Penetrating Combined Arterial and Skeletal Extremity Trauma, Management of

Published 2002

Level 1

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

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.

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.