Penetrating Combined Arterial and Skeletal Extremity Trauma, Management of

Authors

EAST Practice Management Guidelines Work Group

Abenamar Arrillaga, MD, Greenville Memorial Hospital, Greenville, SC 
Raymond Bynoe, MD, Richland Memorial Hospital, Columbia, SC 
Eric R. Frykberg, MD, University of Florida Health Science Center, Jacksonville, FL 
Kimberly Nagy, MD, Cook County Hospital, Chicago, IL

Address for correspondence and reprints

Abenamar Arrillaga, MD 
Greenville Memorial Hospital 
890 W. Faris Rd. MMOB, Suite 270, Box 17, Greenville, SC 29605 
Phone: (864) 455-7895 / Fax: (864) 455-4337 
E-mail: aarrillaga@ghs.org

I. Statement of the Problem

Combined arterial and skeletal extremity injury remains a difficult management problem even for the most experienced trauma surgeons. While over 95% of extremities are now successfully salvaged following uncomplicated penetrating arterial injury, an associated skeletal injury may still result in amputation rates as high as 70% in major trauma centers. These results are most pronounced in the lower extremity, which has more tenuous vascular collaterals and more adverse consequences from nerve injury than the upper extremity.In the past, virtually all of the combined extremity injuries have been due to blunt trauma in the civilian sector and high velocity missile trauma in the military sector. Over the last two decades their has been an increase of these injuries from a penetrating mechanism. Improved limb salvage rates have been reported recently in these difficult injuries as those factors most closely correlating with limb loss have been identified and addressed. However individual trauma centers and trauma surgeons see relatively few of these injuries, and there are virtually no scientifically sound studies of the proper approach to their management. Several issues remain unclear relating to the appropriate diagnosis, prioritization and treatment of combined arterial and skeletal injuries from penetrating trauma.

II. Process

A Medline computer search was conducted on all articles in the English Literature during the years 1980-1997 pertaining to arterial injuries of the lower extremity in combination with skeletal injuries. The subject words used included "vascular injury", "artery injury", "extremity trauma", "penetrating trauma", "vascular trauma", "extremity fracture", "extremity dislocation" and "artery trauma". The references of these articles were also used to locate articles not found in the Medline search. Personal files were also used. All letters to the editor, case reports, book chapters, review articles, series involving less than 20 cases, series involving predominantly blunt trauma, and series in which the percentage and outcome of the penetrating injuries were not clearly specified were excluded. This left 25 articles of relevance to this practice parameter.

III. Recommendations

A. Level 1

There is no class I evidence to support a standard of care for this parameter.

B. Level 2

The interval between injury and reperfusion should be minimized to less than six hours in order to maximize limb salvage. Restoration of blood flow should always take priority over skeletal injury management, either by temporary shunting to allow stabilization of unstable fractures and/or dislocations prior to definitive arterial repair, or by immediate definitive arterial repair when the skeletal injury is stable and not significantly displaced.

C. Level 3

Orthopedic surgeons should be involved immediately in assessment and management decisions.

1. Arteriography should be done promptly when hard signs of vascular injury are manifest.
2. There is no defined role for the use of noninvasive Doppler pressure monitoring or duplex ultrasonography to confirm or exclude arterial injury in this setting.
3. Evidence suggests that an absence of hard signs of vascular injury in this setting reliably excludes surgically significant arterial injury, and does not require arteriography.
4. Nonoperative observation of asymptomatic nonocclusive arterial injuries may be considered.
5. Four-compartment fasciotomy should be liberally applied at the time of arterial and skeletal repair. If not done compartment pressures should be monitored closely.
6. Completion arteriography should be performed.
7. External fixation is preferable for the immediate management of unstable, displaced, comminuted and open fractures or dislocations. This is especially important in those with severe contamination, extensive soft tissue injury, or in an unstable patient.
8. Primary amputation should be considered in those with tibial or sciatic nerve transection, prolonged ischemia, massive soft tissue injury, severe contamination, open comminuted tib-fib fractures (Gustilo-III), or life-threatening associated injuries.
9. Mangled extremity scoring systems are not sufficiently reliable to serve as the sole determinant of extremity amputation.

IV. Scientific Foundation

All available studies of the epidemiology, diagnosis and management of combined penetrating arterial and skeletal extremity injuries are retrospective. Most civilian series report both blunt and penetrating etiologies, and in some the outcome cannot be related to the mechanism. These considerations prevent firm practice standards from being derived. Nonetheless, these studies provide enough evidence to support a number of recommended management options, as well as directions for future investigation.

Combined extremity injuries are relatively uncommon, making up only 0.2% of all civilian trauma^[1]. Only 1.5% to 6.5% of all extremity skeletal injuries are associated with an arterial injury^[2-5], while 20% to 73% of all extremity arterial injuries may be associated with skeletal fractures or dislocations^{[2] [6-8]}. Blunt trauma is the predominant mechanism for these injuries in most civilian series. However, over the last decade penetrating trauma has increased in its incidence in this setting, causing from 24% to 71% of cases^{[1] [6-8] [9] [10]}. One recent series reported 30 combined injuries from gunshots only^[11].

It is clear that combined extremity injuries pose a substantially increased risk of limb loss and limb morbidity than do isolated or skeletal extremity injuries^{[1] [3] [4] [8] [9] [10]}. This is most likely due to greater disruption of collaterals, soft tissues and nerves. Combined injuries from penetrating trauma have a substantially lower amputation rate than those from blunt trauma in the civilian sector. Five civilian series over the past decade have reported the highest proportions of penetrating trauma as a cause of these complex injuries in the literature, being 50%^[8], 57%^[2], 67%^[9], 71%^[5], and 100%^[11]. Their combined results show a total of 39 amputations among 228 patients (17%), but only 9 amputations among the 147 patients (6%) with penetrating trauma. In three of these series reporting 88 patients with penetrating combined injuries there were remarkably no amputations^{[2] [5] [11]}. The apparent increasing trend in penetration as the etiology of these injuries in recent years may have made in of itself a substantial contribution to reducing limb loss. It should be noted that three recent series of combined extremity trauma showed either no difference in amputations between blunt and penetrating trauma or a higher amputation rate among the penetrating injuries^{[1] [4] [10]}. However, these series involved small numbers ( 40 total) of especially severe injuries. Nonetheless, they demonstrate that there are still other variables which affect outcome besides mechanism.

Prompt diagnosis of vascular injury in any injured extremity is essential because of the well established direct relationship between the time interval from injury to treatment and the chance of limb loss. This principle is confirmed by several series which cite prolonged ischemia, delay in restoration of blood flow, or failure of vascular repair as the most common reasons for limb loss in combined arterial and skeletal extremity injuries^{[3] [4] [6-8] [10]}. Arteriography is the modality of choice to confirm or exclude arterial injury, although the indications for its use are debated. Unlike isolated arterial injuries, an associated skeletal injury significantly decreases the predictive value of physical exam findings, since hard signs of vascular injury may be due solely to the bone injury or associated soft tissue injury, without any damage to major vessels, in as many as 60% to 70% of cases^{[2] [3] [17]}. Therefore, immediate arteriography is warranted in combined extremity trauma manifesting hard signs, in order to avoid up to a 70% rate of unnecessary limb exploration^[10].

Several recent series suggest that a negative physical examination following combined injury (i.e. no hard signs present) reliably excludes vascular injury which requires repair. Nonocclusive vascular injuries with benign natural history, however, may occur. Three series report a total of 98 asymptomatic combined extremity injuries from both blunt and penetrating trauma, of which only one underwent surgical repair: an intimal flap of a distal radial artery which may have not required surgery^{[5] [11] [17]}. One series followed 15 asymptomatic nonocclusive arterial injuries from combined extremity trauma for a mean of 6.5 months, none requiring intervention^[5]. Authors now recommend that arteriography is not necessary for combined extremity trauma with no hard signs of vascular injury.

Although noninvasive vascular studies, Doppler pressure measurements and duplex ultrasonography, have been used in this setting, there is no evidence of any benefit or role for these studies in this setting^{[2] [17] [18]}. In fact, the significant swelling, soft tissue and bone disruption, bulky splints and dressings that characterize these injuries cast doubt on the utility and validity of these tests. Arteriography is clearly the modality of choice for evaluation of high risk extremity skeletal trauma for vascular injury.

Studies have shown that restoration of blood flow within six hours, both with and without skeletal injury significantly improves limb salvage^{[3] [10]}. There are studies which fail to show a clear correlation between time delay and outcome and some with average treatment delays in excess of eight hours which report amputation rates equivalent to those with prompt treatment within six hours^{[1] [2] [4] [5] [8] [9] [10]}. This again stresses that multiple variables affect outcome, and they cannot be controlled in retrospective reports. However, the weight of evidence indicates that rapid diagnosis must be followed as expeditiously as possible by restoration of blood flow.

Studies in the past have recommended that skeletal repair should be done routinely prior to vascular repair^[19]. More recent studies have advocated selective initial vascular repair only when limb ischemia is clinically evident^{[1] [2] [4] [7]}. The rationale for orthopedic priority was the potential disruption of a fresh vascular anastomosis by subsequent manipulation of bone fragments, or length discrepancies in the vascular repair caused by subsequent stabilization of comminuted, unstable skeletal injuries. However, evidence has refuted these conjectures. Snyder et al, noted vascular repair disruption in only 2/29 (7%) cases, neither of which affected outcome as they were repaired immediately^[6]. Howe et al, found no cases of vascular disruption in 21 combined injuries with subsequent orthopedic repair^[3]. This data is further supported by studies showing significantly lower amputation rates in those undergoing restoration of blood flow prior to skeletal repair than in those undergoing skeletal repair first^{[19] [22]}. Although some studies showed either a higher amputation rate, or no difference in amputations, when revascularization was done first, their validity is suspect because vascular priority was only applied to the most ischemic limbs^{[1] [4] [8]}. Howe et al, emphasize that the known importance of a short time interval to revascularization, as discussed above, as well as the absence of any demonstrable disadvantage, should be enough justification to always revascularize first, which is the current consensus^{[3] [5] [6] [9] [14] [23]}.

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

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

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

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

Combined arterial and skeletal trauma poses a high risk for compartment syndrome. Its presence must be considered in every case. Several series of lower extremity vascular trauma have partially attributed excellent limb salvage rates to aggressive use of early fasciotomy^{[14] [19]}. In combined injuries, fasciotomy has been applied in 30% to 71% of combined cases^{[2] [5] [9] [10]}. In virtually all reported cases its application has been recommended either at the time of, or before, the vascular repair is undertaken^{[2] [5] [6] [8] [9] [23]}. It is widely agreed that prophylactic rather than therapeutic fasciotomy, offers the best opportunity for limb salvage and limb function. The nonspecific clinical manifestations of compartment syndrome are late manifestations which are not reliable in helping to avoid limb morbidity^[18]. When fasciotomy is not performed, compartment pressures should be closely monitored.

Current evidence suggests that nonoperative observation of asymptomatic nonocclusive extremity arterial injuries found on arteriography is safe^[21]. This appears true in the specific setting of combined arterial and skeletal trauma, where some arterial injuries have been observed^{[2] [5] [10] [11]}. In two studies, only one of 45 nonocclusive arterial injuries in this setting underwent surgery, without a single amputation or complication related to arterial injury. Fifteen of these occult vascular injuries were followed for an average of 6.5 months, and the avoidance of vascular exploration in these severely injured limbs was felt to contribute to the low (7.3%) overall amputation rate^[5].

Early amputation may sometimes provide better long term outcome, in terms of cost and function, than overly extensive attempts at limb salvage^[1]. Gustilo III-C injuries (open comminuted tib-fib fractures with arterial injury), sciatic or tibial nerve transection, severe prolonged ischemia, older age with comorbidity, multiple long bone fractures, crush or extensive soft tissue trauma and severe contamination are factors predicting a high rate of amputation^{[3] [8] [24]}. Although several scoring systems for predicting the need for early amputation have been proposed, none have yet shown sufficient prospective reliability to permit a firm decision for amputation^{[3] [4] [25]}. Initial revascularization and skeletal stabilization should be done in most cases before a decision is made.

V. Summary

There is an increased risk of limb loss with combined skeletal/arterial extremity injuries. The associated skeletal injury will significantly decrease the value of physical examination, thus warranting immediate angiography in patients with hard signs of vascular injury. Patients with a negative physical examination or soft signs of arterial injury do not need angiography.

It is extremely important that blood flow to the distal extremity be restored within six hours. This may be accomplished through use of a temporary vascular shunt while the orthopedic stabilization is accomplished, followed by definitive vascular repair.

Combined injuries are at a high risk for compartment syndrome. Prophylactic fasciotomies should be performed early to reduce the incidence of limb loss.

VI. Future Investigation

Several issues in diagnosis and management of combined arterial and skeletal extremity injuries remain unresolved. Future studies should focus on prospective evaluation of the following:

1. Proper sequence of vascular and skeletal repair in stable, nonischemic extremities
2. Indications for internal fixation of extremity skeletal trauma in this setting
3. Prophylactic vs. Therapeutic fasciotomy
4. Role of arteriography in extremity skeletal trauma with no signs of vascular injury
5. Nonoperative observation of asymptomatic nonocclusive arterial injuries
6. Role of noninvasive tests to evaluate extremities with skeletal injuries for vascular trauma
7. Prognosis and implications of penetrating vs. Blunt mechanisms
8. Indications for immediate or early amputation
9. Role of intraoperative arteriography

VII. References

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2. Bishara RA, Paasch AR, Lim LT, et al. Improved Results in the Treatment of Civilian Vascular Injuries Associated with Fractures and Dislocations. J Vasc Surg 3: 707-711, 1986.
3. Howe HR, Poole GV, Hansen KJ, et al. Salvage of Lower Extremities Following Combined Orthopedic and Vascular Trauma: A Predictive Salvage Index. Am Surg 53: 205-208, 1987.
4. Poole GV, Agnew SG, Griswold JA, et al. The Mangled Lower Extremity: Can Salvage be Predicted? Am Surg 60: 50-55, 1994.
5. Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Patterns of Arterial Injuries Associated with Fractures and Dislocations. J Am Coll Surg 183: 377-383, 1996.
6. Snyder WH. Vascular Injuries Near the Knee: An Updated Series and Overview of the Problem. Surgery 91: 502-506, 1982.
7. Keeley SB, Snyder WH, Weigelt JA. Arterial Injuries Below the Knee: Fifty-one Patients with 82 Injuries. J Trauma 23: 285-292, 1983.
8. Russell WL, Sailors DM, Whittle TB, et al. Limb Salvage Versus Traumatic Amputation: A Decision Based on a Seven-Part Predictive Index. Ann Surg 213: 473-481, 1991.
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10. Bongard FS, White GH, Klein SR. Management Strategy of Complex Extremity Injuries. Am J Surg 158: 151-155, 1989.
11. Norman J, Gahtan V, Franz M, et al. Occult Vascular Injuries Following Gunshot Wounds Resulting in Long Bone Fractures of the Extremities. Am Surg 61: 146-150, 1995.
12. Graham JM, Mattox KL, Feliciano DV, et al. Vascular Injuries of the Axilla. Ann Surg 195: 232-238, 1982.
13. Borman KR, Snyder WH, Weigelt JA. Civilian Arterial Trauma of the Upper Extremity: An 11 Year Experience in 267 Patients. Am J Surg 148: 796-799, 1984.
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15. McCroskey BL, Moore EE, Pearce WH, et al. Traumatic Injuries of the Brachial Artery. Am J Surg 156: 553-555, 1988.
16. Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-522, 1991.
17. Applebaum R, Yellin AE, Weaver FA, et al. Role of Routine Arteriography in Blunt Lower Extremity Trauma. Am J Surg 160: 221-225, 1990.
18. Gates JD. The Management of combined Skeletal and Arterial Injuries of the Lower Extremity. Am J Orthoped 24: 674-680, 1995.
19. Lim LT, Michuda MS, Flanigan DP, et al. Popliteal Artery Trauma. Arch Surg 115: 13071313, 1980.
20. Itani KMF, Burch JM, Spjut-Patrinely V, et al. Emergency Center Arteriography. J Trauma 32: 302-307, 1992.
21. Frykberg ER, Crump JM, Dennis JW, et al. Nonoperative Observation of Clinically Occult Arterial Injuries: A Prospective Evaluation. Surgery 109: 85-96, 1991.
22. McCabe CJ, Ferguson CM, Ottinger LW. Improved Limb Salvage in Popliteal Artery Injuries. J Trauma 23: 982-985, 1983.
23. Allen MJ, Nash JR, Ioannidies TT, et al. Major Vascular Injuries Associated with Orthopedic Injuries to the Lower Limb. Arch SurgAnn Royal Coll Surg 66: 101-104, 1984.
24. Moniz MP, Ombrellaro MP, Stevens SL, et al. Concomitant Orthopedic and Vascular Injuries as predictors for Limb Loss in Blunt Lower Extremity Trauma. Am Surg 63: 24-28, 1997.
25. Bonanni F, Rhodes M, Lucke JF. The Futility of Predictive Scoring of Mangled Lower Extremities. J Trauma 34: 99-104, 1993.

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