Tourniquets in Vascular Trauma
	Date: Tue, 11 Jun 1996 19:54:33 From: Karim Brohi [karim@trauma.org] Just a quick question whose answer seems obvious to me, but not to some people I know. In a limb with arterial trauma, say an intimal tear to the axillary artery, with weak or absent distal pulses but with a warm limb with good capillary return, would you let an orthopaedic surgeon use a tourniquet (distal to the lesion) to say, fix a forearm fracture. (Assuming the vascular surgeons do not want to operate on the artery emergently). Is this clear-cut? or is there room for debate?
	Date: Tue, 11 Jun 1996 12:35:12 From: Eric Frykberg M.D. [ERF.TRAUMAONE@mail.health.ufl.edu] We've published several studies of nonocclusive arterial injuries of the extremities such as "intimal flaps" and showed (within the limits fo our now 2 year average followup) that they do not require "repair" in the absence of arteriographic evidence of occlusion or gross extravasation, as most will resolve or at least not progress, and less than 5% will ever go on to require surgery (in every case due to the development of falso aneurysm--not a single case of delayed vessel occlusion has ever been documented to follow these lesions. One puzzling aspect of your case is the diminished distal pulses, as this should not occur merely from an intimal flap--is this a subjective impression, or documented by Doppler pressures, and is there a more proximal lesion you're missing near the aortic arch??? No data exists to contraindicate the Orthopods doing whatever repair or manipulation they need to for their injury--in fact we have often allowed this in limbs with such an arterial injury without complication. You may ultimately restrict them based on "gut" feeling (meaning, of course, you don't know the answer), but understand this can't be supported, and in fact goes against what data does exist( not only in our studies, but those from several other centers as well). Remember, too, that tourniquets themselves are associated with a small incidence of vessel thrombosis, when you are tempted to blame the intimal flap for an adverse outcome. Tourniquets are in fact unnecessary in repairing upper extremity bony injuries--I can't remember the last time our group has used them--so this may be the first thing you ask your colleagues. Any comments????
	Date: Tue, 11 Jun 1996 15:54:00 From: Ronald M. Stewart [stewartr@uthscsa.edu] I am relatively aggressive about repairing the injuries with decreased pulses......and I definitely would fix the lesion if there were absent pulses. In either case, I would not want them to use a tourniquet distal to the lesion, as I would suspect that this decreases some flow (or flow velocity) in the proximal vessel, and might predispose the injury to thrombose. So....one vote for No tourniquet
	Date: Wed, 12 Jun 1996 18:43:03 From: Dave Adams I don't have any definite data on this but it seems likely that the combination of stasis (tourniquet) and endothelial damage is setting up a thrombosis or likely to extend one that's already there. Not much point in the "pods" straightening out the arm if its dead afterwards! The patient needs arteriography and consideration of stent placement, arterial repair or bypass before the distal tourniquet is applied. I guess the debate might start to arise if there is urgency about the orthopaedic procedure due to open wound (tho' this could probably be ex-fixed without tourniquet)or if there's neuro-vascular compromise, but in the latter case all the more resaon to get arteriogram and sort out the vascularity first.
	Date: Wed, 12 Jun 96 14:28:43 From: Alexander N. Chelnokov [alex@uniito.e-burg.su] In this particular case IMHO external fixation by apparatus and no tourniquet would be preferrable...
	Date: Thu, 13 Jun 1996 00:15:15 From: Aviel Roy-Shapira, M.D. [avir@bgumail.bgu.ac.il] Why would they not want to operate on the artery emergently? It is well known, since the work of Norman Rich that the best results are obtained by early repair. Why wait for flow to stop completely? I think that with absent or weak pulses, an angiogram and vascular repair, before any bone work, is mandatory.
	Date: Wed, 12 Jun 1996 03:49:44 From: Eric Frykberg M.D. [ERF.TRAUMAONE@mail.health.ufl.edu] One more thought--with a combined extremity vascular injury that requires surgical repair and bone fracture, doesn't it make sense that fixing the artery and establishing reperfusion should always be the first priority????? Blood supply is the sine qua non of viability, which can't be said of the fracture. Reperfusion can be accomplished by either temporary indwelling shunt for unstable fractures that require fixation prior to definitive arterial repair, or immediate definitive repair in stable fractures, followed by debridement and orthopedic repair with no urgency or risk of ischemia to tissues. We know that time delay is the single most common cause of tissue damage following arterial trauma, regardless of how "good" the distal extremity may "look". The main argument against this is the potential disruption of a vascular repair by the Orthopods, but in fact the literature documents (as does our experience) that this almost never happens--only 2 of 29 cases of combined popliteal artery injury and leg fracture in Snyder's 1982 series from Dallas, and 0/21 cases in Howe's series in 1987--and in each of those 2 cases, the disruption was fixed with no harm to the extremity and no long-term disability from ischemia. This argument springs more from our imagination than from reality, so I can't see how in 1996 we can justify NOT establishing arterial perfusion first in any of these combined limb injuries.
	Date: Wed, 12 Jun 1996 22:35:03 From: Robert Lipovec [Robert.Lipovec@guest.arnes.si] Of course I agree that tourniquet is out of the question, and is not necessary for any means of internal or external fixation.Plate fixation provides best reduction with the possibilty of compromizing soft tissues. External fixation is an alternative which preserves soft tissues to some degree (carries high complications rate). Perhaps with evidence of vascular compromise my choice would be an intramedullary ulnar nail and K wires for radius.
	Date: Thu, 13 Jun 96 13:57:22 From: Alexander N. Chelnokov [alex@uniito.e-burg.su] >no tourniquet would be preferrable... >Of course I agree that tourniquet is out of the question, and is not >necessary for any means of internal or external fixation. I would add that we here (i thought there is common approach but the question arised) immediately call angiosurgeon to perform vascular repair and then bone stabilization at the same surgical procedure... >Plate fixation provides best reduction with the >possibilty of compromizing soft tissues. And some devitalization of open bone ends. > External fixation is an alternative which preserves > soft tissues to some degree (carries high complications rate) And doesn't require to strip bone ends. >Perhaps with evidence of vascular compromise my choice would be >an intramedullary ulnar nail and K wires for radius. I would prefer ex-fix because tissues in ischaemia plus implant(s) can result with high infection rate. It provides good closed reduction including precise correction of radius rotation displacement...
	Date: Wed, 12 Jun 1996 23:55:20 From: Marcus J K Bankes [marcus@bankes.org.uk] I would just like to take issue with this business of performing the revascularisation surgery first in preference to stabilisation of a fracture. Firstly there is no doubt that some vascular injuries correct themselves following reduction of the fracture eg a supracondylar humerus in a child thereby completely obviating the need for vascular surgery. Secondly you can't do fine reconstructive vascular surgery held together with 6/0 nylon and expect it to hold while a fracture is being reduced and stabilised. I acknowledge Dr Frykberg's scholarship by citing two references but worrying about the reconstruction the whole time is bound to slow down and limit options in fracture stabilisation. I know that shunts give you more leeway but why bother? By the time you've fiddled about with a shunt, fixed the fracture, and performed definitive reconstruction you could have stabilised the fracture, performed the definitive reconstruction, and be halfway through the tibial nail you had to postpone because of this vascular injury. If things are that desperate you can bung on some kind of external fixator in 10 minutes before tackling the vessels and if things are less desperate you can do definitive fixation if you're quick. I believe this to be a basic principle of fracture treatment associated with vascular injuries. Most vascular surgeons in the UK have little experience of vascular trauma, except of course those in Belfast, and are by and large very unwilling to revascularise anything that is viable because they are in the business of avoiding amputations. In vascular trauma complicating closed fractures pulses may be lost but the limb remains viable due to collaterals so no vascular surgery. This is wrong. Before the fracture the limb was NORMAL not just viable and there is a definite risk of chronic ischaemic contracture, claudication, and digital ischaemia if you do not revascularise these previously normal limbs back to normality. They are a completely different kettle of fish to elderly smokers with rest pain. By the way, I wouldn't use a tourniquet because I can tie knots and use a diathermy.
	Date: Sat, 15 Jun 1996 19:33:55 From: Aviel Roy-Shapira, M.D. [avir@bgumail.bgu.ac.il] The original question was about the use of tourniquet to repair the fracture. This is not the same as stabilization. Of course one needs to set the fracture temporarily, with a splint, traction, or perhaps ex-fix, before one proceeds with angiography. If not for the possiblity that the pulses will return, obviating the need for arteriogram, then at least to reduce the pain. One does not need tourniquet to stabilize a fracture. One may need it to do some complex ORIF, and fit the bone particles together. In my opinion, it is the latter that should be postponed until after vascular reconstruction.