Combined Vascular & Skeletal Trauma

Table of Contents

Objectives

1. Understand the clinical manifestations of vascular injury and the diagnostic approaches to confirm or exclude vascular injury in complex extremity trauma.

2. Know the appropriate prioritization of management of vascular injury, skeletal injury, and soft tissue and nerve and tendon injury in complex extremity trauma

3. Be familiar with the criteria for early amputation in complex extremity trauma.

Overview

Complex extremity trauma involving both arterial and skeletal injuries remains challenging. This combination of injuries is rare, comprising only 0.2% of all military and civilian trauma, and only 0.5%-1.7% of all extremity fractures and dislocations. Vascular and trauma surgeons are more likely than orthopedic surgeons to encounter these injuries, as 10%-70% of all extremity arterial injuries are associated with skeletal trauma. In past years, the great majority of complex extremity injuries in the civilian sector have been caused by blunt trauma, although in some recent series penetrating trauma has caused a majority of these injuries. Combat injuries of this type from military series usually are due to high velocity penetrating trauma.

Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries. Debakey and Simeone documented this in WWII battle casualties, in which all injured arteries were ligated, reporting amputation in 60% of all combined injuries and 42% in isolated arterial injuries. Although McNamara and coworkers(65) reported a substantial improvement in limb salvage from isolated arterial injuries in the Vietnam War, combined injuries still had a 10-fold greater rate of limb loss(23% vs 2.5%). These authors also documented a higher incidence of failed vascular repair among combined extremity injuries (33%) than among isolated extremity arterial injuries(5%). Romanoff and coworkers reported more than a 3-fold increase in limb loss in combined combat extremity trauma compared to isolated arterial injuries (36% vs 11%) in the hostilities in Israel. This trend has continued into recent years in the civilian sector, even in the most experienced trauma centers, where amputation rates approaching 70% still are reported from combined arterial and skeletal extremity trauma, while less than 5% of limbs currently are lost following isolated arterial or skeletal trauma. Limb loss most commonly is attributed to delay in diagnosis and revascularization in most published series of this unique trauma. Major nerve damage, extensive soft tissue injury which disrupts collaterals and prevents adequate vessel coverage, infection, and compartment syndrome are other reasons for such a high rate of loss of these severely compromised limbs.

Diagnosis

Prompt diagnosis is essential if rapid treatment and optimal limb salvage is to be achieved in these complex extremity injuries. This requires that a high index of suspicion of arterial trauma be applied to every injured extremity by noting whether any hard signs are present (i.e. active hemorrhage, large, expanding or pulsatile hamatoma, bruit or thrill over wound, absent distal pulses, and signs of distal ischemia—the 5 P’s: pain, pallor, paralysis, paresthesias, poikilothermy, or coolness). The presence of hard signs in any blunt or complex extremity trauma requires immediate arteriography due to the relatively low incidence of surgically significant arterial injury in this setting. This is best done by the surgeon as a percutaneous hand-injected study in the trauma center, or on the operating table, to minimize time delay while achieving excellent accuracy.

Popliteal artery injury	Popliteal artery injury
Popliteal artery injuries following leg fractures with hard signs of vascular injury (reduced or absent distal pulses). Both angiograms were done as one-shot percutaneous angios and patients were then operated on immediately.

The absence of hard signs excludes major arterial injury with sufficient accuracy to allow further diagnostic workup to be avoided. Since most complex extremity trauma does not manifest hard signs, avoiding the considerable expense of arteriography in this population has substantial economic advantages.

Superficial femoral artery injury - intimal flap	Resolution at 6 weeks	Popliteal artery injury - nonocclusive	Resolution at 1 week
Blunt supracondylar femur fracture with asympomatic superficial femoral artery nonocclusive intimal flap identified on ER angiography. Non-operatively observed. 6 weeks later, after ORIF, repeat angiogram documents complete resolution of arterial injury.		Undisplaced tibial plateau fracture from gunshot wound with no hard signs. Angiogram shows non-occlusive intimal injury of the popliteal artery. The injury was observed and repeat angiogram one week later documents complete resolution.

This principle holds true even for the especially high-risk injury of posterior knee dislocation, in which setting routine arteriography has been advocated in all cases, due to a substantial risk of popliteal artery disruption and its associated high rate of limb loss. However, those published studies that compare the clinical manifestations of patients with posterior knee dislocation with outcome show no surgically significant arterial injuries in that majority of patients who have no hard signs (Table 1), confirmed by follow-ups of up to 2 years. Again, most cases present without hard signs, allowing major resource savings at no harm to the patient by using only physical findings to exclude arterial injury. Arteriography is indicated only in that minority of patients with knee dislocation presenting with hard signs, to exclude the need for surgery in those 30% of patients who do not have an arterial injury. Immediate surgery without imaging may be undertaken if the clinical picture clearly indicates vascular injury(i.e. absent pulse, cold ischemic foot).

There is no clear role for noninvasive testing in the initial evaluation of complex extremity injuries (Doppler pressures or signals, duplex U/S), due to a paucity of studies of their use in this category of trauma, and uncertainty over its accuracy in the presence of severe tissue disruption and large bulky dressings. Further study is necessary to clarify this. Again, the physical exam quite clearly answers all questions of management in this setting, as absent pulses mandates ruling out vascular injury, and present pulses in the absence of other hard signs reliably excludes vascular injury as well as any imaging modality. Noninvasives add nothing and may lead the examiner astray, as Doppler flow signals may be transmitted by collaterals around a completely occluded or transected vessel, while a pulse can not. Thus, Doppler flow signals DO NOT exclude a vascular injury. The presence or absence of a pulse is all that is necessary to decide on the next step in diagnosis.

Management

Appropriate prioritization of the management of the vascular and skeletal injuries is a major determinant of limb salvage. Initial fracture stabilization and fixation has been advocated in past years, due to concerns that an established vascular repair will be disrupted by subsequent orthopedic manipulation, as long as there is no overt ischemia. However, published evidence has refuted such concerns, showing minimal disruption of initial vascular repairs, and no adverse impact of prompt revascularization on outcome. Also, substantial tissue damage still can occur in the absence of clinical signs of ischemia, as our understanding of compartment syndrome has made clear. Further, clinical studies have shown a substantially higher rate of limb salvage among combined vascular and skeletal extremity injuries in which revascularization is performed first, compared with those in which it is delayed until the skeleton is addressed.

ER Arteriogram	Popliteal artery - End to end anastomosis	Completion arteriogram
Undisplaced, stable blunt tibial plateau fracture with no distal pulses. ER angiogram identified the popliteal artery injury. Immediate exploration and repair with end to end anastomosis, followed by internal fixation. Completion angiogram documents two vessel flow to foot. Prophylactic fasciotomy was performed.

In fact, definitive vascular repair should be delayed in cases of unstable or severely comminuted fractures or dislocations, segmental bone loss, or severe soft tissue destruction and contamination, due to the risk of undue tension or slack on the repaired vessel when the limb is fixed at its proper length, and to the possibility of disruption from skeletal manipulation. But this should not ever delay immediate restoration of perfusion to the extremity, which can be accomplished rapidly by temporary intraluminal shunting until skeletal stabilization and soft tissue debridement has been completed. Alternatively, immediate definitive vascular repair should be the means of initial revascularization in the setting of uncomplicated and stable skeletal injuries in which minimal subsequent manipulation and length discrepancy is anticipated.

Arteriogram	Popliteal artery injury	Shunt in place
Comminuted supracondylar femur crush fracture with no pulses. On-table angio in the operating room documented popliteal artery injury, leading to immediate vascular exploration. Transected popliteal artery was isolated, controlled, and shunted to restore distal flow while ex-fix placed to stabilize joint. Definitive arterial repair was then performed.

External fixation of the skeleton is preferred when rapid stabilization is necessary, in open, comminuted and unstable fractures, or in the presence of severe soft tissue disruption and contamination. Internal fixation has been used successfully in this setting, and is preferred if the patient’s condition permits.

The consensus of authorities now favors limb revascularization as the first priority in all combined extremity trauma. How the revascularization is accomplished(i.e. definitive repair or temporary shunting) is a matter of judgement based on the nature of the skeletal and soft tissue injuries and the condition of the patient. Only with a cooperative multidisciplinary effort, with close communication between the trauma, orthopedic and plastic surgeons, can the outcome of these injuries be optimized.

Elbow fracture-dislocation	Shunt in brachial artery
Saphenous vein repair	Completion arteriogram
Blunt elbow fracture-dislocation with brachial artery transection and large soft tissue degloving. Transected brachial artery was shunted and a cross-elbow ex-fix placed to stabilize the joint. Then a reversed saphenous vein graft arterial repair was performed. The completion angio documents two vessel flow to hand.

In addition to prompt diagnosis with on-table arteriography, liberal use of a number of surgical adjuncts has improved limb salvage following combined arterial and skeletal extremity trauma. Intra-operative completion arteriography is important to document patency of the repair, as any technical errors could easily result in limb loss in these severely compromised limbs. Four compartment fasciotomy should be applied liberally and prophylactically in this setting due to the high risk of compartment syndrome following reperfusion. Extra-anatomic bypass, and pedicled or free-tissue flap coverage should be considered in the setting of severe contamination and soft tissue injury or loss to protect the vascular repair. Careful attention to all of these considerations, as well as to avoiding unnecessary surgery for nonocclusive arterial lesions, and meticulous postoperative surveillance, has led to dramatic improvements in limb salvage, with amputation rates even in this challenging setting falling below 10% in a small number of recent studies.

The decision to amputate

Among the most difficult challenges in the management of complex extremity trauma is the decision as to whether and when amputation is indicated. Recent advances in the ability to salvage limbs have led to prolonged and aggressive reconstruction efforts following injuries which would have undergone amputation in the past. Such heroic efforts actually may harm patients in terms of prolonging hospitalization and time lost from work, as well as increasing sepsis, operative procedures, and even mortality. These outcomes are especially undesirable if amputation or severe limb dysfunction ultimately occur anyway.

Although it is often difficult to predict soon after injury which extremities will require amputation, there are injuries of such destruction and severity that a decision for immediate, or primary, amputation can be made easily. These are injuries in which it is obvious that attempts at revascularization are futile due to the extent of soft tissue and skeletal trauma, major nerves are transected, or other life-threatening injuries are present which prevent any attention to the limbs. Gustilo III-C injuries (comminuted open tibial-fibular fractures with arterial injury) are an example of limb trauma generally mandating immediate amputation.

However, most complex extremity injuries are not that clear cut. In these cases, immediate revascularization should be performed, along with important surgical adjuncts such as shunts, fasciotomy, or extra-anatomic bypass, the skeleton should be stabilized promptly by either traction or external fixation, and then the extremity should be observed over the next 24-48 hours to determine what level of function and tissue viability returns. Nerve transection never should be assumed, but only determined by direct visualization, as vascular insufficiency or muscle damage alone may cause profound deficits that can be confused with nerve damage. If revascularization fails, tissue loss is severe or worsens, systemic sepsis or crush syndrome develops, or profound neurologic or functional deficits persist, amputation then should be performed. If improvement occurs, limb salvage may proceed, but should be assessed just as critically at each successive stage to minimize unnecessarily prolonged, costly and futile efforts.

Mangled Upper Extremity	Crush to lower leg
Mangled upper extremity treated by immediate amputation.	Comminuted tibia & fibula fractures from crush injury in a 64 year old diabetic male with no distal pulses and acute ischemic changes. Underwent immediate below-knee amputation.

A number of scoring systems have been developed to objectify this difficult decision that is so often clouded by subjective and wishful thinking, often at the patient’s expense. Although none have been found to be prospectively useful in predicting amputation or the degree of functional impairment, they do focus attention on those factors which most closely correlate with outcome, and which must be a part of the treatment decision.

High-Risk Factors for Ultimate Limb Loss or Severe Dysfunction

• Gustilo III - C skeletal injuries
• Transected tibial or sciatic nerve
• Transection of 2 of 3 upper extremity nerves
• Prolonged ischemia (> 6-12 hours)
• Shock and life-threatening associated injuries
• Below-knee arterial injury
• Extensive soft tissue loss
• Crush injury
• Multiple fractures
• Elderly with medical comorbidity
• Severe contamination
• Patient preference

Another major consideration in this decision is whether the injury is in the upper or lower extremity, as the former is less likely to require amputation, being more tolerant of deficits in protective sensation, motor function, weight-bearing concerns, and length discrepancy, and prostheses tend to be less satisfactory.

This decision must be a matter of clinical judgement based on each individual case, and it must always involve a consensus of the entire health care team, including the trauma, orthopedic, vascular and plastic surgeons, rehabilitation specialist, psychologist, nursing, and most importantly the patient and family. The sophistication of limb prostheses, prompt return to work, short hospitalizations and lower costs and morbidity following early amputation are often preferable to salvage efforts which may take months or years and still fail. The ultimate goal is to return the patient to a comfortable, self-sufficient and productive life as quickly as possible.

Management Algorithm

1. Resuscitation

Resuscitation and management of all life-threatening injuries must take priority over any extremity problems. Only active extremity hemorrhage must be controlled at this time by direct pressure, tourniquet, or direct clamping of visible vessels (in that order of preference) as a life saving measure. Blind clamping in wounds is discouraged and potentially harmful to limb salvage.

Once attention is directed to the extremity, neurovascular injury must be assumed in all injured extremities until definitively excluded as the first diagnostic priority. Vascular injury must be found and treated within 6 hours to maximize the chance of limb salvage, as it is the major determinant of limb salvage.

2. Risk factors for amputation

• Gustilo III-C injuries – comminuted, open tib-fib fractures with vascular disruption.
• Sciatic or tibial nerve, or two of the three major upper extremity nerves, anatomically transected
• Prolonged ischemia (>4-6 hours)/muscle necrosis
• Crush or destructive soft tissue injury
• Significant wound contamination
• Multiple/severely comminuted fractures/segmental bone loss
• Old age/severe co-morbidity
• Lower vs. upper extremity
• Apparent futility of revascularization/failed revascularization

These factors have been applied over the course of the last two decades in several scoring systems to predict primary amputation. Although the scoring systems have validated these factors to be associated with a worse prognosis for limb salvage, none have adequate prospective reliability to permit a definitive decision for amputation to be made solely based on a score alone.

3. Amputation technique

If early amputation is deemed necessary, a “guillotine-type” amputation should be performed at an appropriate level above the destructive wound. Marginally viable soft tissue should be preserved and the open wound copiously irrigated and débrided of contaminating debris. The amputation stump should be dressed with a bulky absorbent dressing and protective splint if amputation is below the knee and/or elbow. Early return to the operating room for further wound debridement and definitive management should be anticipated.

If the need for amputation is not clear on initial presentation, limb salvage should be attempted and the extremity observed carefully for the next 24-48 hours for soft tissue viability, skeletal stability, and sensorimotor function.

4. Hards signs of vascular injury

• Active hemorrhage
• Large, expanding or pulsatile hematoma
• Bruit or thrill over the wound(s)
• Absent palpable pulses distally
• Distal ischemic manifestations (pain, pallor, paralysis, paresthesias, poikilothermy, or coolness)

5. Investigation

The presence of any one or more hard signs mandates immediate arterial imaging to confirm or exclude vascular injury. Most hard signs in this setting (as much as 87%) are NOT due to vascular injury, but rather to soft tissue and bone bleeding, traction of intact arteries to lose pulses, or compartment syndrome. When imaging is not possible, immediate surgical exploration of the vessel at risk must be done. If these measures exclude surgically significant vascular injury (i.e. no occlusion, extravasation, transection) then the treatment of soft tissue and skeletal injuries may proceed. *How this reperfusion is achieved depends on the patient’s hemodynamic status, physiologic parameters, skeletal stability, wound characteristics, and resource availability.

6. Fasciotomy

A 2-incision, 4 compartment fasciotomy of the distal extremity should be performed liberally in complex extremity trauma at the time of initial revascularization due to the high risk of compartment syndrome. If it is elected not to do this immediately, observation must include the frequent direct measurement of compartment pressures due to the poor sensitivity of the clinical examination for the presence of compartment syndrome.

7a. Damage control

A definitive vascular repair should be avoided, and there should be consideration for placement of a temporary intraluminal shunt in the proximal and distal ends of the injured vessel after distal thrombectomy and regional or systemic heparinization (if not contraindicated) in the following settings:

• Hemodynamic instability, coagulopathy, acidosis, hypothermia of the patient
• Unstable skeleton
• Major wound contamination/infection or soft tissue deficits precluding wound coverage
• Requirement for any definitive repair more complex than lateral suture or end to end anastomosis (i.e. extra-anatomic bypass, interposition graft)
• Austere environment with no resources for definitive management
• Other life threatening injuries requiring urgent management

If tourniquet control or ligation of injured extremity vessels are the only means of controlling life-threatening hemorrhage, and reperfusion is not possible due to the nature of the wound or the environment, then immediate evacuation is necessary to achieve revascularization within 6 hours if limb salvage is to be attempted.

7b. Definitive repair

Definitive repair should be performed provided:

• Hemodynamic and physiologic stability of patient
• Stable skeleton
• Clean wound with adequate viable soft tissue
• Availability of necessary time and resources
• No other injuries requiring more urgent management

8. Vascular shunts

Many commercial plastic intraluminal shunts are available. However plastic IV tubing, or connecting tubing that accompanies many closed suction drains, is sufficient if irrigated with heparinized saline before use. The ends of the tubing are placed in the proximal and distal segments of the injured artery, secured by a silk suture tied around the vessel over the shunt and then also tied directly on the shunt itself to prevent dislodgement. Alternatively, shunt clamps are available to clamp the vessel over the shunt. Flow through the shunt should be monitored regularly by palpating distal arterial pulsation and/or using a Doppler device to detect flow signals through the shunt or distal vessel. If flow ceases, the shunt and distal vessel must be thrombectomized with a Fogarty catheter and reinserted. If not contraindicated, systemic heparinization may facilitate shunt flow.

9. Skeletal stabilization

Only skeletal stabilization by splint or external fixation should be done after reperfusion in those settings found in 7a above. Definitive internal fixation of skeletal extremity injuries should be delayed until conditions in 7b above are reached, and after definitive vascular repair is performed.

10. Exclusion of clinically significant vascular injury

The absence of any hard sign in an injured extremity excludes a surgically significant vascular injury as reliably as any imaging modality. If all hard signs are absent, no vascular imaging or exploration is necessary, and treatment of skeletal and soft tissue injuries may proceed immediately.

11. Wound management

Wounds should be inspected frequently and any dead/necrotic tissue should be débrided and dressings changed accordingly.

12. Secondary amputation

Amputation after initial attempts at limb salvage should be considered if risk factors for limb loss persist. However, the patient’s family, as well as involved surgical specialists, should be informed and involved in this decision whenever possible. Efforts to avoid excessive morbidity, cost, procedures, and hospital stay for limbs that will ultimately be amputated or without function should be avoided. Any adverse impact of the extremity on the patient’s health, i.e. sepsis, rhabdomyolysis, hyperkalemia, ARDS, or other life-threatening problems mandate immediate secondary amputation.

13. Limb salvage

Continue limb salvage efforts and monitor patient closely for changes that may warrant secondary amputation.

References

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Authors & Contributors

Eric R. Frykberg, MD. FACS

Professor of Surgery, University of Florida, Jacksonville, Florida