Excerpts from EAST Practice Management Guidelines for
Combined Vascular and Skeletal Trauma
The EAST Practice Management Guidelines Work Group:
Prompt diagnosis of vascular injury in any injured extremity is essential because of the well established direct relationship between the time interval from injury to treatment and the chance of limb loss. This principle is confirmed by several series which cite prolonged ischemia, delay in restoration of blood flow, or failure of vascular repair as the most common reasons for limb loss in combined arterial and skeletal extremity injuries (3,4,6-8,10). Arteriography is the modality of choice to confirm or exclude arterial injury, although the indications for its use are debated. Unlike isolated arterial injuries, an associated skeletal injury significantly decreases the predictive value of physical exam findings, since hard signs of vascular injury may be due solely to the bone injury or associated soft tissue injury, without any damage to major vessels, in as many as 60% to 70% of cases (2,3,17). Therefore, immediate arteriography is warranted in combined extremity trauma manifesting hard signs , in order to avoid up to a 70% rate of unnecessary limb exploration (10).
Several recent series suggest that a negative physical examination following combined injury (i.e. no hard signs present) reliably excludes vascular injury which requires repair. Nonocclusive vascular injuries with benign natural history, however, may occur. Three series report a total of 98 asymptomatic combined extremity injuries from both blunt and penetrating trauma, of which only one underwent surgical repair: an intimal flap of a distal radial artery which may have not required surgery ( 5,11,17). One series followed 15 asymptomatic nonocclusive arterial injuries from combined extremity trauma for a mean of 6.5 months, none requiring intervention (5). Authors now recommend that arteriography is not necessary for combined extremity trauma with no hard signs of vascular injury.
Current evidence suggests that nonoperative observation of asymptomatic nonocclusive extremity arterial injuries found on arteriography is safe (21).
This appears true in the specific setting of combined arterial and skeletal trauma, where some arterial injuries have been observed (2,5,10,11). In two studies, only one of 45 nonocclusive arterial injuries in this setting underwent surgery, without a single amputation or complication related to arterial injury. Fifteen of these occult vascular injuries were followed for an average of 6.5 months, and the avoidance of vascular exploration in these severely injured limbs was felt to contribute to the low (7.3%) overall amputation rate (5).
Although noninvasive vascular studies, Doppler pressure measurements and duplex ultrasonography, have been used in this setting, there is no evidence of any benefit or role for these studies in this setting (2,17,18). In fact, the significant swelling, soft tissue and bone disruption, bulky splints and dressings that characterize these injuries cast doubt on the utility and validity of these tests. Arteriography is clearly the modality of choice for evaluation of high risk extremity skeletal trauma for vascular injury. Studies have shown that restoration of blood flow within six hours, both with and without skeletal injury significantly improves limb salvage (3,10). There are studies which fail to show a clear correlation between time delay and outcome and some with average treatment delays in excess of eight hours which report amputation rates equivalent to those with prompt treatment within six hours (1,2,4,5,8,9,10). This again stresses that multiple variables affect outcome, and they cannot be controlled in retrospective reports. However, the weight of evidence indicates that rapid diagnosis must be followed as expeditiously as possible by restoration of blood flow.
Studies in the past have recommended that skeletal repair should be done routinely prior to vascular repair (19). More recent studies have advocated selective initial vascular repair only when limb ischemia is clinically evident (1,2,4,7). The rationale for orthopedic priority was the potential disruption of a fresh vascular anastomosis by subsequent manipulation of bone fragments, or length discrepancies in the vascular repair caused by subsequent stabilization of comminuted, unstable skeletal injuries. However, evidence has refuted these conjectures. Snyder et al, noted vascular repair disruption in only 2/29 (7%) cases, neither of which affected outcome as they were repaired immediately (6). Howe et al, found no cases of vascular disruption in 21 combined injuries with subsequent orthopedic repair (3). This data is further supported by studies showing significantly lower amputation rates in those undergoing restoration of blood flow prior to skeletal repair than in those undergoing skeletal repair first (19,22). Although some studies showed either a higher amputation rate, or no difference in amputations, when revascularization was done first, their validity is suspect because vascular priority was only applied to the most ischemic limbs (1,4,8). Howe et al, emphasize that the known importance of a short time interval to revascularization, as discussed above, as well as the absence of any demonstrable disadvantage, should be enough justification to always revascularize first, which is the current consensus (3,5,6,9,14,23).
VII. References
1. Drost TF, Rosemurgy AS, Proctor D, et al. Outcome of Treatment of Combined Orthopedic and Arterial Trauma to the Lower Extremity. J Trauma 29: 1331-1334, 1989.
2. Bishara RA, Paasch AR, Lim LT, et al. Improved Results in the Treatment of Civilian Vascular Injuries Associated with Fractures and Dislocations. J Vasc Surg 3: 707-711, 1986.
3. Howe HR, Poole GV, Hansen KJ, et al. Salvage of Lower Extremities Following Combined Orthopedic and Vascular Trauma: A Predictive Salvage Index. Am Surg 53: 205-208, 1987.
4. Poole GV, Agnew SG, Griswold JA, et al. The Mangled Lower Extremity: Can Salvage be Predicted? Am Surg 60: 50-55, 1994.
5. Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Patterns of Arterial Injuries Associated with Fractures and Dislocations. J Am Coll Surg 183: 377-383, 1996.
6. Snyder WH. Vascular Injuries Near the Knee: An Updated Series and Overview of the Problem. Surgery 91: 502-506, 1982.
7. Keeley SB, Snyder WH, Weigelt JA. Arterial Injuries Below the Knee: Fifty-one Patients with 82 Injuries. J Trauma 23: 285-292, 1983.
8. Russell WL, Sailors DM, Whittle TB, et al. Limb Salvage Versus Traumatic Amputation: A Decision Based on a Seven-Part Predictive Index. Ann Surg 213: 473-481, 1991.
9. Swetnam JA, Hardin WD, Kerstein MD. Successful Management of Trifurcation Injuries. Am Surg 52: 585-587, 1986.
10. Bongard FS, White GH, Klein SR. Management Strategy of Complex Extremity Injuries. Am J Surg 158: 151-155, 1989.
11. Norman J, Gahtan V, Franz M, et al. Occult Vascular Injuries Following Gunshot Wounds Resulting in Long Bone Fractures of the Extremities. Am Surg 61: 146-150, 1995.
12. Graham JM, Mattox KL, Feliciano DV, et al. Vascular Injuries of the Axilla. Ann Surg 195: 232-238, 1982.
13. Borman KR, Snyder WH, Weigelt JA. Civilian Arterial Trauma of the Upper Extremity: An
11 Year Experience in 267 Patients. Am J Surg 148: 796-799, 1984.
14. Ashworth EM, Dalsing MC, Glover JL, et al. Lower Extremity Vascular Trauma: A Comprehensive Aggressive Approach. J Trauma 28: 329- 336, 1988.
15. McCroskey BL, Moore EE, Pearce WH, et al. Traumatic Injuries of the Brachial Artery. Am J Surg 156: 553-555, 1988.
16. Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-522, 1991.
17. Applebaum R, Yellin AE, Weaver FA, et al. Role of Routine Arteriography in Blunt Lower Extremity Trauma. Am J Surg 160: 221-225, 1990.
18. Gates JD. The Management of combined Skeletal and Arterial Injuries of the Lower Extremity. Am J Orthoped 24: 674-680, 1995.
19. Lim LT, Michuda MS, Flanigan DP, et al. Popliteal Artery Trauma. Arch Surg 115: 1307-1313, 1980.
20. Itani KMF, Burch JM, Spjut-Patrinely V, et al. Emergency Center Arteriography. J Trauma 32: 302-307, 1992.
21. Frykberg ER, Crump JM, Dennis JW, et al. Nonoperative Observation of Clinically Occult Arterial Injuries: A Prospective Evaluation. Surgery 109: 85-96, 1991.
22. McCabe CJ, Ferguson CM, Ottinger LW. Improved Limb Salvage in Popliteal Artery Injuries. J Trauma 23: 982-985, 1983.
23. Allen MJ, Nash JR, Ioannidies TT, et al. Major Vascular Injuries Associated with Orthopedic Injuries to the Lower Limb. Ann Royal Coll Surg 66: 101-104, 1984.
24. Moniz MP, Ombrellaro MP, Stevens SL, et al. Concomitant Orthopedic and Vascular Injuries as predictors for Limb Loss in Blunt Lower Extremity Trauma. Am Surg 63: 24-28, 1997.
25. Bonanni F, Rhodes M, Lucke JF. The Futility of Predictive Scoring of Mangled Lower Extremities. J Trauma 34: 99-104, 1993.