Excerpts from EAST Practice Management Guidelines for

Combined Vascular and Skeletal Trauma

The EAST Practice Management Guidelines Work Group:

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).

Restoration of blood flow does not have to be through immediate definitive vascular repair. Temporary vascular shunts effectively solve the dilemma of severely comminuted and unstable fractures/dislocations, in which setting definitive vascular repair cannot be accomplished until the skeleton is stabilized. Shunting still allows immediate restoration of blood flow, without worry of anastomotic disruption. It should also be considered in unstable patients who will not tolerate further surgery. The definitive vascular and skeletal repair may then follow whenever appropriate (3,6,7,18,23).

It is reasonable to recommend that orthopedic surgeons be consulted and actively participate in the management decisions immediately after combined extremity injury is diagnosed, although there is no firm evidence to prove benefit. Smooth interdisciplinary teamwork is essential to achieving the primary goal of rapid diagnosis and treatment.

In order to document anastomotic patency and distal flow, performance of intra-operative completion arteriography is considered critical following arterial repair in combined extremity trauma (6,23). This is especially important when palpable pulses and signs of distal perfusion are uncertain. Bishara et al, reported that routine completion arteriograms led to detection of unsuspected problems which required revision of repairs in 16% of cases (2). Certainly any loss of pulses postoperatively mandates immediate investigation by either arteriography or surgery, as further ischemia will threaten limb salvage.

The proper method of fracture management has been debated, although it is probably not affected by the concomitant arterial injury to any great extent. Military series have demonstrated a clear advantage of external fixation over internal fixation in the immediate management of these complex, open and highly contaminated combat fractures. Civilian series, which involve lower risk and less complex wounds, have shown good results with internal fixation, although some exclusively applied external fixation (2,9,10). This evidence suggests that combined injuries with a substantial risk of infection (i.e. open, comminuted, severe soft tissue damage), with very comminuted or unstable skeletal injuries, or those in unstable patients who require rapid treatment, are best managed with external fixation, either as a definitive or temporizing measure.

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.