Evaluation and Treatment of

Vascular Injury

Heather Vallier, MD
Original Author: Timothy McHenry, MD; March 2004
New Author: Heather Vallier, MD; Revised January 2006

Potential Orthopedic Emergencies

Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury

Potential Orthopedic Emergencies

Open fracture
Irreducible dislocations
Vascular injury
Amputation
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury

Vascular injury
the clock starts ticking

Blood loss
Progressive ischemia
Compartment syndrome
Tissue necrosis

Irreversible damage after 6 hours

Vascular injury
Potentially frequent incidence
Proximity of vessels to bone
Tethering of vessels at joints
Superficial location of vessels

Arterial injuries associated with

fractures or dislocations
Clavicle fracture
Shoulder fx/dislocation
Supracondylar humerus fx
Elbow dislocation
Pelvic fracture
Femoral shaft fx
Distal femur fracture
Knee dislocation
Tibial shaft fx

subclavian artery
axillary artery
brachial artery
brachial artery
gluteal arteries
femoral artery
popliteal artery
popliteal artery
tibial arteries

Incidence
Overall uncommon
3% of long bone fractures
Specific circumstances
Fractures with GSW (up to 38%)
Knee dislocations (16-40%)

Mechanism of Injury
Penetrating trauma
GSW
Stab
Blunt trauma
High energy
Low energy
iatrogenic

Types of vascular injuries

Spasm
Intimal flaps
Subintimal hematoma
Laceration
Transection
A-V fistula

Some require treatment, some do not

Consequences of vascular injury

Blood loss
Ischemia
Compartment syndrome
Tissue necrosis
Amputation
Death

Prognostic factors
Level and type of vascular injury
Collateral circulation
Shock/hypotension
Tissue damage (crush injury)
Warm ischemia time
Patient factors/medical conditions

Speed is crucial
Rapid resuscitation
Complete, rapid
evaluation
Urgent surgical
treatment

PROTOCOL IS ESSENTIAL !

Immediate treatment
Control bleeding
Replace volume loss
Cover wounds
Reduce
fractures/dislocations
Splint
Re-evaluate

Diagnosis
Physical exam
Doppler pressure (Ankle/brachial
systolic pressure index)
Duplex scanning
Arteriogram
Exploration

Diagnosis
Physical exam
Doppler pressure (Ankle/brachial
systolic pressure index)
Duplex scanning
Arteriogram
Exploration

Careful physical exam and

high index of suspicion are
most important !

Physical exam
Major hemorrhage/hypotension
Arterial bleeding
Expanding hematoma
Altered distal pulses
Pallor
Temperature differential between extremities
Injury to anatomically-related nerve

 Asymmetric pulses warrant doppler

examination (determine ABI)
Absent pulses warrant emergent
vascular consultation/surgical
exploration

Doppler ultrasound
Determine presence/absence of arterial supply
Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY !

Doppler ultrasound
Normal ABI > 0.95
Abnormal < 0.90
Does not define extent or level of injury
Abnormal values warrant further evaluation

Mills, et al. J. Trauma 2004

Duplex scanning

Noninvasive
Safe
Rapid
Reliable for
Injury to arteries and veins
A-V fistulas
Pseudoaneurysms

Click image to zoom out

Duplex scanning
Requires technician and scanner availability
Not all surgeons will operate based on duplex
information

Click image to zoom out

Angiography
Locates site of injury
Characterizes injury
Defines status of vessels
proximal and distal
May afford therapeutic
intervention

Angiography
Identify and control
bleeding from pelvic
fractures

Angiography

Expensive
Time-consuming
Difficult to monitor/treat patient
Procedural risks
Renal burden from dye
Possibility of anaphylaxis
Injury to proximal vessels

Operative angiography
Single view in operating
room
Rapid
Excellent for detecting
site of injury

Surgical exploration
Immediate exploration is indicated
for:
Obvious arterial injury on exam
No doppler signal
Site of injury is apparent
Prolonged warm ischemia time

Reduce, stabilize, resuscitate

No pulses

Asymmetric pulses

Doppler

Multilevel
injury ?

Injury
obvious

ABI <0.9
Angiography
or duplex

Surgery

Normal exam

ABI >0.9

Observation
Modified from Brandyk, CORR 1005

Continued evaluation
Vascular injuries are dynamic
Evaluation should continue after the initial
injury or surgery

Continued evaluation
Circulation
Neurologic function
Compartment pressures

Surgical considerations
Who goes first?
Temporary shunts
Fracture stabilization techniques
Salvage vs amputation
Fasciotomies

Conclusions
Potential exists with every orthopedic injury
Uncommon
Be aware of injuries associated
Understand signs and symptoms of arterial injury

Conclusions
Time is crucial
Most important for diagnosis
High index of suspicion
Thorough physical exam
Have a defined protocol/relationship with your
colleagues from vascular and trauma surgery
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