EVALUATION AND

TREATMENT OF
VASCULAR INJURY
R&B
 ORTHOPAEDIC
EMERGENCIES
Life Treathening :
- Major Pelvic Ring Injury
- Crush Injury Syndrome
- Vascular injury

Limb Threatening :
1. Trauma
- Open Fracture
- Dislocation
- Compartement Syndrome
- Fat Embolism
- Unstable Cervical Fracture
2. Non Trauma
- Septic Artritis
- Acute Hematogenesis Osteomyelitis
DEFINITION
:
VASCULAR TRAUMA —> INJURY TO A BLOOD VESSEL—AN ARTERY, WHICH
CARRIES BLOOD TO AN EXTREMITY OR AN ORGAN, OR A VEIN, WHICH RETURNS
BLOOD TO THE HEART.
HIGH RISK TO LIFE AND LIMB.

MECHANISME OF INJURY :
1. SHARP / PENETRATION TRAUMA
• HANDGUN 50%
• STAB WOUND 30 %
• SHOTGUN 5%
2. BLUNT TRAUMA : 5% (FR, DISLOCATION, CRUSH INJURY, &
TRACTION)

• MOST COMMON LOCATION : FEMORAL ARTERY AND

POPLITEA ARTERY (50% TO 60%), BRACHIAL ARTERY (30%)
 CONSEQUENCES OF VASCULAR
INJURY
• BLOOD LOSS
• ISCHEMIA
• COMPARTMENT SYNDROME
• TISSUE NECROSIS
• AMPUTATION
• DEATH

Irreversible damage after 6 hours

 TYPES OF VASCULAR INJURIES
• SPASM

• INTIMAL FLAPS

• SUBINTIMAL HEMATOMA

• LACERATION

• TRANSECTION

• THROMBOSIS/OCCLUSION

• A-V FISTULA

Some require treatment, some do not

 VASCULAR INJURY
INCREASED INCIDENCE WITH:

• PROXIMITY OF VESSELS TO BONE

• TETHERING OF VESSELS AT JOINTS

• SUPERFICIAL LOCATION OF VESSELS

 INCIDENCE OF FRACTURE OR
DISLOCATION WITH VASCULAR INJURY
UNCOMMON

• 3% OF LONG BONE
FRACTURES
SPECIFIC CIRCUMSTANCES

• FRACTURES WITH GSW

(UP TO 38%)
• KNEE DISLOCATIONS (16-
40%)
 PROGNOSTIC FACTORS

• LEVEL AND TYPE OF VASCULAR INJURY

• COLLATERAL CIRCULATION
• SHOCK/HYPOTENSION
• TISSUE DAMAGE (CRUSH INJURY)
• WARM ISCHEMIA TIME
• PATIENT FACTORS/MEDICAL CONDITIONS
EARLY TREATMENT
PRIMARY SURVEY OF ATLS SECONDARY SURVEY
• ABCDE
• STOP BLEEDING
1. MANUAL COMPRESSION
2. COMPRESSION
DRESSING
3. TOURNIQUET
4. FOLEY CATHETER
5. CLAMPING AND LIGASI
SECONDARY SURVEY AND CLINICAL FINDINGS
 DIAGNOSIS
• PHYSICAL EXAM
• DOPPLER PRESSURE (ANKLE/BRACHIAL SYSTOLIC
PRESSURE INDEX (ABI))
• DUPLEX SCANNING
• ARTERIOGRAM
• EXPLORATION
 PHYSICAL
EXAMINATION
• ADANYA KELAINAN TULANG PANJANG DAN SENDI YG
JELAS
• OPEN FRACTURE, BONE EXPOSED OR KREPITASI TULANG
• WARNA KULIT EKTREMITAS DISTAL (BANDINGKAN DGN SISI
BERLAWANAN)
• CRP < 2 DETIK
• PX MOTORIK DAN SENSORIK
 IMMEDIATE TREATMENT
• CONTROL BLEEDING
• REPLACE VOLUME LOSS
• COVER WOUNDS

• REDUCE
FRACTURES/DISLOCATIONS
• SPLINT
• RE-EVALUATE
 SPEED IS CRUCIAL

• RAPID RESUSCITATION
• COMPLETE, RAPID EVALUATION
• URGENT SURGICAL TREATMENT
 PHYSICAL EXAM
• MAJOR HEMORRHAGE/HYPOTENSION
• ARTERIAL BLEEDING
• EXPANDING HEMATOMA
• ALTERED DISTAL PULSES
• PALLOR
• TEMPERATURE DIFFERENTIAL BETWEEN EXTREMITIES
• INJURY TO ANATOMICALLY-RELATED NERVE
 DOPPLER ULTRASOUND
• DETERMINE PRESENCE/ABSENCE OF ARTERIAL SUPPLY
• ASSESS ADEQUACY OF FLOW

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY !
 DOPPLER ULTRASOUND FOR
KNEE DISLOCATION

• ABNORMAL ABI < 0.90

• DOES NOT DEFINE EXTENT OR LEVEL OF INJURY
• ABNORMAL VALUES WARRANT FURTHER EVALUATION
• ABI > 0.90 CAN BE OBSERVED (I.E. NO ARTERIOGRAM)
 DUPLEX SCANNING
• NONINVASIVE
• SAFE
• RAPID
• RELIABLE FOR

• INJURY TO ARTERIES AND

VEINS
• A-V FISTULAS
• PSEUDOANEURYSMS
 DUPLEX SCANNING
• REQUIRES TECHNICIAN AND SCANNER AVAILABILITY

• NOT ALL SURGEONS WILL OPERATE BASED ON DUPLEX

INFORMATION ALONE
 ANGIOGRAPHY

• LOCATES SITE OF INJURY

• CHARACTERIZES INJURY
• DEFINES STATUS OF VESSELS
PROXIMAL AND DISTAL
• MAY AFFORD THERAPEUTIC
INTERVENTION
 ANGIOGRAPHY

IDENTIFY AND CONTROL (I.E.

EMBOLIZATION) BLEEDING
FROM PELVIC FRACTURES
 ANGIOGRAPHY
• EXPENSIVE
• TIME-CONSUMING
• DIFFICULT TO MONITOR/TREAT TRAUMA PATIENT IN
ANGIOGRAPHY SUITE
• PROCEDURAL RISKS

• RENAL BURDEN FROM DYE

• POSSIBILITY OF ANAPHYLAXIS
• INJURY TO PROXIMAL VESSELS
 CT ANGIOGRAPHY
• ALTERNATIVE TO CONVENTIONAL ANGIOGRAPHY
• GOOD SENSITIVITY AND SPECIFICITY
• COSTS MUCH MORE

- ANGIOGRAPHY WILL DELAY REVASCULARIZATION. IT IS NOT

INDICATED IN CASES WITH ABSENT PULSES/COMPLETE
TRANSECTION, WHICH SHOULD GO IMMEDIATELY TO SURGERY
 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 Normal exam

Injury Multilevel Doppler

obvious injury ?

ABI <0.9 ABI >0.9

Angiography
or duplex
Observation
Surgery
 CONTINUED EVALUATION
• VASCULAR INJURIES ARE DYNAMIC

• EVALUATION SHOULD CONTINUE AFTER THE INITIAL

INJURY OR SURGERY

• ADDITIONAL DEBRIDEMENT AND/OR FIXATION

UNDERTAKEN AFTER SUCCESSFUL REVASCULARIZATION
 TREATMENT
• ADEQUATE EXPOSURE AND VASCULAR CONTROL
• DEBRIDEMENT OF THE INJURED VESSEL WALL TO HEALTHY
INTIMA,
• PROXIMAL AND DISTAL BALLOON CATHETER
THROMBECTOMY,
• TENSION-FREE END-TO-END REPAIR OR APPROPRIATELY
SIZED INTERPOSITION GRAFT
• GOOD SOFT TISSUE COVERAGE
• STABLE BUT EXPEDITIOUS FRACTURE FIXATION
• ADEQUATE FASCIOTOMIES.
 CONTINUED EVALUATION

• CIRCULATION

• NEUROLOGIC FUNCTION

• COMPARTMENT PRESSURES
 SURGICAL CONSIDERATIONS
• WHO GOES FIRST? DISCUSS WITH VASCULAR SURGEON
• TEMPORARY SHUNTS WILL BENEFIT SOME PATIENTS
• FRACTURE STABILIZATION CONSIDER PROVISIONAL EX FIX
• SALVAGE VS AMPUTATION TREND TOWARD SALVAGE (LEAP)
• FASCIOTOMIES PROPHYLACTIC AFTER ISCHEMIA
 CONCLUSIONS

• POTENTIAL EXISTS WITH EVERY ORTHOPEDIC

INJURY
• UNCOMMON
• BE AWARE OF INJURIES ASSOCIATED
• UNDERSTAND SIGNS AND SYMPTOMS OF
ARTERIAL INJURY
 CONCLUSIONS
• TIME IS CRUCIAL
• PARAMOUNT FOR DIAGNOSIS

• HIGH INDEX OF SUSPICION

• THOROUGH PHYSICAL EXAM
• HAVE A DEFINED PROTOCOL/RELATIONSHIP WITH YOUR
COLLEAGUES FROM VASCULAR AND TRAUMA SURGERY