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Trauma, Peripheral Vascular Injuries
Updated: Jul 11, 2007
Introduction
Background
Peripheral vascular injuries may occur through multiple mechanisms. These injuries may be difficult to detect; however, they may also cause serious morbidity and on occasion be life-threatening. Therefore, having a rational approach to the diagnosis and treatment of such patients to prevent a potentially catastrophic outcome is important.
Pathophysiology
Penetrating trauma to the extremities may result in peripheral vascular injury. Stab and gunshot wounds can both result in partial or complete transection of vascular structures via direct contact. In addition, gunshot wounds may indirectly cause vascular trauma. As a consequence of the cavity left behind by a bullet, the tissue recoils back to fill the space, and this motion may cause injury to adjacent vascular structures. The amount of indirect damage done relies on the velocity and mass of the bullet.
Blunt forces may also result in vascular injury. This may occur via shearing forces transmitted to the vessel or direct crushing of the vessel. These injuries may be associated with obvious mechanisms, such as motor vehicle accidents or severe crush injuries, but they should also be suspected in cases of bites from large dogs, electrical injuries, and other instances where large amounts of force may be applied to the tissue surrounding a vascular structure.
Searching for neurologic damage as well as fractures is important in patients with peripheral vascular injuries. Peripheral nerves are usually closely associated with vascular structures in the limbs, and the large forces often involved in vascular injuries may result in fractures.
Frequency
United States
Peripheral vascular injuries comprise approximately 3% of major injuries. Most are caused by penetrating trauma, but blunt trauma and iatrogenic injuries are also important mechanisms.
Mortality/Morbidity
- Mortality directly relates to other injuries (injury severity score) and to the degree of hemorrhage.
- Isolated peripheral vascular trauma usually has a low mortality rate.
- Morbidity increases with prolonged ischemia, which can result in amputation of the affected limb.
- Morbidity associated with arterial reconstruction includes postrepair edema, infection, arterial compression, and anastomotic thrombosis.
- Neurologic deficits from peripheral nerve damage may occur.
Sex
Penetrating peripheral vascular injuries secondary to gunshots or stab wounds are more common in males than in females.
Age
Traumatic injury disproportionately affects younger persons and is the leading cause of death in those aged 1-44 years.
Clinical
History
- Tetanus status
- Timing of wound
- History of abuse or danger to patient if discharged
- Paresthesia or loss of function in a limb
- Information regarding the number of gunshots heard may be helpful.
- Knowing the type of weapon used and the velocity or potential path of the missile may help in assessment.
- In blunt vascular injury, a detailed mechanism of injury often helps in appreciating subtle injuries.
Physical
Always assess ABCs first. During the primary survey, any extremity hemorrhage should be addressed. The patient can then be examined for potential vascular injury. A thorough examination of all injured extremities should be performed. Particular attention should be paid to assessing pulses, capillary refill, deformities, and neurologic function. Two-point discrimination and strength testing should be included in the neurologic examination.
Below are clusters of physical examination findings and historical features that aid in the diagnostic and therapeutic approach to patients in whom vascular injury is considered.
- Hard signs of vascular injury
- Expanding hematoma
- Palpable thrill or audible bruit
- Pulsatile hemorrhage
- Pain on passive extension of muscle compartment
- Pallor
- Paresthesias
- Pulselessness (palpable pulse does not exclude diagnosis)
- Prolonged capillary refill
- Paralysis
- Soft signs of vascular injury
- Large hematoma
- Isolated peripheral nerve deficit
- Delayed capillary refill
- High-risk injuries
- Proximity injuries (within 1 cm of vascular bundles, ie, common femoral, axillary, brachial, and popliteal)
- Associated fractures or dislocations
- Bites from large dogs or other animals
- Crush injuries
- Shotgun injuries
Causes
Most injuries are secondary to acts of violence involving gunshot or stab wounds. Vascular injuries usually are caused by penetrating trauma from knives, bullets, and glass. Motor vehicle accidents, heavy machinery-related injuries, and falls cause a small proportion of blunt vascular injuries secondary to decelerating or crushing forces.
Penetrating injuries cause damage to vascular structures by direct injury (eg, secondary to stab or low-velocity missile wounds) and/or high-velocity injury (eg, cavitation effect by passage of a high-velocity missile through tissue with transfer of large amounts of kinetic energy). Destructive power increases proportionately with missile velocity and mass. These types of injuries can cause severe damage, even in the absence of direct vascular trauma.
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| References |
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References
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Further Reading
Keywords
peripheral vascular injury, vascular trauma, tensile strain, shear strain, vessel rupture, intimal rupture, penetrating trauma, blunt trauma, stab wounds, gunshot wounds
