Review Article
Vascular Injury Associated With
Jason J. Halvorson, MD
Adam Anz, MD
Maxwell Langfitt, MD
Joel K. Deonanan, MD
Aaron Scott, MD
Robert D. Teasdall, MD
E. A. Carroll, MD
From the Department of
Orthopaedic Surgery &
Rehabilitation, Wake Forest
University Baptist Health, Winston-
Salem, NC.
Dr. Scott or an immediate family
member is a member of the editorial
or governing boards of the Journal
of Surgical Orthopaedic Advances
and Arthroscopy. None of the
following authors or any immediate
family member has received
anything of value from or owns
stock in a commercial company or
institution related directly or
indirectly to the subject of this
article: Dr. Halvorson, Dr. Anz,
Dr. Langfitt, Dr. Deonanan,
Dr. Teasdall, and Dr. Carroll.
J Am Acad Orthop Surg 2011;19:
495-504
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.
August 2011, Vol 19, No 8
Extremity Trauma: Initial
Diagnosis and Management
Abstract
Vascular injury associated with extremity trauma occurs in <1% of
patients with long bone fracture, although vascular injury may be
seen in up to 16% of patients with knee dislocation. In the absence
of obvious signs of vascular compromise, limb-threatening injuries
are easily missed, with potentially devastating consequences. A
thorough vascular assessment is essential; an arterial pressure
index <0.90 is indicative of potential vascular compromise.
Advances in CT and duplex ultrasonography are sensitive and
specific in screening for vascular injury. Communication between
the orthopaedic surgeon and the vascular or general trauma
surgeon is essential in determining whether to address the
vascular lesion or the orthopaedic injury first. Quality evidence
regarding the optimal fixation method is scarce. Open vascular
repair, such as direct repair with or without arteriorrhaphy,
interposition replacement, and bypass graft with an autologous vein
or polytetrafluoroethylene, remains the standard of care in
managing vascular injury associated with extremity trauma.
Although surgical technique affects outcome, results are primarily
dependent on early detection of vascular injury followed by
immediate treatment.
V ascular injury secondary to ex-
tremity trauma is rare, with a
reported incidence of <1% in pa-
blunt trauma, floating joint, crush
injury, and dislocation.6-11 Successful
management requires a multidisci-
tients with long bone fractures.1-4 In plinary approach that includes the or-
the setting of knee dislocation, the thopaedic surgeon and a vascular or
incidence of vascular injury has been general trauma surgeon. Prompt and
reported to be as high as 16% based accurate diagnosis of vascular compro-
on the combined results of five retro- mise is imperative because delays in di-
spective studies.5 A high index of agnosis are associated with a lower ex-
suspicion for vascular injury should tremity amputation rate as high as
be maintained in patients with high- 86%.7,8 Although arterial injury can oc-
risk fractures or fracture characteris- cur with upper and lower extremity
tics, such as comminuted tibial pla- trauma, most of the literature focuses
teau fracture, severely displaced on the diagnosis, initial management,
fracture, open fracture, and segmen- treatment considerations, and out-
tal shaft fracture, as well as in pa- comes of vascular injury associated
tients with injuries associated with with lower extremity trauma.
495
Vascular Injury Associated With Extremity Trauma: Initial Diagnosis and Management
Figure 1
A, AP pelvic radiograph demonstrating subtrochanteric femoral fracture caused by a gunshot. AP angiograms obtained
before (B) and after (C) successful coiling of the profunda femoris artery.
Incidence
The overall incidence of vascular injury
following extremity trauma varies
widely by population (military versus
civilian), geographic location (urban
versus rural), and mechanism (pene-
trating versus blunt trauma). The rate
of vascular injury depends on the type
of injury. For example, closed diaphy-
seal long bone fracture carries a re-
ported risk of vascular injury as low as
0.1%.2-4 Severe open tibial fractures
are associated with a 9% incidence
of vascular injury,9 whereas knee dis-
locations have been associated with
vascular injury in ≤16% of cases.4
Diagnostic methodology differs be-
tween studies, which makes it diffi-
cult to determine the true incidence
for a given injury pattern. The sur-
geon must maintain a high index of
suspicion when examining the pa-
tient with extremity trauma, espe-
cially one with injuries associated
with a high risk of vascular injury.
For example, we treated a patient
who sustained a subtrochanteric
femoral fracture secondary to a gun-
496
shot wound (Figure 1). Initial vascu-
lar surgery consult was obtained in
the emergency department; the con-
sultants felt that no acute interven-
tion or further vascular workup was
necessary. Despite normal physical
examination findings and normal
ankle-brachial index (ABI), the pa-
tient’s hemoglobin continued to fall
during hospitalization. Subsequent
arteriography demonstrated transec-
tion of the profunda femoris artery,
which was successfully coiled with in-
terventional radiology. The patient im-
proved and was discharged without
further complication.
Anatomy
Damage to vascular structures may
occur as a result of direct or indirect
trauma. Direct trauma includes
puncture wounds or lacerations of a
vessel caused by a stabbing mechan-
ism of injury, projectile, or sharp
fracture fragment. Indirect trauma
involves stretching or shear forces
that act on a vessel, which may lead
to intimal tear. Indirect mechanisms
Journal of the American Academy of Orthopaedic Surgeons
are responsible for most vascular in-
juries associated with dislocation or
a severely displaced fracture. Recoil
of the soft tissues is common; in gen-
eral, displacement seen at presenta-
tion is not representative of the dis-
placement that occurs at the time of
injury.12
Injury to the popliteal artery is
common with knee dislocation.13
The popliteal artery consists of three
distinct layers. From outside to in-
side, these layers are the tunica ad-
ventitia, tunica media, and tunica
intima. The tunica intima can be fur-
ther subdivided into the endothe-
lium, subendothelium, and basement
membrane. Aneurysms, intimal tears
and/or flaps, fistulas, and other trau-
matic injuries are often defined by
their occurrence within a specific
layer of the vessel. Anatomic loca-
tion of arteries also influences the de-
gree of injury.7,13 Following vascular
injury or occlusion, uninterrupted
tissue perfusion is dependent on col-
lateral circulation. For example, col-
lateral circulation about the knee is
generally considered to be poor, con-
tributing to the relatively high rate of
 Jason J. Halvorson, MD, et al

Figure 2

AP (A) and lateral (B) radiographs demonstrating tibial plateau fracture sustained by a 57-year-old man who fell 20
feet. C, Axial CT angiogram demonstrating the intact popliteal artery (arrow) just proximal to the fracture site. D, Axial
CT angiogram demonstrating loss of the popliteal artery at the level of the tibial plateau. E, Lateral CT angiogram
reconstruction demonstrating loss of the popliteal artery at the fracture site.

amputation associated with vascular
trauma about the knee.14 As the en-
ergy imparted to an injury (eg, frac-
ture, dislocation) increases, so too
does the possibility of vascular in-
sult.12,13
Initial Assessment
Diagnosis of vascular injury in the
setting of blunt trauma begins with
physical examination and radio-
graphic assessment. However, physi-
cal examination can be misleading
or initially unimpressive; a normal
pulse examination may be present in
5% to 15% of patients with vascular
injury.15 Figure 2 illustrates an exam-
ple of a severely comminuted open
tibial plateau fracture. Initial pedal
pulses were normal, but subsequent
CT angiography demonstrated dis-
ruption of the popliteal artery with
reconstitution distally.
Physical Examination
Initial trauma evaluation begins with
the Advanced Trauma Life Support
protocols, including assessment of
airway, breathing, and circulation.
The secondary survey should include
clinical examination of all the ex-
tremities, followed by radiographic
evaluation of the affected extremi-
ties. Thorough motor, neurologic,
and vascular examinations should be
performed on arrival prior to any in-

August 2011, Vol 19, No 8 497

Vascular Injury Associated With Extremity Trauma: Initial Diagnosis and Management
Table 1
Hard and Soft Signs of Vascular
Injury Associated With Extremity
Trauma
Hard signs
Pulselessness
Pallor
Paresthesia
Pain
Paralysis
Rapidly expanding hematoma
Massive bleeding
Palpable or audible bruit
Soft signs
History of bleeding in transit
Proximity-related injury
Neurologic finding from a nerve adja-
cent to a named artery
Hematoma over a named artery
tervention (eg, reduction), and they
should be repeated following the in-
tervention. The vascular examina-
tion includes assessment of capillary
refill and extremity color and tem-
perature, as well as standard docu-
mentation of palpable, Doppler, or
absent pulses in the affected extrem-
ity. Results should be compared with
the contralateral side. For the patient
in whom the physical examination
changes after intervention, further
workup is required to rule out the
presence of vascular insult resulting
from the intervention. Conversely,
reduction of a fracture or dislocation
may improve vascular status.
Patients with fracture associated
with high-energy injury are at high
risk of compartment syndrome, and
additional evaluation may be re-
quired, including compartment pres-
sure measurement. A 59% incidence
of compartment syndrome was re-
ported in a retrospective review of
62 patients with blunt trauma and
vascular injuries.16 In all scenarios,
detailed documentation of the initial
assessment is critical.
498
In the setting of vascular injury,
physical examination findings can be
classified as hard or soft signs (Table
1). Hard signs, such as pulselessness,
pallor, and paresthesia, prompt im-
mediate surgical intervention by the
orthopaedic surgeon, vascular sur-
geon, and/or traumatologist. When
localization of the vascular injury is
required prior to intervention, an ar-
teriogram can be performed in the
operating room or in an arteriogra-
phy suite. Soft signs, such as history
of bleeding in transit and proximity-
related injury, occur in conjunction
with a palpable pulse or Doppler
pressure measurement. Soft signs are
associated with vascular injury in
3% to 25% of cases.17 Treatment al-
gorithms based on these signs vary
by institution.17 Our proposed diag-
nostic algorithm is presented in Fig-
ure 3.
Identification of vascular injury is
the key to management. However,
best practices for injury detection re-
main controversial. Arteriography is
the current standard of care, but this
procedure is not without risk. Com-
plications such as entry site hema-
toma, vessel thrombosis, emboliza-
tion, and contrast reaction have been
reported in 2% of patients.18,19 These
findings have prompted investigation
into less invasive methods of detect-
ing injury.
Conflicting data have been pub-
lished regarding the reliability of
physical examination in detecting
vascular injury. Numerous studies in-
dicate that physical examination
alone has 94% to 100% specificity
and negative predictive value for ex-
clusion of vascular lesions requiring
surgical repair.5,13 However, some
data suggest that physical examina-
tion may be less reliable than was
initially thought. In a meta-analysis
of vascular injury associated with
knee dislocation, Barnes et al15 re-
ported a 13% incidence of normal
pedal pulses in patients with vascular
Journal of the American Academy of Orthopaedic Surgeons
lesions that required surgical repair,
leading to an overall positive predic-
tive value of 75% and a negative
predictive value of 93%. Many sur-
geons believe that a normal physical
examination on presentation war-
rants only close observation.
The arterial pressure index (API) is
a quick and inexpensive screening
modality that is readily available in
the emergency department. The API
is calculated by measuring the sys-
tolic pressure of two extremities.
One blood pressure cuff is placed
distal to the lower extremity injury,
and another is placed on an unin-
jured upper extremity. A Doppler
probe is then used to determine the
systolic pressure of both extremities.
The systolic arterial pressure in the
injured extremity is divided by the
systolic pressure in the unaffected
upper extremity to calculate the API.
The ABI is calculated in much the
same way, in that the systolic arterial
pressure in the injured lower extrem-
ity is divided by the systolic arterial
pressure in an uninjured upper ex-
tremity.
An API or ABI value of <0.90 ne-
cessitates further workup for poten-
tial vascular injury. This value was
established by Lynch and Johansen,20
who prospectively evaluated 100
consecutive injured limbs (93 pa-
tients) with blunt or penetrating
trauma for vascular injury. All pa-
tients in the study had documented
APIs followed by arteriography. Use
of the API value of 0.90 as a cutoff
resulted in an overall accuracy rate
of 97% in detecting vascular injury,
with positive and negative predictive
values of 91% and 99%, respec-
tively. Mills et al21 confirmed this
finding, reporting positive and nega-
tive predictive values of 100% with
an ABI of <0.90 in their prospective
study of 38 patients with knee dislo-
cation. They found a statistically sig-
nificant correlation between pero-
neal nerve palsy and vascular injury

Figure 3
Diagnostic algorithm for vascular injury associated with extremity trauma. ABI = ankle-brachial index
(P = 0.004). These results highlight the
importance of physical examination
and the presence of soft signs in detect-
ing underlying vascular injury. Johan-
sen et al22 have shown that the API is
not only effective in diagnosing vas-
cular injury but also may be cost ef-
fective. They documented a nearly
9% reduction in the number of arte-
riograms performed in patients with
extremity trauma when API was
used as an initial screening test.
API findings may be misleading,
however, particularly in persons with
injury to vessels such as the profunda
femoris or peroneal arteries that do
not extend distally or are not palpa-
August 2011, Vol 19, No 8
ble12 and in persons with vascular le-
sions that may not cause a decrease
in blood flow (ie, intimal flaps). Fur-
thermore, API measurement assumes
normal patient vasculature, anatomy,
and tissue perfusion for accurate as-
sessment. Patient condition may pre-
clude adequate API assessment, as
when the location of wounds or frac-
ture precludes placement of a blood
pressure cuff, or in the setting of hy-
povolemic shock. Medical conditions
such as severe peripheral vascular
disease and diabetes may provide
false results, given the inherent
changes in the patient’s vasculature
that affect peripheral blood flow.
Jason J. Halvorson, MD, et al
Imaging
The role of duplex sonography in
clinical practice is evolving. This
noninvasive procedure can be per-
formed rapidly at the bedside, and it
has the potential to identify vascular
lesions more quickly and with fewer
complications than CT angiography
or arteriography. Two prospective
studies evaluated the accuracy of du-
plex sonography in detecting vascu-
lar injury. Bynoe et al23 reported only
two false-negative results in 198 pa-
tients, with an overall accuracy of
98%. Knudson et al24 evaluated 77
patients and reported no missed vas-
499
Vascular Injury Associated With Extremity Trauma: Initial Diagnosis and Management
cular injuries on clinical follow-up.
Duplex sonography may be used to
monitor the progression of lesions,25
avoid repeat administration of con-
trast, and avoid more invasive stud-
ies. However, not all centers have
duplex sonography equipment or ad-
equately trained technicians.
Recently, CT angiography has been
advocated for patients who do not
present with hard signs of vascular
injury but in whom soft signs or de-
terioration of the physical examina-
tion are suggestive of such injury.18,26
In a prospective study, Seamon et al26
reported on the accuracy of CT an-
giography in patients who presented
with an ABI of <0.90 without hard
signs of vascular injury. CT angiog-
raphy findings were confirmed in 21
of 22 patients (95%) on subsequent
arteriography. Cost analysis of CT
angiography versus arteriography at
their institution demonstrated a sav-
ings of approximately $13,000 in pa-
tient charges associated with CT an-
giography. CT angiography appears
to be a quick, cost-effective, and reli-
able option for diagnosis of vascular
injury associated with extremity
trauma.
Assessment and diagnosis of pene-
trating trauma to an extremity is
similar to that of blunt trauma. Phys-
ical examination and API measure-
ment are used to determine whether
further evaluation is required. In two
retrospective series, occult vascular
injury in association with gunshot
wounds involving long bone fracture
was reported in 11%27 and 28%28 of
patients (30 of 270 and 17 of 61, re-
spectively). These proximity-related
wounds are often located near large
named neurovascular structures (eg,
injury to the antecubital fossa or
popliteal fossa). However, significant
injury is rare in the absence of hard
or soft signs of vascular injury; such
lesions seldom require surgical in-
tervention.29,30 Thus, a proximity-
related injury and/or missile injury is
500
not an indication for arteriography
in the setting of normal physical ex-
amination and API.
Management
Orthopaedic
For the orthopaedic surgeon, the
goal in managing the traumatized ex-
tremity with associated vascular in-
jury is to stabilize the extremity
while protecting the vascular repair.
Patients with these injuries often
have multiple trauma and significant
resuscitation requirements; thus, dis-
cussion between general trauma, vas-
cular, and orthopaedic teams is para-
mount for optimal patient care. A
predetermined management strategy
helps to streamline diagnosis and
management, thereby decreasing is-
chemia time and optimizing patient
care and outcomes. Our proposed
treatment algorithm is presented in
Figure 4.
When limb salvage is required, the
surgical teams must determine the
timing of orthopaedic and vascular
repair. The sequence of fracture fixa-
tion and vascular repair remains
controversial.2,10,31-33 Proponents of
performing orthopaedic intervention
before vascular repair argue that
bony stabilization is required to pro-
tect the vascular repair and that ma-
nipulation, reduction, and fixation
may endanger a fresh repair. De-
creasing warm ischemia time remains
the primary argument in support of
performing vascular repair first.
Time to limb revascularization may
be delayed an average of 4 to 5
hours when orthopaedic stabilization
is done before vascular repair.33
However, a recent meta-analysis
showed no statistical difference in
overall amputation rate whether vas-
cular repair or orthopaedic repair
was performed first (13% and
11.6%, respectively).2 Likewise, evi-
dence does not indicate an increased
Journal of the American Academy of Orthopaedic Surgeons
incidence of vascular disruption or
damage when orthopaedic manipula-
tion is performed after vascular re-
pair.2,31 Sequence of repair and fixa-
tion should be determined by the
surgical teams on a case-by-case ba-
sis using predetermined protocols.
Temporary versus definitive frac-
ture stabilization at the index proce-
dure is also controversial. Placement
of an external fixation device is fast
and allows quicker stabilization of
the extremity in situations in which
orthopaedic intervention precedes
vascular repair or in which the pa-
tient’s resuscitation status rules out a
long, definitive procedure. External
fixation is also useful when soft-
tissue injury precludes immediate
stabilization. Definitive procedures
allow for fewer trips to the operating
room and provide more stable frac-
ture stabilization. However, open
procedures are associated with in-
creased surgical time and with the
risk of increased dissection and strip-
ping, leading to further devascular-
ization of the collateral circulation to
the extremity.
No high-level evidence exists to de-
finitively indicate whether external
or internal fixation is superior for
fixation at the index procedure, nor
is there an indication which type of
internal fixation is preferred (ie,
plate, intramedullary device). How-
ard and Makin3 recommended exter-
nal fixation for index stabilization
after finding a statistically significant
increase in amputation rates follow-
ing initial definitive fixation (P <
0.01). Allen et al1 reported nonunion
and malunion in five of nine patients
who underwent internal fixation,
and they surmised that external fixa-
tion may be beneficial. In an 18-year
period, Schlickewei et al11 reduced
their use of internal fixation and in-
creased their use of external fixation.
However, internal fixation remained
the standard of care in their practice,
and fracture fixation was performed
 Jason J. Halvorson, MD, et al

Figure 4

Treatment algorithm for the management of vascular injury associated with extremity trauma. Vascular and orthopaedic
surgical teams must work together to determine the sequence of fracture fixation and vascular repair.

while the vascular surgeon harvested
the graft. Although recent trends in-
dicate a preference for external fixa-
tion, further study is required to de-
termine the rates of secondary
amputation, malunion, nonunion,
and infection with this treatment.
Vascular Repair
Open vascular repair techniques
have evolved from Ambrose Pare’s
description of arterial ligation in the
1500s to the first use of autogenous
vein grafts during the Korean War.34
Current therapeutic options include
a host of endovascular techniques
and a spectrum of open reconstruc-
tion options.
Nonsurgical management of arte-
rial injuries remains controversial.
Some authors have proposed that all
detected arterial injuries warrant in-
tervention.35 Others believe that non-
surgical management is reasonable
when clinical and radiographic crite-
ria indicate low-velocity injury, ad-
herent or downstream protrusion of
intimal flaps, intact distal circula-
tion, no active hemorrhage, and min-
imal arterial wall disruption (<5 mm)
for intimal defects and pseudoaneu-
rysms.35 Serial neurovascular testing
and close follow-up are essential in
nonsurgical management.
Endovascular therapy in the setting
of trauma involves therapeutic occlu-
sion of a vessel or use of a covered
stent graft to line the injured artery.
Therapeutic occlusion may be useful

August 2011, Vol 19, No 8 501

Vascular Injury Associated With Extremity Trauma: Initial Diagnosis and Management
in select injuries such as arterio-
venous fistula, arterial pseudoaneu-
rysm, and bleeding from noncritical
arteries. Typically, endovascular oc-
clusion is accomplished with trans-
catheter delivery of thrombogenic
coils, Gelfoam suspension (Pfizer,
New York, NY), glue, or a combina-
tion thereof. Stent grafts exclude the
arterial injury while maintaining lu-
minal patency.36 However, evidence
from large long-term studies is lack-
ing. Endovascular therapy for arte-
rial trauma in an extremity requires
the availability of high-quality angio-
graphic imaging, specialized support
staff, appropriately sized supplies,
procedural expertise, and favorable
patient anatomy. Particularly in
smaller hospitals, logistics and pa-
tient factors may preclude an endo-
vascular approach.
Open surgical management is the
standard of care for peripheral vas-
cular trauma. The patient’s overall
injuries and hemodynamic status
must be assessed when considering
this treatment option. Vascular re-
construction is often performed prior
to orthopaedic fixation, and the vas-
cular surgeon should inspect the re-
pair after fixation and before wound
closure. Patency must be docu-
mented before leaving the operating
room; it can be assessed with arte-
riography or duplex sonography or
by checking palpable pulses.
The contralateral extremity is
placed in the surgical field for poten-
tial harvest of autogenous vein
should the ipsilateral vein be unsuit-
able for use as a graft. To minimize
blood loss during exposure, proxi-
mal and distal control may be
achieved with direct temporary oc-
clusion of the involved vessel, digital
pressure, proximal pneumatic com-
pression, or endoluminal balloon oc-
clusion. Once the injury is identified,
the involved artery must be débrided
back to normal artery to ensure suc-
cessful repair. Balloon mounted cath-
502
eters (eg, Fogarty) are carefully
passed proximally and distally to re-
move intraluminal clots. Local hepa-
rinization through the proximal and
distal site of injury is essential. Sys-
temic heparinization is believed to
prevent propagation of distal small-
vessel thrombosis and has been
shown to have a significant effect on
limb salvage; however, it may be
contraindicated in a patient with
multisystem trauma.37
Once the extent of the arterial in-
jury has been identified, the appro-
priate method of repair can be se-
lected. Options include direct repair
with or without arteriorrhaphy, in-
terposition replacement, and bypass
graft. The most common conduit op-
tions for interposition or bypass
grafts are the autologous vein and
polytetrafluoroethylene (PTFE). We
prefer to use the contralateral sa-
phenous vein. Donor site morbidity
is low with contralateral vein har-
vest, and potential problems associ-
ated with the ipsilateral vein (eg, in-
adequate graft, injury to the vein) are
avoided. The use of PTFE in above-
knee traumatic vascular reconstruc-
tion is controversial. Although pat-
ency rates for PTFE are similar to
those of vein grafts in this setting,
there is concern regarding placement
of artificial material into a contami-
nated field.38 The durability of vein
grafts for below-knee revasculariza-
tion following traumatic injury is
well documented, and they are the
best option. Ligation of a bleeding
arterial vessel may be an option in
noncritical vessels. In the setting of
damage control, use of intravascular
shunts to quickly restore temporary
perfusion is controversial; no large
cohort studies have been performed.
Gifford et al39 reported that in the
setting of damage control, temporary
vascular shunting does not lead to
worse outcomes and may convey
some benefit.
Extensive soft-tissue defects may
Journal of the American Academy of Orthopaedic Surgeons
pose unique barriers to vascular re-
construction. Tissue unavailability
such as in a large mid thigh defect or
marginal viability at the usual arte-
rial anastomotic sites may create
problems with tissue coverage of a
vascular graft. Typical tunnel paths
for bypass grafts may travel through
injury zones, thereby exposing the
graft and affecting tissue flap options
or hardware placement. These situa-
tions require creativity and close co-
ordination with all involved surgical
teams to provide a solution that
works with the overall limb salvage
plan.
Outcomes
Limb salvage outcomes are affected
by the mechanism of injury, associ-
ated injuries, and time to diagnosis
and/or intervention. Recent analysis
of the National Trauma Data Bank
indicates an amputation rate of
14.5% in the setting of traumatic
popliteal injury.4 Compared with a
penetrating mechanism of injury,
blunt vascular disruption of the
popliteal artery is associated with
longer hospital stays, worse func-
tional outcomes, lower limb salvage
rates, and a significantly higher am-
putation rate (9% versus 27%, re-
spectively; P < 0.001).4 High-velocity
gunshot wounds (ie, muzzle velocity
>1,500 ft/sec) are nearly twice as
likely as low-velocity wounds to re-
sult in subsequent amputation.40 Ex-
tensive injury to surrounding soft-
tissue structures is likely the common
factor in increased rates of amputa-
tion following blunt trauma and
high-velocity gunshot trauma.4,16
Few studies have examined the re-
lationship between vascular injury
and the rate of fracture union.
Brinker and Bailey41 found no statis-
tical correlation between vascular in-
jury and fracture union in terms of
method of vascular repair, soft-tissue

management, sequence of the ortho-
paedic and vascular procedures, or
Gustilo open fracture type. They did,
however, find that posterior tibial ar-
terial injuries were associated with a
75% incidence of nonunion.
Time to intervention is the most
important factor under the surgeon’s
control. To avoid permanent soft-
tissue damage, arterial continuity
should be restored in a warm ische-
mia time of <6 hours.7,42 Delay >8
hours is associated with an am-
putation rate of up to 86%.7,8 The
Lower Extremity Assessment Project
(LEAP) study showed that prolonged
ischemia time is the most important
factor associated with amputation in
patients with popliteal injury related
to knee dislocation, whereas the ex-
tent of soft-tissue damage and nerve
dysfunction were the primary deter-
minants of limb salvage.14,43 In pa-
tients with dysvascular knee dis-
location, limb salvage affords a
statistically significant trend toward
better functional outcomes than am-
putation (average Sickness Impact
Profile score, 7.0 and 16.1, respec-
tively; P = 0.32).14 However, based
on Sickness Impact Profile scores of
LEAP cohort patients, long-term
functional outcomes appeared to be
relatively equal at 7-year follow-up.44
The LEAP study also challenged the
validity of historical measures of ex-
tremity severity that rely heavily on
ischemia time or the presence of vas-
cular injury (eg, Mangled Extremity
Severity Score; Limb Salvage Index;
Predictive Salvage Index; Nerve In-
jury, Ischemia, Soft-Tissue Injury,
Skeletal Injury, Shock, and Age of
patient score). Ly et al45 demon-
strated little correlation between
these historical measures of extrem-
ity trauma and functional outcome.
This contradicts findings reported in
a review of the National Trauma
Data Bank, in which fracture and
vascular injury, along with nerve in-
jury and Extremity Abbreviated In-
August 2011, Vol 19, No 8
jury score were found to be predic-
tors of amputation following lower
extremity trauma.4 All of this infor-
mation must be discussed with the
patient and his or her family.
Limb salvage has been shown to re-
sult in an increased number of proce-
dures and hospitalizations in addition
to a higher rate of complications. In
some cases, early amputation may pro-
vide the best functional result. In these
cases, amputation should be thought of
not as a failure but as an option that
enhances the patient’s functional
capacity.
Summary
Vascular injury in extremity trauma
is a relatively rare entity with serious
complications. Prompt recognition is
the key to limb salvage, along with
coordinated management between
the orthopaedic surgeon and the vas-
cular surgeon or general surgery
traumatologist. Numerous diagnos-
tic modalities are available to detect
vascular injury associated with ex-
tremity trauma, including CT an-
giography and duplex sonography.
Direct communication between
surgical teams is essential to deter-
mine the appropriate sequence of the
orthopaedic and vascular interven-
tion. Further studies are warranted
to define the role of temporary exter-
nal fixation and definitive internal
fixation at the time of the index pro-
cedure. Overall outcomes of vascular
injury associated with extremity
trauma appear to be primarily de-
pendent on the time to intervention,
but the patient’s medical status and
the presence of associated injuries
are important factors, as well.
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Evidence-based Medicine: Levels of
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