Head, neck, thorax

In 3 days due to severe head injury In 1 day, due to complications of head and neck injuries

Abdomen, pelvis, thigh Abdomen

During resuscitation

Abdomen Abdomen

Abdomen, spinal cord

HV

Abdominal aorta, inferior vena cava, common iliac vein, inferior mesenteric vein Common and external iliac arteries, both internal iliac arteries and veins Abdominal aorta, renal artery Inferior vena cava

Thorax, abdomen

13

LV

Abdominal aorta

Abdomen

14

HV

Head

15

HV

Common femoral artery and vein Thoracic aorta

16

BE

Radial artery

Abdomen

Thorax, abdomen

Thorax

Thorax, abdomen, limbs

On table during repair In 1 day with persistent hypotension In 24 days due to traumatic pancreatitis and secondary haemorrhage 1 hour postoperatively

84 days later and 5 days after reoperation for obstruction and pelvic abscess In 2 days with persistent bleeding On table. Liver and spleen shattered and cava perforated over 15 cm length On table. Pupils dilated on arrival In 3 days due to complications of head injury Within 24 hours postoperatively. Pupils dilated on arrival. Resuscitated and operated In 3 days due to respiratory, renal and circulaton/failure

LV, low velocity missile; HV, high velocity missile; BE, bomb explosion.

early revision for occlusion. One popliteal wound was re-explored for bleeding and a 2-cm laceration, missed due to insufficient exposure, was patched with vein. Some patients with injured popliteal vessels required additional operations: fasciotomies (4), excision of dead muscle in the lower leg (2) removal of a bullet (1) drainage of haematomas (2) and several operations for associated fractures. Re-operation was necessary for secondary required

haemorrhage associated with traumatic pancreatitis following splenectomy for splenic arterial injury. Repair of a left renal vein and ligation of an artery to the lower pole of the left kidney was complicated by drainage of an abscess that led eventually to nephrectomy. Two patients with serious infections, one acute and one chronic, required amputation. Otherwise, infection in a few patients was at worst non-specific, with pyrexia, erythematous

Right common, external and internal iliac veins ligated; right external iliac vein contused and in spasm -left alone

Interposition vein graft to left superficial femoral artery; left superficial femoral vein ligated

Interposition vein graft right popliteal artery; lateral suture popliteal vein

3

15

18

Claudication right calf; swollen lower leg; no pedal pulses; popliteal bruit

Claudication left leg; no pulses below left femoral

Claudication right thigh downwards; swollen right lower limb and vein engorgement; weak pulses; bruit in right inguinal area

-

14

Left subclavian arteriogram

Bleeding sinus left axilla; swelling and vein engorgement left arm; bruit distal left infraclavicular area

Interposition vein grafts to axillary artery and vein

Right femoral arteriogram; right femoral venogram

Left femoral arteriogram; left femoral venogram

Right femoral venogram; right femoral arteriogram

Left subclavian arteriogram; left subclavian venogram

Radiological studies

Clinical presentation

Initial surgical treatment

Weakness and claudication left arm; thrill and bruit over distal left infraclavicular area

3

Interval after injury (months)

TableX. Diagnostic angiography in 5 cases with late complications

Arteriovenous fistula of right popliteal artery and vein

Occluded artery at site of repair; normal

Severely impaired venous drainage, occurring only slowly via internal iliac vein to left side; false aneurysm right external iliac artery

False aneurysm of axillary artery with fistula into axillary vein

False aneurysm arising from proximal arterial graft anastomosis compressing axillary vein with a cutaneous fistula

Findings

Interposition vein graft to popliteal artery; lateral suture of vein

Resection of occluded segment and replacement by interposition compilation vein graft

Details unavailable

Fistulous aneurysmal segment of artery excised and end-toend anastomosis performed; lateral suture of vein

Resection of false aneurysm and sinus and arterial repair

Management

21

Barros D’Sa et al.: Missile-induced Vascular Trauma Tab/e XL General assessment of results in terms of vascular injuries alone in 97 surviving patients Quality of result Good to excellent Fair with mild limitations Fair with moderate limitations Amputations

No.

%

83 4 5 5

85.5 4.1 5.2 5.2

wound margins and at times seropurulent exudate which cleared as wounds were left open. The infection was self-limiting, without any intervening stage of toxaemia or septicaemia. Amputations, 3 above-knee and 2 belowknee, were performed in 5 out of 73 lower limbs. In 3 cases the wounding agents were bomb, rocket and high velocity missile. One patient received a popliteal arterial injury and 4 sustained direct injury of both main artery and vein of the limb concerned (1 femoral, 3 popliteal). One patient died from his head injury. The amputation rate was 6.9 per cent for all lower limb vascular injuries, and 7.7 per cent for popliteal vascular injuries. The case histories describing the circumstances leading to amputation are instructive and have been documented (Barros D’Sa, 1980). In ensuing months, 5 patients complaining of chronic symptoms related to their vascular injuries were submitted to diagnostic angiography (arteriography and phlebography). The radiological and clinical signs and management in each case are summarized in Table X. One false aneurysm of the thoracic aorta was diagnosed within a week. Of 3 arteriovenous Iistulas, 2 involved axillary vessels, each with a false aneurysm, and 1 involved popliteal vessels. A false aneurysm developed in an external iliac artery, which was contused but left alone at primary operation. Claudication occurred in 4 patients. An objective assessment, purely from a vascular standpoint, of the general quality of the results of operation in the patients who survived can be graded in the manner shown in Table XI. Mild handicaps in lower limb injuries include a slight limp and chronic mild oedema; while moderate handicaps include claudication, ischaemic contracture, wasting, marked limp and sustained severe oedema. The 16 patients who died are not included in Table XI. DISCUSSION

The

outbreak

of

serious

hostilities

within

Northern Ireland in August 1969 has been accorded euphemistic labels such as ‘disturbances’, ‘disorder’ and ‘unrest’, but the scale of damage inflicted mainly on urban populations, especially of Belfast, has often borne a closer resemblance to sporadic warfare or the battlefield itself. The characteristics of vascular injury described in civilian series (Morris et al., 1960; Patman et al., 1964; Morton et al., 1966; Trieman et al., 1966; Dillard et al., 1968; Lozman et al., 1978) were not observed here. The civilian surgeon is confronted with injuries of a ‘front line’ military nature inflicted by high velocity and automatic weapons, rockets, land mines and massive bomb explosions. Tile Royal Victoria Hospital has received most of the injured and during the period covered here 400 patients came in dead, 3000 were admitted and 5000 were treated and sent home. The Royal Victoria Hospital is the main university teaching hospital with a wellequipped and staffed accident and emergency department and intensive care units, and provides a constantly available surgical team specializing in a full range of disciplines. It has adapted itself to treat large numbers of casualties arriving simultaneously. Well-tried disaster plans have been practised successfully (Rutherford, 1975). The closeness of the Royal Victoria Hospital to an area of endemic hostility, and the helicopter transport of the few casualties from further afield, have significantly shortened the time between injury and treatment. This compares well with figures quoted from the Korean and Vietnam wars and civilian series (Drapanas et al., 1970; Hughes, 1971) contributing favourably to the outcome of vascular injuries treated. The seriously injured who might otherwise have perished were often admitted alive. Pathophysiological

considerations

Bullets of all velocities were responsible for vascular injury in 86.8 per cent of patients. The wounding force of high and low velocity missiles varies and is related to their mass and the distance travelled by them (Rich, 1968; De Muth, 1969; Amato et al., 1970; Getzen et al., 1972). A low velocity (500-800 ft/sec) missile usually only disrupts and deforms a vessel in its path (Harvey et al., 1945; Amato et al., 1970, 197 l), but when it has slowed down it may be deflected, underlining the necessity for careful exploration. A high velocity (2000-3000 fi/sec) missile penetrates the arterial wall sharply without

22

stretching it (Amato et al., 1970, 1971). The formation and decay of the temporary cavity (Harvey et al., 1945), the physical aspects of which have been well studied (Krauss, 1957; Hopkinson and Marshall, 1967; Amato et al., 197 l), crushes, stretches and tears vessels which may or may not be directly in the path of the missile (Jahnke and Seeley, 1953; Hughes, 197 1; Ayres and Winspur, 1976). External appearance of the artery may belie intimal damage (Rich and Hughes, 1969). Histologically this appears as endothelial loss, microthrombus formation, breaks in the elastic membrane, haemorrhage and acute inflammation of the media and adventitia with occasional disruption of the external elastic layer (Amato et al., 197 1). Thrombosis is said to be initiated by turbulence and altered electrical polarity af the damaged intima (Sauvage and Wood, 1963). Gross contamination by air, clothing, dirt and debris increases chances of infection and gas gangrene (Hughes, 197 1). The use of synthetic grafts and scanty tissue cover in these cases increases the danger of infection and failure (Jahnke and Howard, 1953; Hughes, 1954, 1971). Bombs, responsible for vascular injury in 13.2 per cent of patients, have been either smallcharge anti-personnel bombs and mines or the notorious massive-charge car bombs and the kind used to blow up buildings. The latter cause extensive destruction of body tissues: directly, from the blast wave which spreads initially faster than the speed of sound, and indirectly, from falling masonry and secondary missiles, as witnessed in World War II as well as in Korea and Vietnam. ‘Knee-capping’

Injuries to the lower femoral and popliteal arteries, peculiar to the conflict here, deserve special mention. ‘Knee-capping’ injuries inflicted by low velocity weapons such as hand guns have paradoxically involved the knee-cap in only 2 instances. A few inferences may be drawn from their clinical presentation. As expected, the assailant seems to have been right-handed, usually standing behind the victim at close range. The nature and position of the entry wound suggest that the assailant’s position was a little lateral to either knee, and that the weapon was often held against the skin above the popliteal crease, thus accounting for more fractures of the lower femur than of the upper tibia and fewer injuries of the lower popliteal artery and its trifurcation.

Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 1

Effects of acute ischaemia

of a limb

Ischaemia due to vascular injury or prolonged hypotension increases capillary endothelial permeability and allows the escape of liquid and organic material into the interstitial compartment, producing oedema. Muscle tibres deprived of blood for more than 4-8 hours become oedematous and obstruct circulation in muscle compartments, so further aggravating ischaemia. Venous injury and soft tissue injury will The considerable swelling. also produce peroneal and posterior tibia1 vessels and the posterior tibia1 nerve are especially vulnerable compression muscle syndrome this &rnstingl 1974). The muscle fibres die after 6 -12 hours of total occlusion whereas the skin can survive 24 hours or more (Nolan and McQuillan, 1965; Bimstingl, 1974). Raised intravascular pressure after restoration of flow augments exudation and oedema and may worsen the ischaemic state: the later the repair the more damaging this factor becomes. Also, with delay in repair, arteries, being elastic, contract so that widespread intravascular clotting sets in (Birnstingl, 1974). Therefore, speed of revascularization has obvious advantages. Clinical presentation

The average age of casualties was comparable 1968; military estimates (Gorman, with McNamara et al., 1973), but well below civilian series (Dillard et al., 1968; Smith et al., 1974). Injuries other than vascular sometimes contributed to shock. While from one-third to one-half of patients in military and civilian series present in such a state, only one-quarter of those in this series had systolic pressures of less than 80 mmHg. Palpable pulses, especially in upper limbs and young patients (Drapanas et al., 1970) should not be construed as evidence of integrity of a proximal vessel, as we discovered. A diagnosis of spasm must not be made except at operation, if necessary by excluding an intimal tear by arteriotomy. Early literature is replete with examples of loss of pulsation due to ‘spasm’, which on later scrutiny turned out to be the result of thrombosis (Smith et al., 1969). Unlike others (Hewitt and Collins, 1969), we have not noted acute arteriovenous listulas; pulses may not be appreciably reduced and one may listen for bruits (Drapanas et al., 1970). Apparent nerve palsy of ‘boot-like’ distribution may be due to ischaemia (Morton et al., 1966). Tests employing capillary or venous filling are unreliable in arterial injury (Gorman, 1968).

Barros D’Sa et al.: Missile-induced Vascular Trauma

In military experience, the lower limb is vulnerable to injury from gunfire and fragmenting missiles (Hughes, 1971). In civilian patients, upper limb injuries are commoner following fights and industrial accidents (Drapanas et al., 1970; Hardy et al., 1975). In our experience, ‘knee-cappings’ account for a preponderance of injuries to the lower limb. The distribution ratios of injuries of upper and lower extremities were approximately 1 : 6 for arteries and 1 : 10 for veins. Angiography

Preoperative angiography usually wastes valuable time in a clinically obvious vascular injury, does not exclude venous injury (Smith et al., 1974) and is sometimes unreliable in revealing an existing injury (DOS Santos, 1963; Patman et al., 1964; Drapanas et al., 1970; Mufti et al., 1970; Bimstingl, 1974; Lozman et al., 1978). A negative angiogram should not contraindicate exploration for arterial injury. It was a valuable aid in 3 patients who had pedal pulses but suspected arterial injury, and in assessing the 2 patients who arrived two or three days after injury. Rigid rules that all wounds should be explored without preoperative angiography (Patman et al., 1964; Trieman et al., 1966; Flint et al., 1973) or that none should be explored without it, are untenable. A rational approach must be based on clinical judgement of the individual case. If conditions permit, it is useful in locating the exact site of injury when multiple vascular injuries are suspected. Operative management of wound

Operation was undertaken with the least possible delay, the objectives being control of bleeding, wound toilet, restoration of circulation and prevention of complications. The severity and number of wounds depended on the muzzle velocity and number of times a gun was fired, the type and size of charge of a bomb and the victim’s proximity to these agents. Exit wounds of high velocity missiles were particularly large. While it is undeniable that adequate wound toilet paid dividends, some workers (Getzen et al., 1972) still suggest that morbidity and infection do not justify routine surgical toilet of all penetrating missile wounds. Certainly exploration and irrigation facilitate thorough search for foreign bodies and removal of contaminants, especially deeply embedded bomb fragments. In ‘knee-cappings’, joints must be cleared of metal which can produce a chemical synovitis. On the evidence that low

23

velocity missiles are not sterilized on firing (Thoresby and Darlow, 1967), the primary closure of such wounds is contraindicated. Operative management of arterial injuries

For popliteal vascular injuries, we found the posterior approach in the prone patient most convenient, using an S-shaped incision, with the upper part of the ‘S’ being medial. After initial digital pressure, control can be assured by an atraumatic vascular clamp or an inflated Fogarty balloon. In latter years, both legs have been prepared to enable a segment of long saphenous vein to be removed from just above the ankle, preferably from the opposite leg, which is fully flexed at the knee with the patient prone. As described, this position also facilitated three-compartment fasciotomy. Fogarty balloon exploration was not performed in all cases because wounds were often explored less than an hour and sometimes less than 30 minutes after injury. When backbleeding is poor or absent, such exploration can often recover clot (Owens, 1963; Trieman et al., 1966). Decreased back-bleeding, though ominous, is less serious in young patients with no established collateral network about the knee, and arterial repair will salvage limbs (Gorman, 1968). Release of the proximal clamps will wash out clot, but balloon exploration is sometimes necessary. In prolonged ischaemia, both proximal and distal artery or vein should be infused with heparinized saline. Systemic heparin is reliable, easily reversed and may be added (Hardy et al., 1975). The argument (Lozman et al., 1978) that judicious ligation of artery or vein in selected instances to reduce operative time, infection, postoperative thrombosis or the need for revision, may be reasonable for minor vessels which do not threaten life, limb or vital organ. With the majority of vessels, however, a vascular channel must be restored. Intimal disruption may underlie apparently innocuous contusion and lead to a false aneurysm. Lateral suture is justifiable only when small wounds can be repaired without narrowing the lumen, and should not be performed at the expense of inadequate excision. Lateral repair without patch grafting led to re-operation in all instances in one series (Gorman, 1968) but gave no serious trouble in another (Drapanas et al., 1970). Patch grafts are best used to close a defect in a small artery (Drapanas et al., 1970). Most civilian and some military vascular injuries of the Korean War were repaired by

24

lateral suture or direct anastomosis (Hughes, 1971). Flexing joints and the sacrifice of major collateral channels to permit end-to-end anastomosis of an arteriosclerotic vessel is unjustifiable (Morton et al., 1966). Recommendations to resect a damaged artery adequately were made during the Korean War (Jahnke and Seeley, 1953) and followed in later military experience (Moore et al., 1954; Owens, 1963; Bradham et al., 1964). Excision of 1 cm of normal vessel adjacent to tissue grossly injured by a high velocity missile may mean the total loss of a 5-cm segment, as was common in our series of popliteal artery injuries, though many of these were caused by low velocity bullets. In distal popliteal arterial and trifurcation injury, repair of at least two of the branches should be attempted. The practice of interposing vein grafts in arterial repair permits adequate excision and avoids the dangers of breakdown, bleeding and thrombosis which follow end-to-end anastomosis under tension. A vein graft adjacent to infection is reported to heal without thrombosis (Hershey and Spencer, 1963). It has remained patent in the canine femoral artery even when arterial flow was lowered to 15-30 ml/min (Greenstein and Mannick, 1966). This method of repair was employed in 56 per cent of cases of arterial injury in which flow was re-established. A third of these were compilation vein grafts. This policy of removal of a vein from the opposite ankle has been adopted because: first, maximal venous flow in the injured limb is preserved (Hoover, 1961) secondly the proximal four-fifths of the vein was conserved, thirdly the segment excised is muscular and of good calibre and fourthly, access is easy when a posterior popliteal exploration is under way. Techniques of constructing compilation vein grafts have been described (Earle et al., 1960; Haimovici et al., 1970) and the grafts must be somewhat longer than the gap to be bridged (Rich, Hobson et al., 1974). Attention must be given to technique, i.e. the use of interrupted suture in small calibre vessels, careful coaptation of intimal surfaces, prevention of intraluminal protrusion of adventitial strands and avoidance of excessive tension at the suture line. Angiography on the table proves valuable in demonstrating inadequacy of repair and allows immediate correction. It is suggested that extra-anatomic bypass procedures are indicated when anastomoses are exposed to risk of infection following tissue destruction and contamination (Lozman et al.,

Injury: the Brutish Journal of Accident Surgery Vol. 1 ~/NO. 1

1978). Infection was not serious in this series and in any case such procedures could be employed if re-operation due to infection became necessary (Rich and Hughes, 1969). Fabric grafts in combat wounds predispose to infection, which is the most common non-fatal complication (Hardy et al., 1975). It is recommended that synthetic grafts be used only when vein grafts are unavailable, or too small to serve as conduits (Drapanas et al., 1970). The only two Dacron interposition grafts were used successfully in relatively high-flow areas of the external iliac and proximal part of the common femoral artery damaged by high velocity missiles. Management

of vein injuries

Over 70 per cent of arterial injuries were accompanied by damage to adjacent veins. World War I observations that the danger of gangrene was raised by simultaneous vein injury (Matas, 192 1). were unfortunately accompanied by one report (Makins, 19 19) recommending ligation of the vein with the artery in the belief that collateral arterial circulation would be better utilized and afford protection against gangrene. The idea that ligation of veins while perhaps not helpful would do no harm was perpetuated for some time until refuted by subsequent experimental work (Montgomery, 1932; Barcia et al., 1972) and clinical experience (De Bakey and Simeone, 1946). In recent years, the management of the venous component of concomitant arterial and venous injuries, especially of the distal femoral and popliteal regions, has been stressed (Hobson, Howard et al., 1973; Swan et al., 1975). Accompanying veins were injured in over 60 per cent of arterial injuries in some war series (Hughes, 1958; Chandler and Knapp, 1967; Rich, Baugh et al., 1969) but in one ofthe earlier Vietnam series (Rich et al., 1970) only one-third were repaired, reflecting the continuing attitude that venous repair was less important. Clinical impressions from conflicts in Korea (Hughes, 1954; 1958; Spencer and Grewe, 1955) and Vietnam (Gorman, 1968; Cohen et al., 1969; Rich, Baugh et al., 1969; Rich et al., 1970; Rich, Jarstfer et al., 1974) suggest that a limb may be lost due to venous stasis even after arterial reconstruction. Experimental occlusion of a limb’s major vein increases peripheral venous resistance and pressure, with reduction in arterial blood flow to the limb (Barcia et al., 1972; Hobson, Howard et al., 1973; Wright and Swan, 1973a), which may lead to thrombosis at

Barros D’Sa et al.: Missile-induced Vascular Trauma

the site of arterial repair, and increasing ischaemia (Greenstein and Mannick, 1966; Chandler and Knapp, 1967; Barcia et al., 1972). Clinical reports have shown that ligation of veins causes acute massive oedema, in some instances leading to gangrene and amputation or to disabling chronic oedema and post-phlebitic changes (Hughes, 1958; Sullivan et al., 1971; Rich, Hobson et al., 1974). These may be averted by early reconstruction of the vein (Wright and Swan, 1973a, b). As a short term goal, repair of a vein will prevent acute venous stasis (Cohen et al., 1969), and even if a repaired segment thromboses later, recanalization will prevent subsequent morbidity due to chronic stasis (Rich et al., 1970; 1972). Deep venous thrombosis and pulmonary embolism associated with thrombosis of a repaired vein did not occur even in the challenging circumstances of this series. These complications, in fact, occur more commonly following ligation (Rich et al., 1970; Birnstingl, 1974; Ayres and Winspur, 1976). We believe in securing at least one good venous channel at popliteal and femoral level. In combined arterial and venous injury, a vein repaired first allows arterial repair to be carried out in a dry field. If the artery is repaired first, the system proximal to the clamped veins may be congested and cause increased oedema. Vein wounds will tolerate lateral suture (Levin et al., 1972; Rich, Hobson et al., 1974). This method was used in 56 per cent of vein injuries in which flow was re-established. An autogenous vein patch can be used to retain diameter but end-toend anastomosis without tension was performed when feasible. Contrary to the belief (Gaspar et al., 1968) that repair of a major vein by interposition of a vein graft was not feasible, such a graft, expecially of the compilation type, is the ideal choice. When venous flow was reestablished, 23 per cent of patients had had this kind of repair and half of these had received compilation grafts. To achieve success a painstaking technique is essential (Haimovici et al., 1970) the margin for error being much less than for arterial anastomoses (Rich, Hobson et al., 1974). Fasciotomy

Fasciotomy has become an invaluable adjunct to repair of injuries of the lower limbs and their vessels (Drapanas et al., 1970) to forestall the serious complications of ischaemia. The muscles in the deep posterior compartment are not only susceptible to compression but also slow to regenerate. Fasciotomy should be con-

25

sidered, especially in association with popliteal vascular injury (Birnstingl, 1974; Hardy et al., 1975), if any of the following conditions exist: (a) sustained hypotension, (b) more than g-hour interval between injury and revascularization, (c) evident oedema or patchy muscle necrosis at operation, (d) injury to main veins, (e) marked injury of distal soft tissue, cf) subfascial haematoma and bleeding and (g) muscle paralysis and fixed flexion deformity after initial vascular repair. With increasing awareness of the importance of the procedure, fasciotomy was applied more frequently after 1972, and in 92.5 per cent was performed promptly. In the past, fasciotomy was done too conservatively and too late. The discovery of immobile, hardened muscle is usually a prelude to amputation (Gorman, 1968) as was true in one of our patients. Complete four-compartment fasciotomy, i.e. including excision of the fibular shaft to decompress the deep posterior compartment, has been employed by other workers (Patman and Thompson, 1970; Birnstingl, 1974) especially if there is a cornminuted fracture. Aids to vascular patency

Adjunctive measures such as heparin, dextran, the construction of a distal arteriovenous fistula and sympathectomy have been recommended to help to keep grafts clear (Rich et al., 1971). Experimentally, the beneficial influence of postoperative administration of dextran and heparin on patency remains questionable (Hobson, Croom et al., 1973). The postoperative use of heparin is said to cause bleeding (Hardy et al., 1975) but this did not occur with the doses administered: the two haematomas were drained in patients not heparinized. Apparently, heparin confers little protection because it fails to influence platelet adhesion (Salzman? 1965) a factor of primary importance in arterial thrombosis, and also because it is considered to be ineffective in a rapid arterial stream (Eastcott, 1965). More recently its use has been recommended in cases of extensive deep venous injury (Bimstingl, 1974). The value of placing an arteriovenous fistula distal to an interposition vein graft in a vein, so as to increase flow through the vein and thus prevent occlusion, has been described (Levin et al., 1972) and its clinical use reported (Johnston and Eiseman, 1969) but in the vast number of cases reviewed in Vietnam, no suitable patients could be found for the procedure (Rich, Hobson et al., 1974).

Injury: the British Journal

26

Arteriovenous

flstula and false aneurysms

The incidence of these lesions was 4.4 per cent. In recent wars they occurred after 7 per cent of vascular injuries (Seeley et al., 1952; Hughes and Jahnke, 1958; Rich et al., 1975) and, with the rise in urban violence, are increasingly reported in civilian series (Cohen et al., 1970). In the absence of hypotension, acute frstulas can apparently be recognized by thrills or bruits, permitting prompt treatment (Hewitt et al., 1973; Hardy et al., 1975). Compression of the artery feeding a large chronic fistula with pulsating venous channels slows down the pulse rate by reducing venous return. This is the Branham-Nicoladoni phenomenon (Birnstingl, 1974). Severe bomb injuries may preclude reconstruction, which is better than obliterative techniques (Hughes and Jahnke, 1958; Rich et al., 1975). Early repair is preferred but later operation can give satisfactory results (Drapanas et al., 1970; Hewitt et al., 1973). A sterile stethoscope to ascertain closure of all fistulas is recommended, especially after shotgun injuries (Hardy et al., 1975). Carotid arterial injury

With an expanding haematoma of the neck, immediate insertion of a cuffed endotracheal tube provides an airway and prevents blood entering the lungs. Time permitting, injuries of a carotid artery at the root of the neck or base of skull should be studied by angiography. The patient with a carotid arterial injury but no neurological deficit (Cohen et al., 1970; Di Vincenti and Weber, 1974) obviously has an effective collateral circulation allowing an unhurried repair to be carried out (Cohen et al., 1970; Di Vincenti and Weber, 1974; Hardy et al., 1975). Immediate exploration without preoperative arteriography in patients who develop neurological signs gradually is practised in some centres (Flint et al., 1973; Knightly et al., 1973); in others (Hardy et al., 1975) exploration is undertaken only if clinical or angiographic evidence of injury exists. In those who develop neurological signs and hemiplegia, management remains controversial. The lesion is often in the internal carotid, compromising even the collateral flow from the external carotid artery. It is feared that revascularization may cause haemorrhagic infarction (McNamara et al., 1973) and it may seem rational to ligate the carotid in such a patient, but this has not been the experience of those with knowledge of this area (Di Vincenti and Weber, 1974).

Subclavian, injuries

of Accident

axillary

and

Surgery Vol. 1 ~/NO. 1

brachial

arterial

These vessels’ injuries cause massive haemorrhage into the neck and chest and demand urgent exploration. The rich collateral circulation around the subclavian causes profuse bleeding regardless of proximal control (Hardy et al., 1975) but it permits safe ligation of the second or third parts if primary repair is not feasible. We believe that the right subclavian is best approached through a median sternotomy and the left by a high thoracotomy through the bed of the third or fourth rib. Brachial plexus injuries are often associated, as was the case in 3 out of 4 patients. Preoperative angiography in this area is usually used only to prove absence of injury. The brachial artery, which was the second most frequently involved vessel in the upper limb in Vietnam (Rich and Hughes, 1969) represented only 4 per cent of arterial injuries in our series. Primary repair is desirable and was easily accomplished. Abdominal

vascular injuries

Regardless of missile velocity, injuries to these major vessels and their visceral ramifications accounted for 56 per cent of the mortality. On opening the abdomen, torrential bleeding is promptly controlled with large gauze packs; after energetic replacement of the blood lost the packs are removed singly and each bleeding vessel attended to. Suprarenal abdominal aortic injury in one moribund patient was difficult to control. A large retroperitoneal haematoma should lead one to suspect aortic or other major arterial injury and must be carefully explored. Primary repair of the aorta may be compromised by contamination from the bowel and it may be better to oversew the aorta and construct a temporary axillary bilateral femoral bypass. Every effort should be made to restore major venous channels, though a badly torn cava or iliac vein is best ligated. The portal vein, hepatic artery and origin of superior mesenteric artery should be reconstructed, while repair of the splenic or inferior mesenteric artery may be useless. Bony injuries

Fractures of lower limb bones occurred almost ten times more frequently than in one other civilian series of vascular injuries (Drapanas et al., 1970). The stabilization of fractures before arterial repair is widely advocated (Smith et al., 1969; Rich et al., 1971) on the premise that manipulation with retraction of the artery could

2-f

Barros D’Sa et al.: Missile-induced Vascular Trauma

distort the vessel (Morton et al., 1966), or an unstabilized fracture could destroy a delicate repair (Rich et al., 197 1). Others (Hardy et al., 1975), more concerned with speedy restoration of distal perfusion, prefer arterial repair followed by final reduction with full muscle relaxation. As a compromise, especially after popliteal injuries, it may be advantageous to follow the sequence of thrombectomy, perfusion of the distal bed with heparin, stabilization of the fracture and, lastly, arterial repair. The Vietnam experience (Rich et al., 1971) tends to support external fixation of open and comminuted fractures associated with vascular trauma as internal fixation was attended by a high rate of infection and amputation. Temporary postoperative traction requires a longer time in hospital, and therefore plaster casts are used to release beds, and the patients allowed home within 3 weeks of injury. Wound infection Several adverse factors played a part in 2 cases of serious wound infection. The first, an early victim of a bomb explosion underwent ligation of both tom popliteal vessels in one limb. The foot became gangrenous and at re-exploration within 24 hours the artery only was repaired, fasciotomy performed and Clostridium welchii was identified in the wound. Immediate treatment with hyperbaric oxygen and penicillin was life-saving but when he collapsed with secondary haemorrhage, above-knee amputation was necessary and a glass fragment was discovered in the calf muscle. Clostridial myositis or true gas gangrene (Smith et al., 1969) was not observed and may have been prevented by treatment. Oxygenation of tissues with hyperbaric oxygen in severe ischaemia may tide a limb over precarious stages until ischaemic oedema regresses and capillary circulation is reestablished (Wang et al., 1966). The opinion that this treatment has not fulfilled its expectations and should be abandoned (Bimstingl, 1974) seems premature and it ought to be given further trial. The second victim developed chronic osteomyelitis well away from the vascular repair and had a late amputation. The absence of significant pyogenic wound infection in other patients may be attributable to several factors, notably, the immediate use of antibiotics effective against a wide range of organisms including penicillin resistant staphylo cocci, urgent exploration, effective toilet and irrigation of the wound, expeditious restoration of vascular continuity, avoiding synthetic

prostheses but using fasciotomy and delayed closure of wounds. Despite prompt restoration of blood flow inadequate surgical toilet is reported to produce advancing cellulitis and patchy necrosis, the predominant organism being Pseudomonas aeruginosa (Gorman, 1968). Once such infection is established, control is difficult despite repeated excision of dead tissue and the presence of a functioning arterial repair, and usually results in amputation. In one civilian series (Drapanas et al., 1970), infection at site of injury occurred in 5 per cent and most of these patients required amputation. The continued policy of prophylactic administration of tetanus toxoid is endorsed by the fact that tetanus did not complicate either these or any of the thousands of other injuries which occurred during the period covered here. Not surprisingly, intra-abdominal sepsis complicated iliac vascular and colonic injury with faecal soiling; the patient died 3 months later from uncontrolled septicaemia. Thrombotic

occlusion

When this complication occurs soon after primary reconstruction it is almost always due to weakness of technique. Insufficient trimming of damaged arterial intima, the use of narrow vein grafts, poorly executed anastomoses and tension at the suture line were responsible for such failure in 14.9 per cent of patients, an incidence which compares well with another large series (Rich and Hughes, 1969). In the latter report, some patients had 5-6 separate reconstructive procedures, but the maximum in one patient of our series was 3 operations. Thrombosis may commence and even occlude the lumen before the end of the operation and would be confirmed by angiography on the table. Infection or residual thrombus may promote late graft thrombosis (Hardy et al., 1975). Widespread venous damage may lead to a chronic ‘postthrombotic syndrome’ with oedema, induration, pigmentation and even ulceration (Birnstingl. 1974). Popliteal

vascular injury and amputation

Experience has shown that popliteal and tibia1 arterial injuries are dangerous, consistently resulting in the highest incidence of amputation (De Bakey and Simeone, 1946; Hughes, 1958, 197 1; Rich and Hughes, 1969; Drapanas et al., 1970). In World War I the amputation rate was 43 per cent and in World War II ligation led to amputation rates of 41 per cent and 72.5 per

28

cent in British and American reports respectively (Ogilvie, 1944; De Bakey and Simeone, 1946) improving to 35.8 per cent when suture repair was instituted (De Bakey and Simeone, 1946). With the introduction of early vascular repair, the amputation rate in the Korean War fell to 32.4 per cent (Hughes, 1958, 1971). In Vietnam, the early amputation rate fell through the duration of the war from 45 per cent to 29.5 per cent (Chandler and Knapp, 1967; Gorman, 1968; Rich and Hughes, 1969; Hughes, 197 1). These military figures cannot be compared with those of civilian series in which different circumstances apply and particularly as some of the latter include minor artery repairs and often report ‘failure’ rates rather than amputation rates. Amputation is often the ultimate sequel to inadequate arterial repair and the case histories of these amputations (Barros D’Sa, 1980) illustrate both the pitfalls which confront the vascular surgeon and the necessity of timely and adequate operation. In these patients late arrival, delayed exploration and fasciotomy, popliteal arterial ligation associated with clostridial infection and chronic osteomyelitis were responsible for eventual amputation. Our amputation rate of 6.9 per cent reflects the benefits of quick revascularization after injury. Popliteal arterial injuries were associated with the greatest number of concomitant injuries of vein, nerve and bone. Nerve injuries contributed to a slow return or the absence of normal function. Fractures compound difficulties in management and are associated with a higher ‘failure’ rate (Drapanas et al., 1970). Massive destruction of a limb may necessitate immediate amputation if complications are to be avoided, but this decision must be weighed very carefully. Should ischaemic gangrene occur, amputation at the appropriate level must be carried out expeditiously, before pain, pyrexia, toxicity and possible renal complications supervene. Acknowledgements

Aires A. B. Barros D’Sa is most indebted to Professor N. M. Rich, Professor L. R. Sauvage and Mr H. H. G. Eastcott for their kindness in reviewing the paper and for their valuable comments and to Miss May Weller for her great help in preparing the manuscript. REFERENCES

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Requesfsfor reppnnfsshould be addrested 10;Mr

Aires A. B. Barros D’Sa, Royal Victoria Hospital, Belfast, BT 12 6BA, Northern

Ireland.

ERRATUM

The publishers of Injury regret that Fig. Ic was inadvertently printed upside down in the article by C. B. Wynn Parry ‘The Ruscoe Clarke Memorial Lecture, 1979: The management of traction lesions of the brachial plexus and peripheral nerve injuries in the upper limb: a study in teamwork’, Injury 11,265-285.