This is an enhanced PDF from The Journal of Bone and Joint Surgery

The PDF of the article you requested follows this cover page.

Vascular Injuries in the Orthopaedic Patient

CARL W. HUGHES
J Bone Joint Surg Am. 1958;40:1271-1280.

This information is current as of June 10, 2009

Reprints and Permissions
Publisher Information
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
 Vascular Injuries in the Orthopaedic Patient
BY LIEUTENANT COLONEL CARL W. HUGHES, Medical Corps, United States Army

Prom the Department of Surgery, Tripler United States Army Hospital,

Honolulu, Hawaii

In time past, arterial injuries complicated by fractures and extensive soft-

tissue destruction, especially of time popliteal area, often have been an indica-
tion for amputation. While patients with conibined orthopaedic and vascular
injuries are seen in increased numbers during war or disaster, frequent cases
are reported in the literature from civilian practice. Certainly the reported cases
represent only a percentage of those treated. Although the trend over the past
few years has been toward reconstructive vascular surgery, occasional cases still
are reported in which obliterative vascular techniques are practiced. While there
are several instructive papers l)Ublished on the subjectof vascularinjuries 5,7,13,14,23,
it is the purpose of this paper to discuss further the practicability of blood-
vessel repairs in the presence of orthopaedic injuries.

CAUSES ANI) INCIDENCE OF VASCULAR INJURIES

As a rule, civilian injuries are not as destructive as those seen in battle

casualties. Various invest igators have reported on battle-incurred vascular in-
juries from both World War II 25 and the Korean War 6,10,h1,22#{149} While most dam-
aged blood vessels were ligated during World War II, the practicability of repair
of acute blood-vessel injuries was proved under conditions which existed in Korea
where the amputation rate following arterial repair was decreased from 36 per
cent in World War II to 13 per cent While the majority of these vascular ‘. injuries
reported had no accompanying bone involvement, many had additional nerve
and soft-tissue destruction.
DeBakey and Simeone 2i rel)orted that during World War II the incidence
of amputation was significantly higher when the acute vascular injury was corn-
j)Iicated i)y a fracture. Most of time vascular injuries comprising their report were
treated by ligation. Although no specific percentage of fractures in acute arterial
injuries from World War II is stated, Elkin and Shumacker 25 reported the
presence of thirty-eight associated fractures in 159 patients with traumatic
aneurysms and ninety-nine fractures in 288 patients with arteriovenous fistulae
(31 per cent incidence of fractures accompanying these lesions).
Individual investigators in Korea reported various percentages of fractures
acconnpanying vascular injuries. Spencer and Grewe 22 found twenty fractures
acconipanying fifty-four cases with popliteal and femoral-artery injuries (37 per
cent incidence of fractures) . Limb loss from gangrene was considerably higher
in those cases with concomitant fractures. Jahnke and Seeley ‘ reported eighteen
fractures accompanying thirty-two major vascular injuries (an incidence of 56
per cent). The author 6 noted compound fractures associated with only 15 per
cent of a series of seventy-nine acute vascular injuries. Morris, Creech, and
DeBakey in reporting a large series of acute vascular injuries occurring in civilian
life noted the presence of fractures in thirteen of 129 patients (10 per cent).
In addition to studying vascular injuries resulting from missiles in Korea,
the author has had occasion to repair surgically a number of vascular injuries
in orthopaedic patients. Fractures of the pelvis have been observed to damage
the iliac arteries by severing and impinging the vessels. In one patient, pelvic
fragments damaged the external iliac artery breaking only the intima circum-
ferentially which became involuted obstructing the artery and requiring resec-
tion and anastomosis. Other injuries observed and treated included those occur-
VOL. 40-A. NO. 6. DECEMBER 1958 1271
1272 C. W. HUGHES

ring in the operating room such as injuries to iliac arteries and veins during sur-
gery for intervertebral-disc disease and injury to the axillary artery during
reduction of a fracture of the neck of the humerus. Among time more common
injuries observed have been severe arterial spasm, sev- spasm and thrombosis,
erance, and compression of the artery by fractured bones.
The recent ort.hopaedic literature contains reports of various types of vas-
cular injuries in orthopaedic patients 1,4,26, These include vessel disruption,
thrombosis, and spasm resulting from fractures 21 Dislocation of shoulders, ci-
bows, and knees not infrequently results in disruption or thrombosis of
vessels 2,3,15,24 Damage to vessels from axillary crutches is not. unusual and
may result in thrombosis or aneurysm formation .

TYPES OF ARTERIAL INJURIES

Tine mniajority of arterial injuries occur as open wounds of the vessel in

which tine vessel may be lacerated, may be severed, or may have a portion

In addition to a severed brachial artery, many collateral vessels also are destroyed
in this large soft-tissime wound. Tine defect in the artery was m-epairenl by an auntogenous-
vein graft (Fig. 5).

avulsed. Open vessel wounds usually are seen in tine presence of open soft-tissue
injuries resulting from gunshot, slmarp weapons, or vehicular accidents. How-
ever, the same injuries may occur to time vessel wall without ‘isible cVi(IeflCC
of soft-tissue damage. Laceration of the vessel by the end of a fractured bone
is probably time most. common cause of disrupted vessels in a closed soft-tissue
compartimient. A shari) blow over an artery can create an oien vascular WOUfl(l
without breaking the skin. Similarly, the dislocation or reduction of a dislocated
joint may rupture a major artery without evidence of soft-tissue (lestm’uction.
While hemorrhage at the site of injury and isclmaemia (listal to time injury may
occur, the violence of the injury, on occasion, may sever time vessel; and con-
traction of time severed ends may be such that hernatoma formation may be
minimal. In the closed soft-tissue wound, the degree of hmenmatoma is indicative
of injury and time amimount of blood lost. Such is not always true in tine open
soft-tissue wound.
The second major group of blood-vessel injuries includes time closed vessel
injuries or those in wimich time wall of tine vessel is not i)roken through. Sucln
acute arterial occlusion may occur in the presence of open or closed soft-tissue
trauma and may be initiated in various ways. Spasm, frequently accompanying
a fracture or initiated by contusion, stretch, or other trauma to some part of

THE JOURNAL OF BONE AND JOINT SURGERY

 VASCULAR INJURIES IN THE ORTHOPAEDIC PATIENT 1273

tine vascular tree, may occlude an artery for an indefinite period of time and
I’(SUlt ill thnroiiibosis om’ irreversible ischaemic changes. Contusion of the vessel
mnmay i)I’eak the intinma and initiate thrombosis or permnit dissection an(l involu-
tiolTi of tIne intima with occlusion of the vessel. An artery may be occluded
IlleChialni(’ttliV i)pT a helimatomnia or swelliiig within a tight fascial compartment
01’ i)\’ conmpression between bone fi’agments. An enibolus may block a vessel
i’esi.iltiiig in Sl)ttsiii an(1 isclnaemmua. \Vhmile an enml)olus conminonly lodges at a
i)ifurcation oi at the origilm of a immajor branch of a vessel, time resulting spasm
oftell mnittkcs it (hifficult to detem’miiiume tine level of tine enibolus.

‘OMPLICATIONS ANI) ‘I’HEIR PREVENTION

lln( mnnot selious (‘Oliil)liciItiOflS of arterial injuries are those which enmdan-
ge1 life. This (hanger exists l)rilflarily in those I)atients with open vascular in-
jul.ies in whommi tine initial threat to life comes from exsanguination. Open injuries
to large vessels imsuahly result in considerai)le blood loss and, even though fatal

FIG. 2
I;nmg( J)lmlsa t imng inerilat olinat
ms t her a
fromii an inj 1mm-emI suI)em-fi(ial femnnom:n 1
:t rt (I’\’ minay he self-rout m)llCd illilcfilnit ely om’ nnay cxi :mmaI vml in (lamnage to
snmmm-oumnding st mrm(’t rmm-es or inemnnom-m’iiag(

lnemniori’lnage iS It\’Oi(le(l, tine resulting smock and its coimnphieations, if improperly

t l(tt (‘( I , miia\’ I’eSU It in loss o f I i fe. I n t ii ITP I’Pl )O1’t S ‘ - 0 1 groups of l)atieflt S
‘ithn injuries to major arteries, it was noted tinat 38 to 66 pe1 cent of tine I)IItieflts
\vei’e admnnitted to time hnosl)itaI in smock.
Tine controlas a lifesaving measure
of inemorrhnage is tine prinnary treat-
mnnemmt of tine patient with open wounds of blood vessels. Such control may be
aj)piie(l as one of many foruns known to tine surgeon. Tine use of pressure dress-
ings is the most desirable means of (‘ontroihing hemorrhage since it usually is
effective and, h)y allowing existing collateral vessels to continue to function,
lnelps to preserve tine limb. Tine use of a tourniquet inampers the flow of blood
througln collateral vessels and when used improperly or over a prolonged period
of timmie may result in irrevem’sihle ischiaeimc cimanges.
Ami :LI’tery wlniein is severed tends to contract and retract which helps to

VOL. 40-A. NO. 6. DECEMBER I958

1274 C. W’. HUGHES

control the inemorrimage. Even tlnoughn tile inemorrimage nitty cease spontaneously,
t.imere is always danger of secondary hemorrhage if proper control is not applied.
Of secondary iminportance only to tile control of hemorrhage is replacement
therapy for the individual in shock. A thorough evaluation of all injuries and
rapid and coimiplete resuscitation in preparation of tile l)atieflt for surgery ai’e
further insurance against ad(litional complications.
Tile vasoconsti’ictive action of shock, while Protective to tine oi’ganisiil, is
injurious to an already ischmaemnic limb. Vasospasmii and low blood pressure conm-
l)hicate arterial occlusion and hasten time onset of gangrene. TIlis is just further
indication for imllle(hiate and coimll)lete resuscitation of the patient in smock.
Tine use of vasoconstrictor (Irugs in patients with an iscinaemie extrenmity is
contra-indicated. Time usefulness of sucim (Irugs in l)atients in hmennorrlnagic smock
is questionable and furt her vasoconstrictive act ion in an already iscliaeniie lifllh
may cause a(lditioflal lmariii. The use of vasodilator (Irugs intra-arterially in the
ischiaeinic extremnmitv is also of doubtful value and inmav, on reaching the general

FIG. 3
This dumb-bell shaped false aneumm-’snn resumlted fmon a tinm-otmgin-:tmi l-t in m-oumgi inn msm
wound of the brachial artery. After exeision, the artery was rep:nim-ed by lmm’e(t anasto-
mosis.

circulation, add to time difficulties of resuscitation of tine patiemmt. Ii(at to iscln:tcmmli(’

hinibs is contra-in(licated since it s’ill increase tIne rate of inietabohisinn an(l tine
oxygen (lemiland. Cooling an extremity is beneficial to a degree, i)m’eferal)lv by
leaving time extremity uncovere(l and exposed at room teimll)erature. Preoperative
synll)at.imetic i)lOcks to suchi an extremity are not ifl(hicated. The time i’equired
for such a Procedure should be devote(l to time iniore rapi(l preparation of tIne

patient for surgery.

Fhie next niost serious colnll)lication to oceiii’ is ischna(Inlia to an ext renmit V
vitln resulting gangrene. In the hands of a trained vascular siii’gcoin, thnis

plication is usually time result of tine time lag from injury to surgery. lmn addi-
tion to time ischaemia resulting from disruption of a major vascular ehnamnnel, tine
minor or collateral channels also may l)e involved. Soft-tissue wounds result in
the destruction of collateral vessels (Fig. 1). Excellent collateral channels exist
in some bones and are disrupted by fracture.
Time lag from injury to surgery is probably tine greatest conmphicating factor
resulting in limb loss. This factor can be nmiproved only by faster methods of
transportation an(I more rapid resuscitation of tine injured individual. In addi-

THE JOURNAL OF BONE ANI) JOINT SURGERY

 VASCULAR INJURIES IN TFIE ORTHOI’AEDIC PATIENT 1275

tion to decreasing tine tinne lag, actual care of time ischiaemic extremity is iimi-

l)ortant in )reventing irreversii)le cinanges. This care of time extreimiity begins

vitii resuscitation of the patient. By re)lacing tine 1)100(1 lost and returning tine
blood volunme and blood h)ressmnre to normal, ample oxygenated blood is made
available to nourisin tine iscimuemic limb timroughi any remaining vascular chain-
nels. Existing collateral channels oftemi are adequate for limb viability if a!-
lowed to function. It is for this i’eason thnat tourniquets and mecinanical com-
pression of any kind, except that necessary for time control of hemorrinage, slnould
l)e av0i(he(l. \Umile it is well to immiloiJihize sucil an injured extrenmity, any splint
or basket 1mse(l shiOuh(l be well l)added.
An ischnaemic extremity usually shows absence of l)UlSe, emnnpty veins, and
pallor; it is cold and pamful. Later it mnnay sinow dependent lividity, become
anaest.lnetic and paralytic witln Spastic Volkmann-hike contracture. Such ischae-
nlic spasm imnay
result from l)el’iO(lS of partial or colnl)lete iscimaeniia. With
return of 1)100(1 supply the previously anoxic muscle often becomes oedematous

#{149}.;:..

FIG. 4
Here a simple traumatic arteriovenous fistula is exposed with
control tapes placed on both vessels prior to CXciSiOfl of time fistula
sith direct anastomosis of the artery and repair of the vein.

and svoh1en. Irreversible muscle changes witinimi tigimt fascial compartments may
result unless decommipression is afforded by fasciotomy. Tile anterior tibia! corn-
1)artlileIlt of time leg arid tine flexor compartment of tine forearm are quite suscep-
tible to these cinallges. Failure to recognize such changes niay result in permanent
nerve dammiage, muscle necrosis, conmpartnient, om even limb, loss.
Vessels winicin are incommnl)letelv severed continue to i)leed and a patient can
I)lee(l to dentin 1)\’ 1)100(1 loss into mis own tinighn. If, however, tine blood becomes
t.1’ap)e(l 1)y l)lanes of fascia, nmumscle, i)one, an(l skin, a )ulsating hematoma may
he created (Fig. 2). If left undisturijed i)y surgery, expansion, or infection,
sucin an injury of an artery alone will develop into a false aneurysm (Fig. 3).
If an artery and vein are injured under time same circumstances, an arteriovenous
fistula develops witim flow of 1)100(1 directly fromim tine artery to the vein limiting
the amount of peripimeral blood flow distal to tine fistula (Fig. 4). Unlike most
ty)es of arterial injuries, a periphieral 1)ulSe usually is palpable in the presence
of these lesions.
The presence of traumatic aneurysms and artem’iovenous fistulae may cause
furtimer comimplications. Large traumatic arteriovenous fi.. ulae between vessels of

VOL. 40-A. NO. 6, DECEMBER 1958

1276 C. W. HUGHES

iliac size may result in cardiac decompensation. Peripheral arteriovenous fistulae

rarely cause cardiac complications. Complications resulting from traumatic
aneurysms are usually local and often consist of expansion with pressure omn
adjacent structures or rupture of the false sac with hemorrhage. In some instances
comminuted bone fragments at a fracture site or a portion of bone may make
up l)art of the false sac. Tile pulsation of an aneurysmal sac may erode bone
or destroy adjacent nerves. Nerves amid bone exposed to time jet stream of blood
within the sac may be denuded and damaged.

OPERATIVE CARE

Vascular injuries are surgical emergencies. Tile urgeicy of the Surgery varies
with the type of injury and the vessel involved. Delay or indecision as to treat-

Fro. 5
Large vascular defects may be bridged by homologous-artem-y grafts, autogenous-
vein grafts, and, in some instances, by woven plastic prostheses. Here an autogenoims
vein has been reversed and placed in the arterial defect (Fig. 1).

mnent may result in loss of limb or life. For that reason, resuscitation, evalua-
tion of injuries, and restoration of blood supply should be accomplished at the
earliest possible nioment. After proper exposure and control of tile involved yes-
sd, repair may be accomplished in one of several ways, depending on the type
and severity of tine injury. A minimal laceration of a vessel wall which requires
no d#{233}bridement may be repaired by simple suture after determining that no
thrombus extends into the lumen. More severely injured vessels require d#{233}bride-
ment with anastomosis when possible. When a defect exists, too great for ap-
position of the vessel ends, then a graft of imomologous artery, autogenous vein,
or possibly woven plastic material is indicated (Fig. 5). Such repairs are satis-
factorily perforlned using 00000 arterial silk as interrupted sutures or as a con-
tinuous everting or simple suture. While the interrupted suture line may leak,
the continuous suture may result in constriction of the vessel lumen if the suture
is pulled too tigiitly (Fig. 6). Excess tension on the ends of the vessel may result
in spasm or separation of the suture line. After the repair of the vessel and

THE JOURNAL OF BONE AND JOINT SURGERY

 VASCULAR INJURIES IN THE ORTHOPAEDIC PATIENT 1277

d#{233}bridement of the wound are completed, time vessel must be covered with time
surrounding tissues for nourishment and for protection from drying and infec-
tion. In cases of open trauma, it is safer to cover time vessel and leave time wound
open for four to six days for delayed closure. Anticoagulants should not be
necessary when an intima-to-intina repair is performed properly without con-
striction of time lumen and establishing a good blood flow. Antibiotics, however,
are protective to such repairs l)erfOrmed in the presence of open wounds.

Although some constriction of lumen exists at this

popliteal artery anastomosis site, the distal circulation is
excellent. Such constriction may result from excess tension
held on the arterial sutimre during repair.

Patency of tine major vascular channel is not always necessary for limb
survival but it is desirable. A surgeon untrained in vascular surgery or lacking
proper instruments and faced witim an injury to a large artery may be forced
to ligate time vessel. Other situations wimicim may demand ligation of time artery
are those in which other priority surgery may prolong the operating time exces-
sively or when a number of patients are awaiting lifesaving surgery. Ligation
may be indicated for an injured vessel running through a large avulsed soft-
tissue wound wimere no tissue remains to cover the vessel. Following ligation of
a major artery, irreversible changes must be expected in a percentage of the
cases. Time incidence of amputation varies according to time vessel involved and
according to time severity of the injury involving the artery. For this reason
various percentages are quoted in the literature 17,25, Even though the limb may
survive ligation of its major vascular channel, the possibility of gaining a good
functional limb after ligation of its artery is limited. The prognosis for limb
VOL. 40-A, NO. 6, DECEMBER 1958
 1278 C. W. HUGHES

survival following ligation of its major artery is better in the upper limb than
in tile lower. Should ligation of a major artery become necessary, this alone is
not an indication for ligation of tile concomitant vein 20#{149}
Treatment of time patient with an acute pulsating hematorna varies with time
situation, the condition of the patient, time availability of proper instruments,
and time ability of time surgeon. The majority of patients with a pulsating hema-
toma will have a palpable pulse distal to the hematoma and a viable extremity.
If proper wound care is given without dislodging the clot, most can be treated
conservatively until tile pulsating hematoma develops into an arteriovenous fis-
tula or false aneurysm at whichi time definitive surgery may be done. In a per-
centage of patients with pulsating hematoma complications of infection,
expansion with pressure on vital structures, or hemorrhage will develop and
will require emergency surgery as report cd by Russell For hemorrhage
19#{149} in the
presence of infection, ligation of time involved artery is indicated. Ideally, if a
surgeon trained in vascular repair is avai’le with necessary supplies and equip-
ment, the vascular injury producing a pulsating hematoma should be repaired
immediately as any other acute vascular injury. However, if the surgeon, un-
familiar in dealing with these injuries, opens such a lesion without proper
vascular control, he may lose a life or be forced to ligate the vessels and l)OSsiblY
lose a limb. While the limb loss is not as great if tine artery feeding a pulsating
hematoma is ligated some days after injury as it is from ligation of an acutely
damaged artery, a degree of functional impairment of the limb still occurs.
The artery usually can be ligated safely some months later after the pulsating
hieniatoma develops into a false aneurysm or an arteriovenous fistula, but arterial
insufficiency will occur in a high percentage of patients. This was demonstrated
in the treatment of 814 arteriovenous fistuiae and false aneurysms reported by
Elkin and Shumacker from World War II 25 The author and his associates
treated 215 arteriovenous fistulae and false aneurysms of which thirty lesions
of major vessels were treated by obliterative surgery months after injury. Of the
patients so treated, arterial insufficiency developed in 30 per cent. A five-year
follow-up study of this group showed that arterial insufficiency had increased
to 50 per cent in the group undergoing obliterative surgery for major vessel
lesions.

THE FRACTURE WITH ARTERIAL INJURY

Fracture associated with disruption of

the main arterial channel is one of
tile more serious complications encountered by the orthopaedist. It is difficult
to treat one without treating bothl. Without restoration of the blood supply,
ischaernic gangrene frequently will result. Even if the extremity retains its viabil-
ity witil its major blood supply ligated, bone repair is slower and the end result
may be less thian desirable. Tile presence of a fracture is no contra-indication
to repairing time injured vessel. One late follow-up study of acute vascular in-
juries simowed no increased incidence of thrombosis in arteries repaired in the
lresence of fractures 12
Time conmplications begin inimmiediately. With vascular disruption at the level
of time fracture site, time application of the desired pressure dressing for control
of imemorrhiage is more difficult. Any angulation or motion of the fractured bones
may increase bleeding. Stabilization by any form of temporary splinting and
t.raction, as with the Thomas splint, results in an already ischaemic foot being
elevated with some traction device applied. This necessary evil, in addition to
the existing spasm and the possibility of some degree of shock in the patient,
further adds to the ischaemia. If a pulsating hematoma exists at the fracture
site in a closed soft-tissue wound, this may interfere with the treatment of tile
fracture; therefore, repair or ligation of the vessel becomes necessary. The open
soft-tissue wound with involvement of bone and artery poses a different prob-
lem. The wound must be debrided and at that time the artery is identified,
bleeding is controlled, and time lesion is repaired. Arterial repair in the presence

THE JOURNAL OF BONE AND JOINT SURGERY

 VASCULAR INJURIES IN THE ORTHOPAEDIC PATIENT 1279

of a coml)lete fracture usually is facilitated by tue overriding of time ends of the

bone, making it possible to appose time ends of time vessel more easily. While
vessels may be repaired in timis immanner, it nmust be realized timat time resulting
excess vessel cannot be excised and time surgeon then expect to reduce time frac-
ture. If niore timan two centimimeters of vessel is destroyed, a graft may be
indicated. After vascular repair is performed, time fracture should be reduced
imianually witim time vessel visualized to be sure that it is not under undue tension,
separated, or that spasm does not result. Soft tissue should be placed between
time vessel and fracture site for nourisimnment to tine vessel and to prevent corn-
pressrnn and incorporation into scar tissue. Precautions as to vessel length also
roust be taken during repairs near fractures about joints. After time repair is
performed with time joint flexed, time joint should be extended with the vascular
repair under vision to be sure adequate vessel lengtim exists.
After vascular repair and wound d#{233}bridement, the method of fixation of
time fracture is time cimoice of time orthmopaedist. Time author has seen complications
of vascular repair occur i)ecause of inadequate and excess traction for the
fracture.
Time utilization of a cast is undesirable for extremities which have been
iscimaemic. There is danger of pressure to time extremity. Ischaemic extremities
often tend to swell after timeir blood supply is returned. Irreversible changes may
develop in muscle in tighmt compartments wimen Imidden by a cast. An improperly
sutured vessel nmay leak and produce hidden imenmorrhage or swelling. Failure or
thnrolmmi)osis of time arterial repair is immore likely to be overlooked in a cast. Cer-
tailmiy, if a cast nmust be used and bivalved for safety of the arterial repair, then
it loses nmucim of its usefulness for treating tine fracture. One limb was lost fol-
lowing vascular repair, done by time autimor, when tine fracture slipped and
compressed time repaired vessel.
Traction also offers disadvantages. Tine extremity in traction is elevated. It
is desirable to hnave tine extreimmity witin newly established blood supply near heart
level. Time fixation of traction or a cast encourages arterial and venous thmroimm-
bosis. Late imeimmorrinage has been observed to result fronm partial separation of a
l)OPliteal artery anastonmosis in time presence of a compound fracture under trac-
t.ion. Ligation of time artery, indicated because of some bone infection, did not
cause loss of time leg but resulted in functional arterial insufficiency.
Orthmopaedic injuries adnmittedly complicate the repair of vascular injuries.
It is difficult in mimany fractures and dislocations to determine whether or not
ai)Seflce of a pulse results because of compression by bone fragments, tlmrombosis,
spasimi, or a severed artery. Time presence of a hmenmatoma suggests tear in time
artery but mimay result from widespread destruction of soft tissue and collateral
vessels. The prognosis of sucim injuries in the past has been poor for extremity
an(l sometinmes for life.
Now tinat reconstitution of arterial channels is practical, we simould enmphasize
the restoration of vessel continuity.
SU M MARY

With time trend toward reconstructive vascular surgery, this paper discusses
time practicability of blood-vessel repairs in time presence of orthopaedic injuries.
Time incidence of vascular injuries in tine presence of fractures is noted as varying
from 10 per cent in civilian injuries to 56 per cent in one group of battlefield
injuries. Time complications of vascular injuries are presented and timeir preven-
tion discussed. Operative care of acute vascular injuries and pulsating hematomata
simould be reconstructive rather thnan obliterative. It is pointed out timat there are
still indications for ligation of major vessels. While ligation of an artery feeding
a pulsating hematoma is safer timan ligation of an acutely injured artery, a high
degree of functional vascular insufficiency may result. Care of the injured
vessel in time presence of fracture is discussed stressing reconstructive vascular
surgery.

VOL. 40-A, NO. 6. DECEMBER 1958

1280 C. W. HUGHES

REFERENCES

1. ELLIOT, J. A. : Acute Arterial Occlusion. An Unusual Cause. Surgery, 39: 825-826, 1956.
2. GOLDMAN, H. : Comphete Dislocation of the Knee with Rupture of the Pophiteal Vessels.
J. Intemnat. Coil. Surg., 19: 237-242, 1953.
3. HENDERSON, R. S., and ROBERTSON, I. M. : Open Dislocation of time Elbow with Rupture of
the Brachial Artery. J. Bone and Joint Surg., 34-B: 636-637, Nov. 1952.
4. HENSON, G. F. : Vascular Complications of Shoulder Injuries. A Report of Two Cases. J.
Bone and Joint Surg., 38-B: 528-531, May 1956.
5. HERRMANN, L. G. : Symposium on Skeletal Trauma. Vascular Complications and Sequels of
Skeletal Trauma. Am. J. Surg., 85: 450-454, 1953.
6. HUGHES, C. W. : Acute Vascular Trauma in Korean War Casualties. Surg., Gynec., and
Obstet., 99: 91-100, 1954.
7. HUGHEs, C. W. : Acute Arterial Injuries. In Instructional Course Lectures, Time Anmerican
Academy of Orthopaedic Surgeons, 1955. Vol. 12, pp. 60-68. Ann Arbor, J. W. Edwards, 1955.
8. HUGHES, C. W. : Arterial Repair During the Korean War. Ann. Surg., 147: 555-561, 1958.
9. HUGHES, C. W., and JAHNKE, E. J., JR. : The Surgery of Traumatic Arteriovenous Fistula
and Aneurysms. Ann. Surg., (in press).
10. INUI, F. K.; SHANNON, J.; and HowiuuD, J. M. : Arterial Injuries in the Korean Conflict.
Surgery, 37: 850, 1955.
11. JAHNKE, E. J., JR., and SEELEY, S. F. : Acute Vascular Injuries in the Korean War. Ann.
Surg., 138: 158, 1953.
12. JAHNKE, E. J., JR. : Late Structural and Functional Results of Arterial Injuries Primarily
Repaired. Surgery, 43: 175-183, 1958.
13. JULIAN, 0. C. : Arterial Trauma. In Instructional Course Lectures, The American Academy
of Orthopaedic Surgeons, 1954. Vol. 11, pp. 261-267. Ann Arbor, J. W. Edwards, 1954.
14. MCALLISTER, F. F. : Vascular Disturbances Associated with Fractures. Bull. New York Acad.
Med., 32: 127-132, 1956.
15. MCKENZIE, A. D., and SINCLAIR, A. M. : Axillary Artery Occlusion Complicating Shoulder
Dislocation. Ann. Surg., 148: 139-141, 1958.
16. MORRIS, G. C., JR.; CREECH, OSCAR, JR.; and DEBAICEY, M. E.: Acute Arterial Injuries in
Civilian Practice. Am. J. Surg., 93: 565-572, 1957.
17. PRATT, G. H. : Cardiovascular Surgery. Philadelphia, Lea and Febiger, 1954.
18. ROB, C. G., and STANDEVEN, A. : Closed Traumatic Lesions of the Axillary and Brachial
Arteries. Lancet, 1 : 579-599, 1956.
19. RUSSELL, J. P. : Secondary Hemorrhage in War Wounds. In Symposium on Military Mcdi-
cine in the Far East Command.
20. SIMEONE, F. A. ; GRILLO, H. C. ; and RUNDLE, F. : On the Question of Ligation of the Con-
comitant when a Major Artery is Interrupted. Surgery, 29: 932-951, 1951.
21. SMYTH, E. H., JR.: Primary Rupture of the Brachial Artery and Median Nerve in Supra-
condylar Fracture of the Humerus. J. Bone and Joint Surg., 38-B: 736-741, Aug. 1956.
22. SPENCER, F. C., and GREWE, R. V.: The Management of Acute Arterial Injuries in Battle
Casualties. Ann. Surg., 141: 304, 1955.
23. STEIN, A. H., JR.: Arterial Injury in Orthopaedic Surgery. J. Bone and Joint Surg., 38-A:
669-676, June 1956.
24. STENER. BERTIL: Dislocation of the Shoulder Complicated by Complete Ruptumre of tine
Axillary Artery.
Succeful Suture of the Artery in an eighty-seven-year-old Man. J. Bone
and Joint Surg.,
39-B: 714-717, Nov. 1957.
25. SURGERY IN WORLD WAR II. Vascular Surgery. Office of the Surgeon General, Dept.. of the
Army, U. S. Government Printing Office, Washington, D. C., 1955.
26. WEST, J. P.; WINANT, E. M.; and Bi..&IR, C. R.: Femoral Artery Reconstruction in a Patient
with Compound Fracture of the Femur. J. Bone and Joint Surg., 39-A: 1394-1397, Dec. 1957.

THE JOURNAL OF BONE AND JOINT SURGERY