今日の臨床サポート

四肢外傷

著者: 松井健太郎 帝京大学 整形外科学講座 外傷センター

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2017/07/31
患者向け説明資料

概要・推奨   

血管損傷を伴う四肢外傷:
  1. 血管損傷を伴う四肢外傷とは、修復が必要な主要血管損傷を伴う外傷を指す。
  1. 時間の遅れ(診断、治療の遅れ)が予後を悪化させる。緊急対応が必要な外傷である。
  1. 骨折、脱臼などを合併することがほとんどであり、「いつ、どのような順番で、何をするか?」などの治療戦略が重要である。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松井健太郎 : 特に申告事項無し[2021年]
監修:箕輪良行 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
血管損傷を伴う四肢外傷:
  1. 血管損傷を伴う四肢外傷とは、修復が必要な主要血管損傷を伴う外傷を指す。
  1. 長管骨骨折に伴う血管損傷の発生率は1%以下とまれである[1][2][3][4]
  1. 四肢外傷の中でも、膝関節脱臼に血管損傷が伴う場合が16%と多い[5]
  1. 脛骨近位部骨折、転位が大きい骨折、開放骨折、分節性長管骨骨折の場合や、鈍的外傷、Floating joint、Crush injury、脱臼の場合には血管損傷の存在を強く疑う[6][7][8][9][10][11]
  1. 阻血時間を6時間以内にすべきである[7][12]。8時間を超えた場合、切断率が86%と高率になる[7][8]
 
Crush injury:
  1. Crush injuryとは四肢の挫滅や長時間圧迫の結果生じる虚血性変化と、圧迫解除後の虚血再還流障害のことである。その結果、局所ではコンパートメント症候群を合併することが多い。Crush syndromeはCrush injuryの結果生じる、全身の症候群である。
  1. 重度四肢外傷における、切断か患肢温存をするかの選択には明確な基準はなく、専門的な判断を要する。
問診・診察のポイント  
問診:
  1. 発症(受傷)時期を確認する。

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文献 

著者: M J Allen, J R Nash, T T Ioannidies, P R Bell
雑誌名: 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.

PMID 6703619  Ann R Coll Surg Engl. 1984 Mar;66(2):101-4.
著者: John Fowler, Neil Macintyre, Saqib Rehman, John P Gaughan, Shawn Leslie
雑誌名: 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.

PMID 19070837  Injury. 2009 Jan;40(1):72-6. doi: 10.1016/j.injury.2008・・・
著者: P W Howard, G S Makin
雑誌名: 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.

PMID 2298768  J Bone Joint Surg Br. 1990 Jan;72(1):116-20.
著者: Philip S Mullenix, Scott R Steele, Charles A Andersen, Benjamin W Starnes, Ali Salim, Matthew J Martin
雑誌名: 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.

PMID 16828431  J Vasc Surg. 2006 Jul;44(1):94-100. doi: 10.1016/j.jvs.・・・
著者: Fernando E Miranda, James W Dennis, Henry C Veldenz, Peter S Dovgan, Eric R Frykberg
雑誌名: 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.

PMID 11834983  J Trauma. 2002 Feb;52(2):247-51; discussion 251-2.
著者: R H Lange, A W Bach, S T Hansen, K H Johansen
雑誌名: 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.

PMID 3981670  J Trauma. 1985 Mar;25(3):203-8.
著者: N E Green, B L Allen
雑誌名: 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.

PMID 845209  J Bone Joint Surg Am. 1977 Mar;59(2):236-9.
著者: L R Stayner, M J Coen
雑誌名: 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.

PMID 10918956  Clin Sports Med. 2000 Jul;19(3):399-413.
著者: R J Caudle, P J Stern
雑誌名: 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.

PMID 3597491  J Bone Joint Surg Am. 1987 Jul;69(6):801-7.
著者: D Karavias, P Korovessis, K S Filos, D Siamplis, J Petrocheilos, J Androulakis
雑誌名: 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.

PMID 1602338  J Orthop Trauma. 1992;6(2):180-5.
著者: W Schlickewei, E H Kuner, A B Mullaji, B Götze
雑誌名: 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.

PMID 1544948  J Bone Joint Surg Br. 1992 Mar;74(2):181-8.
著者: W H Snyder
雑誌名: 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.

PMID 7071739  Surgery. 1982 May;91(5):502-6.
著者: Christopher J Barnes, Ricardo Pietrobon, Laurence D Higgins
雑誌名: 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.

PMID 12478036  J Trauma. 2002 Dec;53(6):1109-14. doi: 10.1097/01.TA.00・・・
著者: K Lynch, K Johansen
雑誌名: 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.

PMID 1741655  Ann Surg. 1991 Dec;214(6):737-41.
著者: Grace S Rozycki, Lorraine N Tremblay, David V Feliciano, Walter B McClelland
雑誌名: J Trauma. 2003 Nov;55(5):814-24. doi: 10.1097/01.TA.0000087807.44105.AE.
Abstract/Text BACKGROUND: Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity.
METHODS: A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted.
RESULTS: From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors.
CONCLUSION: Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.

PMID 14608150  J Trauma. 2003 Nov;55(5):814-24. doi: 10.1097/01.TA.000・・・
著者: 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
雑誌名: 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.

PMID 17161092  Am J Surg. 2006 Dec;192(6):773-8. doi: 10.1016/j.amjsur・・・
著者: A J Starr, J L Hunt, C M Reinert
雑誌名: 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.

PMID 8576991  J Trauma. 1996 Jan;40(1):17-21.
著者: Timothy P McHenry, John B Holcomb, Noriaki Aoki, Ronald W Lindsey
雑誌名: 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.

PMID 12394872  J Trauma. 2002 Oct;53(4):717-21. doi: 10.1097/01.TA.000・・・
著者: Jason J Halvorson, Adam Anz, Maxwell Langfitt, Joel K Deonanan, Aaron Scott, Robert D Teasdall, E A Carroll
雑誌名: 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.

PMID 21807917  J Am Acad Orthop Surg. 2011 Aug;19(8):495-504.

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