1. Evaluation and Treatment of Vascular Injury Heather Vallier, MD Original Author: Timothy McHenry, MD; March 2004 New Author: Heather Vallier, MD; Revised January 2006

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

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

4. Vascular injury “the clock starts ticking” Blood loss Progressive ischemia Compartment syndrome Tissue necrosis Irreversible damage after 6 hours

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

6. Arterial injuries associated with fractures or dislocations Clavicle fracturesubclavian artery Shoulder fx/dislocationaxillary artery Supracondylar humerus fxbrachial artery Elbow dislocationbrachial artery Pelvic fracturegluteal arteries Femoral shaft fxfemoral artery Distal femur fracturepopliteal artery Knee dislocationpopliteal artery Tibial shaft fxtibial arteries

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

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

9. Types of vascular injuries Spasm Intimal flaps Subintimal hematoma Laceration Transection A-V fistula Some require treatment, some do not

10. Consequences of vascular injury Blood loss Ischemia Compartment syndrome Tissue necrosis Amputation Death

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

12. Speed is crucial Rapid resuscitation Complete, rapid evaluation Urgent surgical treatment PROTOCOL IS ESSENTIAL !

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

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

15. 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 !

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

17. Asymmetric pulses warrant doppler examination (determine ABI) Absent pulses warrant emergent vascular consultation/surgical exploration

18. Doppler ultrasound Determine presence/absence of arterial supply Assess adequacy of flow PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !

19. 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

20. Duplex scanning Noninvasive Safe Rapid Reliable for –Injury to arteries and veins –A-V fistulas –Pseudoaneurysms

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

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

25. Angiography Identify and control bleeding from pelvic fractures

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

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

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

29. No pulsesAsymmetric pulsesNormal exam Reduce, stabilize, resuscitate Injury obvious Multilevel injury ? Doppler ABI >0.9ABI <0.9 Angiography or duplex Surgery Observation Modified from Brandyk, CORR 1005

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

31. Continued evaluation Circulation Neurologic function Compartment pressures

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

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

34. 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 Return to General/Principles Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org