M J Allen, J R Nash, T T Ioannidies, P R Bell
Major vascular injuries associated with orthopaedic injuries to the lower limb.
Ann R Coll Surg Engl. 1984 Mar;66(2):101-4.
Abstract/Text
The management of 14 patients with combined orthopaedic and vascular injury of the lower limb have been reviewed. Six of the 14 limbs were amputated, 5 have a residual functional defect and 3 were restored to normal function. Delay in diagnosis and failure to treat the consequences of soft tissue injury and ischaemia were mainly responsible for the poor results. The results of internal fixation were poor and the possible use of external fixation has been discussed. The importance of a sound technique for vascular repair with post reconstruction on-table arteriography has also been discussed.
John Fowler, Neil Macintyre, Saqib Rehman, John P Gaughan, Shawn Leslie
The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: A meta-analysis.
Injury. 2009 Jan;40(1):72-6. doi: 10.1016/j.injury.2008.08.043. Epub 2008 Dec 13.
Abstract/Text
OBJECTIVE: The optimal sequence of surgical repair for lower extremity injury with associated vascular injuries is unclear. Lower extremity injury in our study is defined as femoral fracture, tibial fracture, and/or knee dislocation. Advocates of performing the vascular repair prior to lower extremity fixation argue that reversal of ischaemia in the limb is the most important factor in limb survival and should take precedence. Advocates of lower extremity fixation prior to revascularisation worry that the manipulation during fixation could disrupt the vascular repair and that total ischaemia time is more relative than absolute.
METHODS: A literature search was performed to identify studies with the following criteria: adult population, femoral fracture, tibial fracture, and/or knee dislocation with associated vascular injury, an intervention of fracture fixation or knee stabilisation prior to revascularisation and/or revascularisation prior to fracture fixation, and amputation as an outcome measurement.
RESULTS: 934 articles were identified and narrowed to 14 articles through exclusion criteria. Meta-analysis of the data shows no statistical difference in regards to the incidence of amputation between lower extremity fixation prior to revascularisation and revascularisation prior to fracture fixation.
CONCLUSION: Lower extremity injuries with associated vascular injury are uncommon. There has been a widespread but unsupported belief that manipulation and traction during lower extremity fixation will disrupt the vascular repair. Ischaemic time should be considered a relative, but not absolute predictor of amputation. Soft tissue injury and neurologic deficits have been found highly correlated with disability and amputation. Surgical sequence has not been shown to affect the rate of amputations in lower extremity fractures.
P W Howard, G S Makin
Lower limb fractures with associated vascular injury.
J Bone Joint Surg Br. 1990 Jan;72(1):116-20.
Abstract/Text
We report the management and outcome of 35 lower limb fractures with associated severe vascular injuries treated over a 15-year period. Limb survival was related to the period of ischaemia. Management of the fractures by immediate open reduction and internal fixation was associated with a higher amputation rate than either external fixation or simple splintage, particularly for upper tibial injuries. External fixation is recommended as the method of choice for the stabilisation of the skeletal injury. A selective policy is advised for fasciotomy.
Philip S Mullenix, Scott R Steele, Charles A Andersen, Benjamin W Starnes, Ali Salim, Matthew J Martin
Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank.
J Vasc Surg. 2006 Jul;44(1):94-100. doi: 10.1016/j.jvs.2006.02.052.
Abstract/Text
PURPOSE: Popliteal arterial trauma carries the greatest risk of limb loss of any peripheral vascular injury. The purpose of this study was to analyze outcomes after popliteal arterial injuries and identify factors contributing to disability.
METHODS: A retrospective analysis was conducted of prospectively collected trauma data from the National Trauma Data Bank (NTDB). We studied all patients with popliteal arterial injury in terms of demographics, injury patterns, interventions, limb salvage, resource utilization, and outcomes.
RESULTS: We identified 1395 popliteal arterial injuries among the 1,130,000 patients in the NTDB, for an incidence <0.2%. The patients were 82% male, with a mean age of 33 years, and they presented with a mean initial systolic blood pressure of 124 mm Hg, base deficit -4.6, injury severity score of 11.8, and an extremity abbreviated injury score of 2.6. The mechanism was blunt in 61% and penetrating in 39%, and significant baseline demographic differences existed between the two groups. Associated ipsilateral lower-extremity trauma included combined popliteal arterial and venous (AV) injuries, fractures and dislocations, and major nerve disruptions. Fasciotomies were performed in 49%, complex soft tissue repairs in 24%, and amputations in 14.5%. The overall mean hospital and intensive care unit lengths of stay were 16.9 and 5.9 days. The mean functional independence measure for locomotion was 2.8, but was significantly lower for patients with blunt trauma. In-hospital mortality was 4.5% and did not significantly differ by mechanism. Amputation rates were 15% with combined AV injuries, 21% for associated nerve injuries, 12% for major soft tissue disruptions, and 21% for femur, 12% for knee, and 20% for tibia-fibula fractures or dislocations. Among the 312 patients with combined AV injuries, those with blunt mechanism had a significantly higher amputation rate than those with penetrating injury (27% vs 9%, P < .001). Adjusting for age, gender, mechanism, and overall physiologic impact of injuries sustained, independent predictors of amputation in logistic regression analysis of the entire cohort included fracture (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.4 to 4.1), complex soft tissue injury (OR, 1.9; 95% CI, 1.2 to 3.0), nerve injury (OR, 1.7; 95% CI, 1.1 to 2.8), and extremity abbreviated injury score (OR, 1.6; 95% CI, 1.2 to 2.2).
CONCLUSIONS: Popliteal vascular injury remains an uncommon but challenging clinical entity associated with significant rates of limb loss, functional disability, and mortality. Blunt vs penetrating mechanism and associated musculoskeletal injuries generally involve longer hospital stays, worse functional outcomes, and twice the amputation rate.
Fernando E Miranda, James W Dennis, Henry C Veldenz, Peter S Dovgan, Eric R Frykberg
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 Feb;52(2):247-51; discussion 251-2.
Abstract/Text
BACKGROUND: Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation.
METHODS: All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients.
RESULTS: There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval.
CONCLUSION: This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.
R H Lange, A W Bach, S T Hansen, K H Johansen
Open tibial fractures with associated vascular injuries: prognosis for limb salvage.
J Trauma. 1985 Mar;25(3):203-8.
Abstract/Text
Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.
N E Green, B L Allen
Vascular injuries associated with dislocation of the knee.
J Bone Joint Surg Am. 1977 Mar;59(2):236-9.
Abstract/Text
Two hundred and forty-five knee dislocations were analyzed including forty-one new cases. The high incidence of injuries to the popliteal artery that accompanies this lesion (32 per cent) was confirmed, and it was re-emphasized that vascular repair must be completed within six or at the most eight hours from the time of injury to avoid amputation. Of the patients not treated within that time period, 86 per cent had an amputation and two-thirds of the remaining 14 per cent had ischemic changes.
L R Stayner, M J Coen
Historic perspectives of treatment algorithms in knee dislocation.
Clin Sports Med. 2000 Jul;19(3):399-413.
Abstract/Text
Knee dislocation remains a devastating injury with many complications. It necessitates prompt diagnosis, reduction if needed, and emergent repair of any vascular injury. Serial physical examinations and frequent use of arteriograms are necessary to avoid late vascular complications. Many authors are concerned that normal pulses, normal Doppler signals, and normal ABIs have preceded late ischemia and documented intimal tear, demonstrated by arteriography. More recently, other authors have challenged the gold standard of mandatory arteriography by describing studies in which physical examination was 100% accurate in diagnosing patients without operative vascular injury. If pedal pulses, Doppler signals, or ABIs are asymmetric before or after reduction then either immediate operative exploration or arteriography should be performed. If the initial physical examination is normal, serial examinations are used in the hospital to check for late artery thrombosis. Opponents of mandatory arteriography point to a 5% false-negative rate, high cost, and an 8% complication rate, such as contrast allergy, pseudoaneurysm, local hematoma, and arteriovenous fistula. Today a consensus is that repair and reconstruction of the PCL and posterolateral corner injuries are the primary concerns in the multiple-ligament injured knee after dislocation. The ACL may be repaired later if instability persists, but some investigators believe it should not be repaired acutely, thereby avoiding increased surgical trauma and possible stiffness. Recently one of the goals of ligamentous repair and reconstruction has been to provide stability with the least invasive surgical technique to avoid postoperative stiffness. Recent treatments have focused on early arthroscopic-assisted allograft reconstruction of the ACL and PCL. Allograft provides a less invasive means of graft support than autograft. Early, limited range of motion in a brace helps to maintain flexion and extension.
R J Caudle, P J Stern
Severe open fractures of the tibia.
J Bone Joint Surg Am. 1987 Jul;69(6):801-7.
Abstract/Text
Sixty-two Type-III open fractures of the tibial shaft are reported on. Eleven were Type IIIA, and three of them had non-union while none were associated with deep infection or required secondary amputation. Forty-two were Type IIIB, and fifteen of them had non-union, twelve were associated with deep infection, and seven required secondary amputation. However, in the twenty-four Type-IIIB fractures that were treated with early restoration of the damaged soft tissue by local flaps or free tissue transfer, the rate of complications was significantly reduced to five non-unions, two deep infections, and two secondary amputations. Unfortunately, of the nine Type-IIIC injuries, seven ultimately required secondary amputation, from two days to sixty-three months after the initial injury, because of pain, sepsis, non-union, or failure of the vascular repair. Only two patients who had a Type-IIIC fracture have avoided amputation to date, and their results were poor.
D Karavias, P Korovessis, K S Filos, D Siamplis, J Petrocheilos, J Androulakis
Major vascular lesions associated with orthopaedic injuries.
J Orthop Trauma. 1992;6(2):180-5.
Abstract/Text
Seventeen patients, aged 11-67 years (mean, 32.6), with major vascular injuries associated with traumatic orthopaedic injuries, were treated operatively in the authors' institution over a 4-year period. The most common mechanism of trauma was a high-energy injury (70.8%), and the rate of open injuries was 88.2%; 64.9% of the injuries were located in the lower extremities. The treatment protocol consisted of aggressive resuscitation; Doppler imaging and, when necessary, angiography; stable bone fixation with subsequent vascular repair; and extended wound debridement. The vascular repair for arterial lacerations consisted of (a) end-to-end anastomosis (47.2%); (b) interpositional homologous vein graft (23.6%); (c) vascular decompression through fracture distraction in one patient (5.9%); (d) xenograft interposition (in one patient; 5.9%); (e) venous repair (in three patients; 17.7%); and (f) embolectomy (in all patients). Three vascular reoperations (17.7%) were necessary because of rupture of the anastomosis. The authors' preferred bone stabilization method was external fixation, which was used in 47.2% of cases. Amputation was performed in three cases (17.7%) as a salvage operation. Although six patients (35.4%) were admitted with delayed shock (mean duration, 73.6 +/- 27.8 min), this led to a lethal outcome due to shock lung in only one patient. Another patient developed massive lung embolism 3 months postoperatively and died. The authors believe that this well-organized approach, based on a specific treatment protocol, for patients with severe orthopaedic trauma and concomitant vascular injury, not only improves outcome but gives good to excellent functional results in the majority of patients.
W Schlickewei, E H Kuner, A B Mullaji, B Götze
Upper and lower limb fractures with concomitant arterial injury.
J Bone Joint Surg Br. 1992 Mar;74(2):181-8.
Abstract/Text
We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.
W H Snyder
Vascular injuries near the knee: an updated series and overview of the problem.
Surgery. 1982 May;91(5):502-6.
Abstract/Text
Injury of the popliteal artery results in amputation more often than any other arterial injury. Adjacent injuries, small vessel thrombosis, and muscle necrosis are the major deterrents to limb salvage. This report updates a previously published series, expanded to include 110 injuries treated during a 14-year period. Emphasis is placed on the management of adjacent injuries, errors promoting amputation, and principles of improving limb survival. The hallmark of success is the rapid and complete restoration of arterial and venous flow.
E G Bywaters, D Beall
Crush Injuries with Impairment of Renal Function.
Br Med J. 1941 Mar 22;1(4185):427-32.
Abstract/Text
J Oda, H Tanaka, T Yoshioka, A Iwai, H Yamamura, K Ishikawa, T Matsuoka, Y Kuwagata, A Hiraide, T Shimazu, H Sugimoto
Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake.
J Trauma. 1997 Mar;42(3):470-5; discussion 475-6.
Abstract/Text
OBJECTIVE: To clarify clinical features and determine the severity of injuries in patients with crush syndrome in Hanshin-Awaji earthquake.
METHODS: We retrospectively reviewed medical records of 6,107 patients hospitalized in 95 hospitals, and identified 372 patients with crush syndrome.
RESULTS: The major sites of crush injury were in the lower extremities (74%), followed by the upper extremities (10%), and the trunk (9%). Pelvic fractures, limb fractures, and abdominal injuries were the most frequently associated injury. Patients with trunk compression and/or with abdominal injury had a higher mortality rate. A total of 50 patients (13.4%) died. The causes of death within 5 days after the earthquake were hypovolemia and hyperkalemia. Peak serum creatine kinase concentration increased with the number of crushed extremities. Mortality and the risk of acute renal failure were higher in patients with creatine kinase concentration more than 75,000 micro/L.
CONCLUSIONS: Peak serum concentration of creatine kinase as well as the number of injured extremities serve to estimate the severity of crush syndrome.
A J Collins
Kidney dialysis treatment for victims of the Armenian earthquake.
N Engl J Med. 1989 May 11;320(19):1291-2. doi: 10.1056/NEJM198905113201930.
Abstract/Text
I Nadjafi, M R Atef, B Broumand, A Rastegar
Suggested guidelines for treatment of acute renal failure in earthquake victims.
Ren Fail. 1997 Sep;19(5):655-64.
Abstract/Text
The 1990 Iran earthquake affected two states with a combined population of 2,300,000. It resulted in at least 13,888 deaths, 43,390 injured, and 33,616 hospitalized. The overall mortality among hospitalized patients was 0.17%. Acute renal failure (ARF) requiring dialysis support was diagnosed in 156 patients nationwide, with a mortality rate of 14%. Three teaching hospitals of Tehran University of Medical Sciences (UMS) admitted 495 patients, with total mortality of 7.5%. Of these, 30 patients (6%) required dialysis, with a mortality of 40%, accounting for 12 of the deaths. On admission, patients with ARF were more severely injured and had significantly higher incidence of multiple trauma; peripheral nerve injury; elevated muscle enzymes, potassium, and phosphorus; and abnormal urinalysis. In one of these hospitals, patients were treated with a specific hydration protocol coupled with a cautious approach to fasciotomy. The incidence of ARF, mortality associated with ARF, and fasciotomy were lower in this group. Based on these findings, guidelines are suggested that may be helpful in the treatment of ARF in earthquake victims.
M Rawlins, E Gullichsen, K Kuttila, O Peltola, J Niinikoski
Central hemodynamic changes in experimental muscle crush injury in pigs.
Eur Surg Res. 1999;31(1):9-18. doi: 8616.
Abstract/Text
To investigate central and pulmonary hemodynamics in a standardized normovolemic experimental muscle injury model, 8 anesthetized and mechanically ventilated test pigs were intracavally infused with 100 ml of autologous muscle extract over a period of 100 min; 8 control pigs received Ringer's solution. The cardiac index decreased 20% and the heart rate decreased 10% within 30 min of starting the infusion in the muscle extract group and remained depressed. Mean arterial pressure increased significantly in both groups. The pulmonary capillary wedge pressure and central venous pressure remained relatively unchanged during the 5-hour study. A 2-fold increase in mean pulmonary arterial pressure and a nearly 4-fold increase in the pulmonary vascular resistance index was seen in the muscle extract infusion group, which however returned to normal. Arterial hemoglobin concentration and systemic vascular resistance index remained fairly stationary in both groups. Immediate significant decreases in both arterial oxygen saturation and arterial oxygen tension were observed in the muscle extract group, however both variables recovered towards the end of the experiment. A slight increase in arterial blood pH value was noted during the experiment. In conclusion, autologous muscle extract infusion causes decreases in heart rate and cardiac index, as well as a significant increase in pulmonary vascular tone and systemic hypoxemia, emphasizing the detrimental effects of skeletal muscle injury following severe trauma.
Z A Abassi, A Hoffman, O S Better
Acute renal failure complicating muscle crush injury.
Semin Nephrol. 1998 Sep;18(5):558-65.
Abstract/Text
Extensive skeletal muscle injury, whether caused by mechanical crush or by extreme physical exertion, is incompatible with life, unless treated early and vigorously. The immediate cause of morbidity is leakiness of the sarcolemmal membrane to cardiotoxic or nephrotoxic cations and metabolites (K, PO4, myoglobin and urate) of the sarcoplasma, and rapid massive uptake by the muscles of extracellular fluid, sodium and calcium, leading to profound hypovolemic and hyocalcemic shock. Casualties who survive the early steep of hyperkalemia and arterial hypotension are susceptible to myoglubinuric acute renal failure owing mainly to the combination of renal vasoconstriction, nephrotoxicity, and tubular obstruction by myoglobin plugs and urate. Management includes immediate (prehospital) intravenous volume replacement followed by mannitol-alkaline diuresis. The alkali regimen ameliorates the acidosis associated with shock and the hyperkalemia, and protects against the nephrotoxicity of myoglobin and urate by alkalinization of the urine. Mannitol, through its impermeant hyperoncotic properties, decompresses and mobilizes muscle edema and promotes renal tubular flow, thus flushing myoglobin plugs and enhancing urinary elimination of nephrotoxic metabolites. With this regimen and when necessary also with the use of dialysis, a substantial salvage of lives, limbs, and kidney function has been achieved recently compared with invariable mortality for casualties who were buried for 3 to 4 hours or more in the early 1940s (World War 2).
Christopher J Barnes, Ricardo Pietrobon, Laurence D Higgins
Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis.
J Trauma. 2002 Dec;53(6):1109-14. doi: 10.1097/01.TA.0000025792.36332.D7.
Abstract/Text
BACKGROUND: This systematic review aimed at evaluating the diagnostic accuracy of pulse examination in detecting surgical arterial lesions associated with knee dislocation.
METHODS: MEDLINE, CINAHL, and SportDiscus databases were searched in all languages to review articles concerning human knee dislocation and associated vascular injuries.
RESULTS: We reviewed 116 articles. Seven met our inclusion criteria, providing detailed data on 284 injuries. Pooled data demonstrated that abnormal pedal pulses present a sensitivity of 0.79 (95% confidence interval [CI], 0.64-0.89), a specificity of 0.91 (95% CI 0.78-0.96), a positive predictive value of 0.75 (95% CI, 0.61-0.83), and a negative predictive value of 0.93 (95% CI, 0.85-.96).
CONCLUSION: Our findings suggest that the isolated presence of abnormal pedal pulses on initial examination of patients with knee dislocations is not sensitive enough to detect a surgical vascular injury. On the basis of this meta-analysis, an algorithm for the evaluation of these patients is presented.
James P Stannard, Todd M Sheils, Robert R Lopez-Ben, Gerald McGwin, James T Robinson, David A Volgas
Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography.
J Bone Joint Surg Am. 2004 May;86-A(5):910-5.
Abstract/Text
BACKGROUND: Popliteal artery injury is frequently associated with knee dislocation following blunt trauma, an injury that is being seen with increasing frequency. The primary purpose of the present study was to evaluate the use of physical examination to determine the need for arteriography in a large series of patients with knee dislocation. The secondary purpose was to evaluate the correlation between physical examination findings and clinically important vascular injury in the subgroup of patients who underwent arteriography.
METHODS: One hundred and thirty consecutive patients (138 knees) who had sustained an acute multiligamentous knee injury were evaluated at our level-1 trauma center between August 1996 and May 2002 and were included in a prospective outcome study. Four patients (four knees) were lost to follow-up, leaving 126 patients (134 knees) available for inclusion in the study. The results of the physical examination of the vascular status of the extremities were used to determine the need for arteriography. The mean duration of follow-up was nineteen months (range, eight to forty-eight months). Physical examination findings, magnetic resonance imaging findings, and surgical findings were combined to determine the extent of ligamentous damage.
RESULTS: Nine patients had flow-limiting popliteal artery damage, for an overall prevalence of 7%. Ten patients had abnormal findings on physical examination, with one patient having a false-positive result and nine having a true-positive result. The knee dislocations in the nine patients with popliteal artery damage were classified, according to the Wascher modification of the Schenck system, as KD-III (one knee), KD-IV (seven knees), and KD-V (one knee).
CONCLUSIONS: Selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. There is a strong correlation between the results of physical examination and the need for arteriography. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.
Jason J Halvorson, Adam Anz, Maxwell Langfitt, Joel K Deonanan, Aaron Scott, Robert D Teasdall, E A Carroll
Vascular injury associated with extremity trauma: initial diagnosis and management.
J Am Acad Orthop Surg. 2011 Aug;19(8):495-504.
Abstract/Text
Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.
R J Anderson, R W Hobson, F T Padberg, K G Swan, B C Lee, Z Jamil, G Breitbart, J Manno
Penetrating extremity trauma: identification of patients at high-risk requiring arteriography.
J Vasc Surg. 1990 Apr;11(4):544-8.
Abstract/Text
Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper arm wounds and stab wounds to the extremities.
J Norman, V Gahtan, M Franz, R Bramson
Occult vascular injuries following gunshot wounds resulting in long bone fractures of the extremities.
Am Surg. 1995 Feb;61(2):146-50.
Abstract/Text
The routine use of arteriography following penetrating injuries to the extremities has declined in popularity in recent years. A careful physical examination coupled with Doppler-derived blood pressure has been shown to be sufficient to determine the presence of significant vascular injuries in most circumstances. Evaluating for occult vascular injuries in the presence of a complex wound involving the fracture of a long bone, however, seems to be an exception to this trend in management. This study was undertaken to ascertain the incidence of occult versus clinically apparent vascular injuries in patients suffering gun shot wounds (GSW) to the extremities that were associated with a long bone fracture. To address the value of invasive arteriographic evaluation, physical examination (pulse palpation, Doppler-derived limb blood pressure) was compared to arteriography in 75 consecutive patients following a GSW that resulted in fracture of the tibia/fibula (n = 28), femur (n = 19), humerus (n = 17), or radius/ulna (n = 11). Fourteen patients (19%) had an abnormal physical examination, with 13 (93%) of these also having an abnormal arteriogram. Of the 61 (81%) patients with a normal physical examination, an occult vascular injury was found on subsequent arteriography in 17 (28%). These occult injuries were classified as minor (intimal flap less than one-fourth the diameter of the vessel, segmental narrowing, noncritical branch vessel injury) or major (large intimal flap, occlusion, pseudoaneurysm, A-V fistula). The majority (83%) of occult injuries were minor and did not require operative intervention.(ABSTRACT TRUNCATED AT 250 WORDS)
V Gahtan, R T Bramson, J Norman
The role of emergent arteriography in penetrating limb trauma.
Am Surg. 1994 Feb;60(2):123-7.
Abstract/Text
Routine arteriographic evaluation of patients with penetrating trauma in proximity to major limb arteries has been declining in popularity. Although some controversy still exists, management based on clinical examination alone has been advocated for those without overt signs of vascular injury. To better identify the need for invasive radiologic intervention, 453 limbs (394 patients) sustaining gunshot, shotgun, and stab wounds (331, 28, and 94, respectively) in proximity to a major artery underwent angiography from 1984 through 1990. An arterial injury was demonstrated in 37 (9.4%) of 394 limbs, with a normal vascular examination, but only eight (2.0%) were deemed to require operative intervention. By comparison, 45 (76%) of 59 patients with an abnormal vascular examination (diminished/absent peripheral pulses or decreased Doppler-derived limb blood pressures) had an arterial injury demonstrated by arteriography, with 33 (55.9%) undergoing operative repair. The presence of an associated long bone fracture increased the incidence of angiographically demonstrated vascular injury, but operative intervention was only increased for those with an abnormal vascular exam. A detailed physical examination including Doppler-derived limb blood pressures is essential. In the presence of a normal vascular exam, routine arteriography for proximity of injury is unnecessary. Arteriography should be reserved to identify those few patients with an abnormal vascular examination and an unclear injury who may require vascular repair.
F A Weaver, A E Yellin, M Bauer, J Oberg, N Ghalambor, R P Emmanuel, R M Applebaum, M J Pentecost, R M Shorr
Is arterial proximity a valid indication for arteriography in penetrating extremity trauma? A prospective analysis.
Arch Surg. 1990 Oct;125(10):1256-60.
Abstract/Text
Three hundred seventy-three patients with a penetrating extremity injury were studied to assess the yield of arteriography. Patients underwent arteriography if any of the following was present: bruit, history of hemorrhage or hypotension, fracture, hematoma, decreased capillary refill, major soft-tissue injury, or nerve or pulse deficit. In the absence of these findings, arteriography was performed if the injury was in "proximity" to a major neurovascular bundle. In 216 patients, arteriography was performed when an abnormal finding was noted. Sixty-five injuries were identified, 19 requiring intervention. Proximity was the indication for arteriography in 157 patients. Seventeen injuries were identified, of which one required repair. In penetrating extremity trauma, the need for arteriography is based on clinical findings. The use of arteriography to screen for an arterial injury when proximity alone is the indication rarely identifies a significant injury and should be abandoned.
K Lynch, K Johansen
Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?
Ann Surg. 1991 Dec;214(6):737-41.
Abstract/Text
Although highly accurate, contrast arteriography is a costly, invasive, and time-consuming method to rule out occult arterial damage in injured extremities. Accordingly the authors assessed the sensitivity and specificity of Doppler-derived arterial pressure measurements in trauma victims undergoing evaluation for possible extremity arterial damage. Arterial pressure index (API) was calculated (Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved arm), but not used in clinical decision making in 100 consecutive injured limbs in 93 trauma victims. All patients then underwent contrast arteriography. Twenty limbs had an API less than 0.90 and an abnormal arteriogram, whereas 75 had both a normal API and a normal contrast study. One limb had a significant angiographic abnormality with an API greater than 0.90; two others had API less than 0.90 but normal arteriograms. Two limbs with a normal API had false-positive arteriograms. When compared with arteriography, an API less than 0.90 had a sensitivity of 87% and a specificity of 97% for arterial disruption in this series. Sensitivity and specificity rose to 95% and 97% when API was compared with clinical outcome. In the absence of obvious signs of arterial injury, API may be a reasonable substitute for screening arteriography in the traumatized extremity, particularly if close follow-up observation can be assured.
R P Bynoe, W S Miles, R M Bell, D R Greenwold, G Sessions, J L Haynes, D S Rush
Noninvasive diagnosis of vascular trauma by duplex ultrasonography.
J Vasc Surg. 1991 Sep;14(3):346-52.
Abstract/Text
Duplex ultrasonography was used prospectively in the initial evaluation of 198 patients with 319 potential vascular injuries of the neck and extremities. Patients who were unstable or who had obvious arterial trauma were excluded. Injury was caused by gunshot in 104 (53%), blunt trauma in 42 (21%), stab wound in 34 (17%), and shotgun in 18 (9%). Duplex ultrasonography correctly characterized and localized vascular injuries in 23 patients: arterial disruptions (13), intimal flaps (4), acute pseudoaneurysms (3), arteriovenous fistulas (2), and shotgun pellet arteriopuncture (1). Nineteen other patients had vasospasm (13) or external compression (6) without evidence of intrinsic vessel injury, these 42 studies had true-positive results. Twenty patients underwent arterial repair (13 on the basis of duplex ultrasonography alone), one had primary amputation, three required fasciotomy, and 18 were observed. Two patients with false-negative results had minor shotgun pellet arteriopunctures that were missed by duplex ultrasonography, but neither needed repair. One hundred fifty-three patients had true-negative results on duplex ultrasonography: all clinically had only proximity injuries and easily palpable distal pulses. The result of one duplex ultrasonography study was found to be false-positive on arteriography. The sensitivity of duplex ultrasonography was 95%, the specificity was 99%, and the overall accuracy was 98%. These results closely approximate those reported with the use of exclusion arteriography in the evaluation of similar vascular trauma patients. Furthermore, duplex ultrasonography has no interventional risks and is more cost-effective for screening such injuries than arteriography or exploration. Duplex ultrasonography is a reliable method of diagnosis in patients with potential peripheral vascular injuries.
M M Knudson, F R Lewis, K Atkinson, A Neuhaus
The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma.
Arch Surg. 1993 Sep;128(9):1033-7; discussion 1037-8.
Abstract/Text
OBJECTIVE: To investigate the role of color-flow duplex ultrasound vascular imaging in screening patients for potential arterial injuries following penetrating trauma of the extremities.
DESIGN: In this prospective study, patients with penetrating trauma in proximity to major peripheral vessels but without signs of arterial injury underwent color-flow duplex imaging. Patients with abnormal color-flow duplex examination results were then studied with angiography, and the results of the two studies were compared. In patients who presented with signs of arterial injury, immediate operative exploration and/or angiography was performed.
SETTING: An urban trauma center.
PATIENTS: Patients entering the trauma center with penetrating trauma between April 1991 and December 1992.
RESULTS: Seventy-seven patients with 86 extremity injuries were initially screened with color-flow duplex imaging. Four patients had positive study results, and all injuries were confirmed with angiography (100% true positive). No missed arterial injuries were detected in clinical follow-up.
CONCLUSIONS: Color-flow duplex imaging reliably detects occult arterial injuries and may also have a role in following up minor injuries treated without surgery.
William J Mills, David P Barei, Patrick McNair
The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.
J Trauma. 2004 Jun;56(6):1261-5.
Abstract/Text
BACKGROUND: The risk of arterial injury with knee dislocation is well known. The most effective method for rapidly and accurately diagnosing arterial injury in this setting remains a topic of debate. Both physical examination and arteriography have been advocated, although each of these methods has its critics. The authors propose that the ankle-brachial index (ABI) can accurately predict whether patients with knee dislocations have sustained vascular injury.
METHODS: A prospective study enrolled 38 patients with knee dislocation to evaluate for potential arterial injury using clinical pulse examination and ABI. Patients with an ABI lower than 0.90 underwent arteriography. Those with an ABI of 0.90 or higher were immobilized and admitted for serial examination and delayed arterial duplex evaluation.
RESULTS: Of the 38 patients, 11 (29%) had an ABI lower than 0.90. All 11 had arterial injury requiring surgical treatment. The remaining 27 patients had an ABI of 0.90 or higher. None had vascular injury detectable by serial clinical examination or duplex ultrasonography. The sensitivity, specificity, and positive predictive value of an ABI lower than 0.90 were 100%. The negative predictive value of an ABI that reached 0.90 or higher was 100%.
CONCLUSIONS: The ABI is a rapid, reliable, noninvasive tool for diagnosing vascular injury associated with knee dislocation. Routine arteriography for all patients with knee dislocation is not supported.
Bruce A Levy, Michael P Zlowodzki, Matt Graves, Peter A Cole
Screening for extermity arterial injury with the arterial pressure index.
Am J Emerg Med. 2005 Sep;23(5):689-95. doi: 10.1016/j.ajem.2004.12.013.
Abstract/Text
Certain extremity injuries presenting to the ED or Trauma Unit warrant increased suspicion for underlying arterial trauma. Such injuries include knee dislocations, displaced medial tibial plateau fractures and other displaced bicondylar fractures around the knee, open or segmental distal femoral shaft fractures, floating joints, gunshot wounds in proximity to neurovascular structures, or mangled extremities. Once the diagnosis of arterial trauma is made, a multi-disciplinary approach is warranted. The diagnostic strategies for vascular injury have undergone an evolution over the past 2 decades. One and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular compromise [Bunt TJ, Malone JM, Moody M, et al. Am J Surg 1990;160(2):226-8; Reid JD, Weigelt JA, Thal ER, et al. Arch Surg 1988;123(8):942-6; Applebaum R, Yellin AE, Weaver FA, et al. Am J Surg 1990;160(2):221-4; discussion 224-5; Dennis JW, Frykberg ER, Veldenz HC, et al. J Trauma 1998;44(2):243-52; discussion 242-3]. An efficient and effective evidence-based approach to diagnosing vascular injury is necessary, as the difficulty in diagnosis, the multiplicity of diagnostic strategies, the limited time frame in which to initiate appropriate treatment, the limb threatening complications of a missed diagnosis, and the increased awareness of health care expenditures make this entity an intimidating diagnostic challenge [Johansen K, Lynch K, Paun M, et al. J Trauma 1991;31(4):515-9; discussion 519-22; Lynch K, Johansen K. Ann Surg 1991;214(6):737-41; Walker ML, Poindexter Jr JM, Stovall I. Surg Gynecol Obstet 1990;170(2):97-105; Kendall RW, Taylor DC, Salvian AJ, et al. J Trauma 1993;35(6):875-8]. The purpose of this article is to present an evidence-based algorithm for patients who present with either arterial injury or a high-risk of arterial injury. A diagnostic algorithm will be presented, and the rationale for diagnostic interventions will be discussed in the context of current medical literature.
Mark J Seamon, David Smoger, Denise M Torres, Abhijit S Pathak, John P Gaughan, Thomas A Santora, Gary Cohen, Amy J Goldberg
A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography.
J Trauma. 2009 Aug;67(2):238-43; discussion 243-4. doi: 10.1097/TA.0b013e3181a51bf9.
Abstract/Text
INTRODUCTION: Arteriography is the current "gold standard" for the detection of extremity vascular injuries. Less invasive than operative exploration, conventional arteriography (CA) still has a 1% to 3% risk of morbidity and may delay definitive repair. Recent improvements in computed tomography (CT) technology has since broadened the application of CT to include the diagnosis of cervical, thoracic, and now extremity vascular injury. We hypothesized that CT angiography (CTA) provides equivalent injury detection compared with the more invasive CA, but is more rapidly completed and more cost effective.
METHODS: A prospective evaluation of patients, ages 18 to 50, with potential extremity vascular injuries was performed during 2006-2007. Ankle-brachial indices (ABI) of injured extremities were measured on presentation in all patients without hard signs of vascular injury. Patients whose injured extremity ABI was <0.9 were enrolled and underwent CTA followed by either CA or operative exploration if CTA findings were limb threatening. Interventionalists were blinded to CTA findings before performing and reading CAs.
RESULTS: Twenty-one patients (mean age, 26.1 +/- 7.1 years) had 22 extremity CTAs after gunshot (82%), stab (9%), or pedestrian struck by automobile (9%) injuries to either upper (32%) or lower (68%) extremities. Eleven of 22 (50%) extremities had associated orthopedic injuries while the mean ABI of the study population was 0.72 +/- 0.21. Twenty-one of 22 (96%) CTAs were diagnostic and all CTAs were confirmed by either CA alone (n = 18), operative exploration (n = 2), or both CA and operative exploration (n = 2). Diagnostic CTAs had 100% sensitivity and specificity for clinically relevant vascular injury detection. Unlike rapidly obtained CTA, CA required 131 +/- 61 minutes (mean +/- SD) to complete. In our center, CTA saves $12,922 in patient charges and $1,166 in hospital costs per extremity when compared with CA.
CONCLUSIONS: With acceptable injury detection, rapid availability, and a favorable cost profile, our results suggest that CTA may replace CA as the diagnostic study of choice for vascular injuries of the extremities.
M J Bosse, E J MacKenzie, J F Kellam, A R Burgess, L X Webb, M F Swiontkowski, R W Sanders, A L Jones, M P McAndrew, B M Patterson, M L McCarthy, J K Cyril
A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.
J Bone Joint Surg Am. 2001 Jan;83-A(1):3-14.
Abstract/Text
BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems.
METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation.
RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation.
CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.
D L Helfet, T Howey, R Sanders, K Johansen
Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score.
Clin Orthop Relat Res. 1990 Jul;(256):80-6.
Abstract/Text
Objective criteria can predict amputation after lower-extremity trauma. The authors examined the hypothesis that objective data, available early in the evaluation of patients with severe skeletal/soft-tissue injuries of the lower extremity with vascular compromise, might discriminate the salvageable from the unsalvageable limbs. The Mangled Extremity Severity Score (MESS) was developed by reviewing 25 trauma victims with 26 severe lower-extremity open fractures with vascular compromise. The four significant criteria (with increasing points for worsening prognosis) were skeletal/soft-tissue injury, limb ischemia, shock, and patient age. (There was a significant difference in the mean MESS scores; 4.88 in 17 limbs salvaged and 9.11 in nine limbs amputated; p less than 0.01). This scoring system was then prospectively evaluated in 26 lower-extremity open fractures with vascular injury over a 12-month period at two trauma centers. Again, there was a significant difference in the mean MESS scores; 4.00 for the 14 salvaged limbs and 8.83 for the 12 amputated limbs (p less than 0.01). In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value for amputation. This relatively simple, readily available scoring system of objective criteria was highly accurate in acutely discriminating between limbs that were salvageable and those that were unsalvageable and better managed by primary amputation.
W L Russell, D M Sailors, T B Whittle, D F Fisher, R P Burns
Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index.
Ann Surg. 1991 May;213(5):473-80; discussion 480-1.
Abstract/Text
In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.
H R Howe, G V Poole, K J Hansen, T Clark, G W Plonk, L A Koman, T C Pennell
Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index.
Am Surg. 1987 Apr;53(4):205-8.
Abstract/Text
A retrospective review of 676 tibial-fibular fractures and 985 femoral fractures treated over a 71-month period yielded associated major vascular trauma in 12 (1.7%) tibial-fibular fractures and in five (0.5%) femoral fractures. Vascular trauma combined with orthopedic trauma was also identified in four other cases--two disruptions of the pubic symphysis and two dislocations of the knee without fracture. Nine (43%) of the 21 involved limbs were eventually amputated. Limb survival was not related to the temporal relationship of vessel repair to skeletal stabilization; the presence or absence of shock on admission; the presence of associated but repaired venous injury; or the presence of unrelated injuries. Limb survival was related to the interval from injury to arrival in the operating room; the level of arterial injury; and the quantitative degree of muscle, bone, and skin injury. By combining these variables a limb salvage index was established that identified lower extremities likely to require amputation after combined orthopedic and vascular trauma (sensitivity 78%, specificity 100%). Use of this predictive salvage index may prevent the trauma surgeon from attempting to salvage a doomed or useless lower extremity and may thus permit early prosthetic rehabilitation to follow definitive primary amputation.
M G McNamara, J D Heckman, F G Corley
Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS)
J Orthop Trauma. 1994;8(2):81-7.
Abstract/Text
Recent reports using the Mangled Extremity Severity Score (MESS) suggest that a score of > or = 7 is 100% accurate in predicting the need for amputation of severely injured lower extremities. To further evaluate the value of the MESS in predicting amputation, specifically with respect to type IIIB and type IIIC (Gustilo and Anderson) open fractures of the tibia, we retrospectively evaluated 24 patients with these injuries. A significant difference (p = 0.001) between MESS values of 13 salvaged (6.36 +/- 0.35 SEM) and 11 amputated limbs (6.36 +/- 0.54 SEM) was found. A MESS value of > or = 4 was most sensitive (100%); a MESS value of > or = 7 was most specific, and a MESS value of > or = 7 was found to have a positive predictive value of 100%. Subsequently, we addressed recent criticisms of the MESS by including nerve injury in the scoring system and by separating soft-tissue and skeletal injury components of the MESS. We modified the MESS with a score called the NISSSA and applied it retrospectively to our cases. After careful statistical comparison we found both the MESS and NISSSA to be highly accurate (p < 0.005) in predicting amputation. The NISSSA was found to be more sensitive (81.8% versus 63.6%) and more specific (92.3 versus 69.2%).
C Krettek, A Seekamp, H Köntopp, H Tscherne
Hannover Fracture Scale '98--re-evaluation and new perspectives of an established extremity salvage score.
Injury. 2001 May;32(4):317-28.
Abstract/Text
OBJECTIVE: as the treatment of open fractures has improved over the years, the prognosis of open fractures has also changed. Thus, a re-evaluation of the Hannover Fracture Score (HFS), first introduced in 1983, has become necessary.
DESIGN: retrospectively all parameters of the HFS were evaluated in 182 open fractures of the upper and lower extremity treated in our institution between June 1994 and 1996. Statistical means included multivariant analysis, ROC analysis, calculation of sensitivity, specificity and accuracy. Finally the HFS 98 was established, which is characterised by eight domains with a total score range from 0 to 22 points and a cut off point (amputation recommended) at a score > or =11. This score was then prospectively applied on another 87 open long bone fractures, treated during July 1996 and December 1997.
RESULTS: this validation of the HFS '98 revealed a sensitivity of 0.82 and a specificity of 0.99. In comparison the NISSSA and the MESS presented a lower sensitivity and same specificity based on the same study group.
CONCLUSION: in conclusion the HFS '98 has become a reliable extremity salvage score with a fairly high positive predictive value of 0.99, which is applicable for all the open long bone fractures regardless of their location.
O S Better, J H Stein
Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis.
N Engl J Med. 1990 Mar 22;322(12):825-9. doi: 10.1056/NEJM199003223221207.
Abstract/Text
O S Better
Rescue and salvage of casualties suffering from the crush syndrome after mass disasters.
Mil Med. 1999 May;164(5):366-9.
Abstract/Text
Extensive muscle crush injury culminating in the crush syndrome (CS) is often lethal unless promptly and vigorously treated. The causes of death in the CS are extreme hypovolemic shock, hyperkalemia, hypocalcemia, metabolic acidosis, acute myoglobinuric renal failure, and the compartment syndrome. Treatment consists of early massive volume replacement, preferably administered in the field, followed by forced alkaline solute (mannitol) diuresis. With this regimen, it is possible to increase substantially the survival of lives and limbs and to prevent acute myoglobinuric renal failure in patients suffering from the CS. Preliminary experience suggests that intravenous hypertonic mannitol is protective also to the injured muscle and can be used as a noninvasive adjunct in the management of compartment syndrome in humans. Moreover, by preserving muscular integrity, mannitol can conceivably reduce sarcolemmal leakage of the nephrotoxic myoglobin urate and phosphate and thus further defend kidney function. Furthermore, mannitol reduces the plasma pool of these nephrotoxic metabolites by increasing urinary elimination.
M Michaelson, U Taitelman, Z Bshouty, G Bar-Joseph, S Bursztein
Crush syndrome: experience from the Lebanon War, 1982.
Isr J Med Sci. 1984 Apr;20(4):305-7.
Abstract/Text
Eight patients with crush syndrome were treated in our department during the Lebanon War, 1982. They arrived after having been trapped under fallen masonry for 4 to 28 h. They all had injuries of the lower limbs, with neurological deficiency and myoglobinuria. The local and general aspects of the syndrome are presented and discussed and a successful treatment protocol outlined.
D Ron, U Taitelman, M Michaelson, G Bar-Joseph, S Bursztein, O S Better
Prevention of acute renal failure in traumatic rhabdomyolysis.
Arch Intern Med. 1984 Feb;144(2):277-80.
Abstract/Text
Following the collapse of a building, seven subjects (aged 18 to 41 years) were released from under the rubble within one to 28 hours. All seven suffered from extensive crush injuries with evidence of severe rhabdomyolysis and were treated by the induction of an alkaline solute diuresis immediately on their extrication from the debris. The leakage of muscle constitutents was estimated by quantifying the net total body potassium losses, which averaged 395 mEq (SD, +/- 198) over the first 60 hours of therapy. In the past, injuries of similar severity have been associated with a high incidence of acute renal failure and a high mortality rate, yet none of our patients had azotemia or renal failure. We attribute this success to the unprecedented early institution of appropriate therapy.
T Shimazu, T Yoshioka, Y Nakata, K Ishikawa, Y Mizushima, F Morimoto, M Kishi, M Takaoka, H Tanaka, A Iwai, A Hiraide
Fluid resuscitation and systemic complications in crush syndrome: 14 Hanshin-Awaji earthquake patients.
J Trauma. 1997 Apr;42(4):641-6.
Abstract/Text
BACKGROUND: Crush syndrome is a form of traumatic rhabdomyolysis characterized by systemic involvement, in which acute renal failure is potentially life-threatening.
METHODS: Clinical and laboratory data of 14 crush-syndrome patients transferred to a tertiary emergency department after the Hanshin-Awaji earthquake were analyzed. The patients were buried under collapsed houses for the average of 6.7 +/- 5.7 (SD) hours (range, 1 to 24 hours). They were referred to us 6 to 250 hours after the earthquake.
RESULTS: Of those who arrived at our institution within 40 hours, 25% (two of eight) developed renal failure, whereas all six patients who arrived after 40 hours developed renal failure. Peak serum creatine kinase ranged from 6,677 to 134,200 U/L (51,674 +/- 41,776). Renal failure was highly associated with massive muscle damage (serum creatine kinase above 25,000 U/L) and insufficient initial fluid resuscitation (below 10,000 mL/2 days).
CONCLUSIONS: Prompt and adequate, if not massive, fluid resuscitation is the key to preventing renal failure after such injury.
Jason Smith, Ian Greaves
Crush injury and crush syndrome: a review.
J Trauma. 2003 May;54(5 Suppl):S226-30. doi: 10.1097/01.TA.0000047203.00084.94.
Abstract/Text
Crush injuries and the subsequent systemic manifestations are well described, but there is limited evidence on which to base protocols for optimal management. Given that in most environments such in-juries are relatively rare, there is, however, an undoubted need for such guidelines. This article reviews the currently available evidence and summarizes the treatment options available.
Tam T T Huynh, Mai Pham, Lance W Griffin, Martin A Villa, J Alan Przybyla, Ricardo H Torres, Kourosh Keyhani, Hazim J Safi, Frederick A Moore
Management of distal femoral and popliteal arterial injuries: an update.
Am J Surg. 2006 Dec;192(6):773-8. doi: 10.1016/j.amjsurg.2006.08.043.
Abstract/Text
BACKGROUND: The management of combined arterial and musculoskeletal injuries to the lower extremity remains controversial, particularly with regard to the initial order of intervention and the use of intravascular shunting. In this study, we review the contemporary management and outcome of patients treated for acute traumatic distal femoropopliteal arterial injuries.
METHODS: From January 2001 to January 2006, we repaired 57 acute traumatic lower-extremity arterial injuries in a level 1 trauma center. Our approach was to perform surgical revascularization without intraluminal shunting as soon as the arterial injury was recognized. There were 44 men (77%). Mean age was 31 years (range, 5-68). The mechanism of injury was blunt in 42 of 57 (74%) patients. Vascular reconstruction was achieved by using an autogenous saphenous vein graft in 52 of 57 (91%), a vein patch in 3 of 57 (5%), or primarily in 2 of 57 (4%) patients.
RESULTS: The limb-salvage rate was 92% (53/57). Thirty-six patients (63%) had associated orthopedic fixation: 12 of 36 (33%) before and 24 of 36 (67%) after revascularization. Twenty-one of 57 patients (37%) had vascular repair only without orthopedic fixation. Thirty-four patients (60%) required fasciotomy. Four patients had subsequent above-knee amputation: 3 because of wound complications despite successful revascularization and 1 because of failed revascularization. There were no complications related to the arterial repairs that were performed before orthopedic fixation.
CONCLUSION: Our study shows that arterial reconstruction for acute traumatic lower-limb injuries results in a good limb-salvage rate. We advocate prompt vascular repair before orthopedic intervention for combined vascular and skeletal injuries of the lower extremity, without using intravascular shunting.
A J Starr, J L Hunt, C M Reinert
Treatment of femur fracture with associated vascular injury.
J Trauma. 1996 Jan;40(1):17-21.
Abstract/Text
OBJECTIVE: The aim of this study was to determine (1) if internal fixation was associated with a high amputation rate in patients with femur fracture and vascular injury; and (2) if patients who underwent internal fixation before vascular repair had a higher amputation rate.
DESIGN: This is a retrospective analysis.
MATERIALS AND METHODS: Twenty-six patients requiring femoral stabilization with injury to the superficial femoral artery, popliteal artery, or common femoral vein were studied. The Injury Severity Score and the Mangled Extremity Severity Score were calculated for each. Nineteen patients underwent internal fixation. Ten patients had internal fixation before vascular repair.
RESULTS: Sixteen of 19 patients treated with internal fixation had limb salvage. Nine of 10 patients who had internal fixation before vascular repair had limb salvage. Poor outcomes (gangrene, amputation, or death) were associated with a Mangled Extremity Severity Score > or = 6 (p = 0.005).
CONCLUSIONS: In these patients, poor outcome is associated with severe leg injury, (with a Mangled Extremity Severity Score of > or = 6). Internal fixation can be safely used, and skeletal stabilization can be safely performed before vascular repair. If ischemic time is prolonged, vascular shunts should be used until skeletal stabilization is completed.
Timothy P McHenry, John B Holcomb, Noriaki Aoki, Ronald W Lindsey
Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence.
J Trauma. 2002 Oct;53(4):717-21. doi: 10.1097/01.TA.0000028450.41774.48.
Abstract/Text
BACKGROUND: The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study.
METHODS: A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed.
RESULTS: There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 +/- 8.6 days compared with 10.8 +/- 8.1 days (p = 0.03). CONCLUSION For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.
