g03 evaluation treatment of vascular injury
TRANSCRIPT
Evaluation and Treatment of Vascular Injury
Heather Vallier, MD
Original Author: Timothy McHenry, MD; March 2004New Author: Heather Vallier, MD; Revised January 2006
Potential Orthopedic EmergenciesOpen fractureIrreducible dislocationsVascular injuryAmputationCompartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injuryDisplaced femoral neck and talar neck fractures
Potential Orthopedic EmergenciesOpen fractureIrreducible dislocationsVascular injuryAmputationCompartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injury
Vascular injury“the clock starts ticking”
• Blood loss• Progressive ischemia• Compartment syndrome• Tissue necrosis
Irreversible damage after 6 hours
Vascular injury
Increased incidence with:
• Proximity of vessels to bone
• Tethering of vessels at joints
• Superficial location of vessels
Arterial injuries associated with fractures or dislocations
Clavicle fracture subclavian arteryShoulder fx/dislocation axillary arterySupracondylar humerus fx brachial arteryElbow dislocation brachial arteryPelvic fracture gluteal arteries
iliac arteriesFemoral shaft fx femoral arteryDistal femur fracture popliteal arteryKnee dislocation popliteal arteryTibial shaft fx tibial arteries
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%)
Mechanism of Injury• Penetrating trauma
– GSW
– Stab
• Blunt trauma– High energy
– Low energy
• IatrogenicBlunt trauma with 27% amputation rate vs 9% for
penetrating in Natl Trauma Database, Mullenix PS, et al. J Vasc Surg 2006
Types of vascular injuries• Spasm
• Intimal flaps
• Subintimal hematoma
• Laceration
• Transection
• Thrombosis/Occlusion
• 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 (ABI))
• Duplex scanning
• Arteriogram
• Exploration
Diagnosis• Physical exam
• Doppler pressure (Ankle/brachial systolic pressure index (ABI))
• 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 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)
Mills, et al. J. Trauma 2004
Duplex Scanning• Noninvasive• Safe• Rapid• Reliable for
– Injury to arteries and veins– A-V fistulas– Pseudoaneurysms
Duplex vs Arteriography in Evaluating Iatrogenic Arterial Injuries in Dogs
Duplex scanning
• Requires technician and scanner availability
• Not all surgeons will operate based on duplex information alone
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 (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
Redmond, et al. Orthopedics 2008
Operative angiography
• Single view in operating room
• Rapid
• Excellent for detecting site of injury
Surgical explorationImmediate exploration is
indicated for:
• Obvious arterial injury on exam
• No doppler signal
• Site of injury is apparent
• Prolonged warm ischemia time
No pulses Asymmetric pulses Normal exam
Reduce, stabilize, resuscitate
Injury obvious
Multilevel injury ?
Doppler
ABI >0.9ABI <0.9
Angiography or duplex
SurgeryObservation
Modified from Brandyk, CORR 2005
Continued evaluation• Vascular injuries are dynamic
• Evaluation should continue after the initial injury or surgery
• Additional debridement and/or fixation undertaken after successful revascularization
Continued evaluation
• Circulation
• Neurologic function
• Compartment pressures
Surgical considerations
• Who goes first?
• Temporary shunts
• Fracture stabilization
• Salvage vs amputation
• Fasciotomies
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
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