Assessment, Interventions for Vascular Injuries in Fractures

Abstract and Introduction

Abstract

Vascular injuries associated with fractures are limb-threatening injuries with notable morbidity. The prompt and thorough evaluation of these patients is imperative to diagnose vascular injuries, and coordinated multidisciplinary care is needed to provide optimal outcomes. The initial assessment includes a detailed physical examination assessing for hard and soft signs of arterial injury, and the arterial pressure index can be used to reliably identify vascular compromise and the need for additional assessment or intervention. Advanced imaging in the form of CT angiography is highly sensitive in additional characterization of the potential injury and can be obtained in an expedient manner. The optimal treatment of fractures with vascular injuries includes providing skeletal stability and confirming or reestablishing adequate distal perfusion as soon as possible. Options for vascular intervention include observation, ligation, direct arterial repair, vascular bypass grafting, endovascular intervention, and staged temporary shunting, followed by bypass grafting. Although the optimal sequence of surgical intervention remains an incompletely answered question, the orthopaedic role in the care of patients with these injuries is to provide mechanical stability to the injured limb to protect the vascular repair and surrounding soft-tissue envelope.

Introduction

Historically, traumatic vascular injuries associated with fractures have been more commonly studied in military populations in contrast to civilian settings. Because of improved overall trauma care, resuscitation, and patient survival, these injuries have become increasingly more prevalent in the modern society and are frequently encountered by orthopaedic surgeons.^[1] Prompt recognition of a vascular injury is an essential skill for any practicing orthopaedic surgeon because these injuries can be subtle during initial presentation. Minimizing warm ischemia time is critical in successful treatment of vascular injuries because this has been shown to prevent irreversible muscle and neurologic changes and the need for potential limb amputation.^[2] Patients presenting with fractures of long bones, pelvic fractures, dislocations adjacent to major vessels, or crush injuries are at markedly higher risk for loss of limb or life when the recognition of vascular trauma is delayed. The incidence of vascular injury is widely variable and dependent on multiple factors such as fracture location and mechanism of injury. Low-energy pelvic ring fractures, for example, are rarely associated with vascular injuries.^[3] By contrast, the incidence of vascular injuries in open tibial fractures has been shown to be as high as 29%.^[4]

In the acute setting, combined vascular and orthopaedic trauma may be managed with temporary intravascular shunts or definitive vascular repair or reconstruction.^[5] After the diagnosis of a vascular injury with an associated fracture, injured limbs should be reperfused, and fractures should be stabilized to allow for prompt restoration of arterial blood flow and adequate skeletal stability to prevent secondary vascular injury. Previous studies have highlighted the importance of surgical intervention within 6 to 8 hours after the event because delay in arterial continuity >8 hours is associated with an amputation rate as high as 86%. Specifically, the Lower Extremity Assessment Project study showed that prolonged ischemia time after popliteus artery injury and knee dislocation was the primary factor determining the need for amputation.^[2,6,7] Regardless of the treatment strategy, management should involve a multidisciplinary approach and direct communication among trauma, vascular, and orthopaedic surgeons to determine the sequence and priority of surgical procedures. In this article, we present a comprehensive review of these injuries with an emphasis on assessment and surgical interventions.