Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma

Abstract

Objective: In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients.

Methods: Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded.

Results: A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study.

Conclusion: In orthopedic trauma, “Hard signs” and “soft signs” combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients’ prognosis.

Keywords

Angiography / Extremity trauma / Fracture / Orthopedic trauma / Vascular injury

References

[1] Herrera MA, Millán M, Del Valle AM, Betancourt-Cajiao M, Caicedo Y, Caicedo I, et al. Damage control of peripheral vascular trauma -Don’t be afraid of axillary or popliteal fosses. Colomb Med (Cali). 2021; 52(2): e4074735.

[2] Johannesdottir BK, Geisner T, Gubberud ET, Gudbjartsson T. Civilian vascular trauma, treatment and outcome at a level 1-trauma centre. Scand J Trauma Resusc Emerg Med. 2022; 30(1): 74.

[3] Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. J Pediatr Surg. 2010; 45(7): 1404–1412.

[4] Mavrogenis AF, Panagopoulos GN, Kokkalis ZT, Koulouvaris P, Megaloikonomos PD, Igoumenou V, et al. Vascular injury in orthopedic trauma. Orthopedics. 2016; 39(4): 249–259.

[5] Romagnoli AN, DuBose J, Dua A, Betzold R, Bee T, Fabian T, et al. Hard signs gone soft: a critical evaluation of presenting signs of extremity vascular injury. J Trauma Acute Care Surg. 2021; 90(1): 1–10.

[6] Perkins ZB, De’Ath HD, Aylwin C, Brohi K, Walsh M, Tai NR. Epidemiology and outcome of vascular trauma at a British major trauma Centre. Eur J Vasc Endovasc Surg. 2012; 44(2): 203–209.

[7] Alavi A, Sibbald RG, Nabavizadeh R, Valaei F, Coutts P, Mayer D. Audible handheld Doppler ultrasound determines reliable and inexpensive exclusion of significant peripheral arterial disease. Vascular. 2015; 23(6): 622–629.

[8] Khajuria A, Geoghegan L, Solberg Y, Reissis D, Jain A, Ives M, et al. Selective non-operative management for penetrating extremity trauma: a paradigm shift in management? J Plast Reconstr Aesthet Surg. 2018; 71(9): 1239–1244.

[9] Kwasnicki RM, Burgin J, Paton C, Hettiaratchy S. Pulse oximetry for the diagnosis of vascular injury following limb trauma. J Plast Reconstr Aesthet Surg. 2022; 75(9): 3182–3189.

[10] Perry MO. Complications of missed arterial injuries. J Vasc Surg. 1993; 17(2): 399–407.

[11] Feliciano DV. Management of peripheral arterial injury. Curr Opin Crit Care. 2010; 16(6): 602–608.

[12] Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, et al. Evaluation and management of penetrating lower extremity arterial trauma: an eastern Association for the Surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 suppl 4): S315–S320.

[13] Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg ER. Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study. J Trauma. 2002; 52(2): 247–251. discussion 51–2.

[14] Marcia L, Kim DY. Predictors of peripheral vascular injury in patients with blunt lower extremity fractures. Ann Vasc Surg. 2019; 57: 35–40.

[15] Kauvar DS, Wade CE. The epidemiology and modern management of traumatic hemorrhage: US and international perspectives. Crit Care. 2005; 9(suppl 5): S1–S9.

[16] Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al. Vascular injury associated with extremity trauma: initial diagnosis and management. J Am Acad Orthop Surg. 2011; 19(8): 495–504.

[17] Gilbert F, Schneemann C, Scholz CJ, Kickuth R, Meffert RH, Wildenauer R, et al. Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma. BMC Musculoskelet Disord. 2018; 19(1): 404.

[18] D’Alessio I, Domanin M, Bissacco D, Romagnoli S, Rimoldi P, Sammartano F, et al. Operative treatment and clinical outcomes in peripheral vascular trauma: the combined experience of two centers in the endovascular era. Ann Vasc Surg. 2020; 62: 342–348.

[19] White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011; 253(6): 1184–1189.

[20] Stefanou N, Arnaoutoglou C, Papageorgiou F, Matsagkas M, Varitimidis SE, Dailiana ZH. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop. 2022; 13(5): 411–426.

[21] Rollo G, Falzarano G, Ronga M, Bisaccia M, Grubor P, Erasmo R, et al. Challenges in the management of floating knee injuries: results of treatment and outcomes of 224 consecutive cases in 10 years. Injury. 2019; 50(suppl 4): S30–S38.

[22] Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics. 2008; 31(8): 761–767.

RIGHTS & PERMISSIONS

2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.