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Extremity Vascular Trauma

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Coauthor(s): David FE Stuhlmiller, MD, FACEP, EMS Medical Director, Emergency Medical Associates of Westchester Medical Center; Medical Director, LifeNet of New York, An Air Methods Company; Medical Advisor, International Association of Flight Paramedics
Contributor Information and Disclosures

Updated: Jun 18, 2009

Introduction

Patients with extremity vascular traumas present daily in emergency departments (EDs) and trauma centers worldwide. While much of the current state-of-the-art information is the result of wartime observations, the incidence of civilian extremity vascular trauma is significant. A basic understanding of both blunt and penetrating injuries to the extremities and the resultant vascular abnormalities that occur with these injuries helps minimize mortality and morbidity in these patients.

History of the Procedure

Extremity vascular injuries have been documented during episodes of armed conflict as far back as the Greek and Roman civilizations and undoubtedly occurred before those eras. Extremity amputations were the most common procedure performed by military surgeons in the US Civil War and World War II. DeBakey and Simeone calculated the amputation rate from vascular injuries in World War II as greater than 40%.¹ Amputation was primarily a means of saving the life of the soldier in an era with no antibiotics, limited surgical technology, and no critical care.

With the advance of general medical and surgical science and a concomitant improvement in military technology, the amputation rate from vascular injury in the Korean War and the Vietnam War dropped to approximately 15%. Rich and colleagues collected the vascular database information that has provided modern surgeons with an invaluable source of data that sets the standard for management of extremity vascular injury.^2,3

Problem

Civilian extremity vascular injury, as with the wartime experience, is most prevalent in cases of penetrating trauma; however, unlike the military experience, this penetrating trauma is usually due to knife wounds or low-velocity handgun injuries.⁴ Fortunately, high-velocity assault weapon injuries and explosive injuries are rare in the United States.

In many parts of the world, regional conflicts in which antipersonnel mines are used has given rise to a large population of children and civilian adults with extremity vascular and soft tissue injuries resulting in amputations. Civilian trauma surgeons expecting to render aid and services in these areas can refer to references such as Husum and colleagues' War Surgery Field Manual to augment their knowledge of civilian wartime injuries.⁵

Frequency

The actual frequency of extremity vascular injuries worldwide is difficult to quantify.

In the United States, it is possible to separate iatrogenic vascular injury from traumatic injury and to reference hospital discharge data for the frequency of diagnosis codes. However, this method may significantly underestimate the actual frequency based on the method used to code the diagnosis and the importance and ranking attached to the diagnosis. In many cases, government report forms only record the top 3 discharge diagnostic codes, enough to potentially miss codes due to iatrogenic injury.

With the increased interest in the United States, more precise incidence numbers may be observed in the next few years. Mattox et al⁶ and Feliciano et al⁷ have shown an increasing number of iatrogenic vascular injuries occurring in Houston over the last few decades, an observation that is probably mirrored nationwide.

Data on blunt and penetrating injury are somewhat easier to derive. In wartime circumstances, the number of injuries may be extreme. Sherif reported 224 extremity vascular injuries in 18 months during the Afghanistan War, roughly 150 per year.⁸ Fasol et al reported 94 patients in 3 months (ie, approximately 376/y) on the Thailand-Cambodia border.⁹ In both studies, antipersonnel mines caused the majority of civilian extremity vascular injuries.

At a university teaching hospital in Australia, Tobin;¹⁰ reported 10 cases per year of extremity vascular injuries in Tbilisi, Georgia, Razmadze¹¹ reported 10.5 cases per year; in Sweden, Kjellstrom and Risburg¹² reported 8.2 cases per year; and in Oxford, United Kingdom, Magee et al¹³ reported 4.7 cases per year. Penetrating injuries, both violent and nonviolent, predominated as the causes of vascular injuries in these reviews.

In the United States, the situation is similar, although numbers are generally higher. Humphrey et al¹⁴ reported 12.4 extremity vascular injuries per year at a rural trauma center in Missouri; Feliciano et al⁷ reported approximately 55 lower extremity vascular injuries per year at Ben Taub General Hospital (a high-volume urban trauma center) in Houston, TX. In both extremes, the predominant cause of injury, especially in isolated vascular injury, was due to penetrating causes. Mattox et al⁶ and Feliciano et⁷ al have also pointed out that the number of iatrogenic vascular injuries has significantly increased since 1958 as more and varied physician specialties access the vascular tree. (See Caps' excellent article on the epidemiology of vascular injuries in Seminars in Vascular Surgery¹⁵ and Mattox and colleagues' paper on epidemiological evolution of these injuries in Annals of Surgery [1989]).⁶

Etiology

Extremity vascular injury may result from penetrating injury (eg, gunshot wounds,¹⁶ knife injuries), but not all penetrating injuries are violent in nature. Many penetrating extremity injuries reported in the literature are from industrial accidents (eg, nail guns) or are iatrogenic complications of vascular access procedures for other medical problems.

Blunt injuries causing vascular injury typically result from motor vehicle accidents but may include falls, assaults, and crush injuries. Fractured long bones or dislocated joints frequently increase the overall risk of vascular injury, but certain injuries (eg, posterior knee dislocation) are more likely to cause vascular injury than other injuries (eg, a Colles fracture of the wrist, which rarely results in radial or ulnar artery injury).

The worldwide increase in explosive-type injuries constitutes an emerging third modality that combines the pathology of both blunt and penetrating injury to the extremities. Terrorist bombings, civilian land mine injuries, and combat-related injuries are becoming more common, and all physicians will undoubtedly encounter these patients sometime in their career.

Pathophysiology

As noted by the preponderance of penetrating injury in the published medical literature, the vascular tree, both arterial and venous, appears to have some limited natural protection from stretching and bending, which results in fewer blunt injuries to the extremity vasculature following trauma. The smooth muscle of the arterial media protects the patient from both stretch-type injuries and minor puncture wounds, which heal spontaneously in most cases. The smooth muscle layer also offers mild protection from death due to ongoing hemorrhage.

When the arterial vessel is transected, vascular spasm coupled with low systemic blood pressure appears to promote clotting at the site of injury and to preserve vital organ perfusion better than that which occurs with ongoing uncontrolled hemorrhage. This partially explains the prehospital finding that, in the subset of penetrating trauma, limited or no fluid resuscitation until arrival at the hospital may improve patient survival and outcome.

Presentation

Worldwide, patients with extremity vascular injuries most frequently present after a penetrating injury to an extremity. In the United States, high-speed motor vehicle accidents, often with fractures or dislocations, result in the next largest group of patients. In patients with large lacerations or open wounds, persisting or increasing hemorrhage with resuscitation is an early indication of vascular injury requiring operative exploration.

Vascular injuries can be classified clinically into hard signs and soft signs of injury based on examination. Classic so-called hard signs of vascular injury include the following:

• Observed pulsatile bleeding
• Arterial thrill (ie, vibration) by manual palpation
• Bruit over or near the artery by auscultation
• Signs of distal ischemia
• Visible expanding hematoma

These signs are used to identify patients requiring surgical intervention. A finding of cool, cold, and pulseless extremities may be attributable to a low systemic blood pressure, but isolated pulse abnormalities and significant variation in pulse quality from side to side are strong indicators of underlying proximal vascular injury. Neurologic deficit, delayed capillary refill, and bony abnormalities should increase the suspicion of extremity vascular injury and the need for emergent arteriography or surgical exploration and repair.

Soft signs of vascular injury include the following:

• Significant hemorrhage found on history
• Decreased pulse compared to the contralateral extremity
• Bony injury or proximity penetrating wound
• Neurologic abnormality

Clinical examination and reexamination remain the mainstays for identifying and treating these wounds. Clinical examination and findings should determine the need for adjunctive studies such as noninvasive Doppler ultrasound and arteriography. The physical examination may be augmented by measurement of the ankle-brachial index (ABI), also referred to as the arterial pressure index in the literature. Measurement of the ABI is a standard component in the evaluation of atherosclerotic peripheral vascular disease, and its value extends to the identification of penetrating injuries to extremity vessels. Both hard and soft signs help direct the physician to the best diagnostic and treatment options for an individual patient.

Indications

In general, hard signs (eg, change in pulse quality compared to the opposite extremity, loss of pulse in the extremity) are absolute indications for further diagnostic studies (eg, arteriogram, exploration and direct visualization in the operating room). Softer signs (eg, temperature change, color change, delayed capillary refill, neurologic deficit) should alert the clinician to the need for close observation and monitoring. If the ABI is higher than 0.9, many authors advocate observation, but if the ABI is lower than 0.9, further evaluation is warranted. In these cases, many authors now recommend duplex Doppler vascular studies as a rapid, noninvasive method of assessing vascular injury. However, an arteriogram in stable patients and operative exploration in unstable or bleeding patients remain the criterion standards of care.

Relevant Anatomy

A thorough knowledge of basic medical school anatomy of the extremities is essential in the evaluation and management of extremity vascular injuries. While it is often possible to directly visualize an arterial injury through an open wound, obtaining proximal and distal control for vascular reconstruction requires intimate knowledge of vascular, muscular, and bony anatomy to allow rapid access to the arterial tree proximally and distally, while minimizing incision length and surgical tissue dissection.

Frequently, especially in cases of blunt trauma and arterial trauma with ongoing hemorrhage, the normal tissue planes are destroyed and the smooth muscle in both the artery and the vein cause retraction of the vessels into the depths of the wound. Operative identification of arterial and venous injury as a prelude to repair often requires proximal and distal control of the artery or vein, which may require extending the wound in both directions or making counterincisions.

Temporary vascular control can be achieved by simply applying pressure to the vessel proximal to the injury (eg, femoral pressure in a lower extremity wound). The use of tourniquets, while helpful in the operating room, should be limited to patients at risk for exsanguination in the prehospital and field environments who are not responsive to direct pressure for hemorrhage control. The use of tourniquets, especially those left for prolonged periods, markedly increases the incidence of amputation of an injured extremity. Any medical personnel applying a prehospital tourniquet for extremity vascular injury should clearly document its necessity as a lifesaving anti-exsanguination device when direct pressure fails and should understand that, in most cases, a tourniquet saves a life but results in loss of an extremity.

Contraindications

Preexisting renal insufficiency and allergies (seafood, iodine, contrast dye) are relative contraindications for arteriography in the assessment of vascular injury of an extremity. Pre-angiography volume resuscitation and sodium bicarbonate may help minimize the complications noted above.

Persistent massive hemorrhage and hemodynamic instability are principal contraindications for any diagnostic studies, and patients with these conditions require urgent operative exploration for diagnostic and therapeutic measures. Duplex Doppler studies may provide important information regarding vascular injury in most stable patients who have contraindications to arteriography.

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