eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Peripheral Vascular Injuries
Updated: Sep 2, 2009
Introduction
Background
Peripheral vascular injuries may result from penetrating or blunt trauma to the extremities. If not recognized and treated rapidly, injuries to major arteries, veins, and nerves may have disastrous consequences resulting in the loss of life and limb.
See Medscape's Vascular Surgery Resource Center and Trauma Resource Center for related information.
Pathophysiology
In the upper extremity, the areas of greatest concern include the axilla and the area from the deltopectoral groove distally across the elbow to the proximal forearm. The axilla, medial and anterior upper arm, and antecubital fossa particularly are considered high-risk areas because of the superficial location of the axillary and brachial arteries in these regions.
Wounds distal to the bifurcation of the brachial artery are less likely to result in serious limb ischemia, as long as the ulnar and radial arteries remain intact. Injuries to a single distal artery can often be managed by ligation alone if the palmar arches are complete and no prior injury is present. This is the case in 95% of these patients.
In the lower extremity, the area of greatest concern extends from the top of the leg marked by the inguinal ligament anteriorly and by the inferior gluteal fold posteriorly, across the knee inferiorly to the level of the mid calf. The inguinal region, medial thigh, and popliteal fossa particularly are considered high-risk locations.
Below the knee, the popliteal artery trifurcates to form the anterior and posterior tibial arteries and the peroneal artery. Arterial wounds affecting a single vessel distal to the trifurcation are unlikely to produce serious limb ischemia. If distal collateralization is adequate, injuries to a single branch may therefore be managed by ligation.
The highest risk of serious vascular injury is associated with high-energy gunshot wounds such as those produced by military rifles and shotguns. Blunt and penetrating trauma resulting in extremity fractures also have a high incidence of concomitant vascular injuries, even in the absence of clinical signs. The likelihood of serious vascular injury is lower in patients who sustain low-energy wounds such as those produced by handguns and knives.
Frequency
United States
Peripheral injuries account for 80% of all cases of vascular trauma. The lower extremities are involved in two thirds of all patients with vascular injuries.
Penetrating trauma accounts for 70-90% of vascular injuries. In the past, iatrogenic injuries related to endovascular procedures accounted for less than 10% of all cases. This percentage is increasing due to the growing use of endovascular procedures for diagnostic and therapeutic purposes.
Mortality/Morbidity
Death due solely to peripheral vascular injuries is uncommon, but does occur due to exsanguination or development of a necrotizing myofascial infection. Major venous injuries accompany 13-51% of significant arterial injuries.
- Compartment syndrome may result from ischemia of a muscle compartment. Limb survival is threatened by delays in diagnosis and treatment, particularly when limb perfusion is compromised for more than 6 hours at body temperature ("warm" ischemia).
- Extensive concurrent musculoskeletal, nerve, and skin injuries indicate a poor prognosis.
- Crush injuries associated with open tibial fractures are particularly likely to result in loss of the lower leg and amputation.
Sex
Ninety percent of patients with peripheral vascular injuries are male.
Age
Vascular injuries most often occur in patients aged 20-40 years.
Clinical
History
- In peripheral vascular injury, the mechanism of injury is an important prognostic factor. Shotgun and military rifle injuries as well as knee dislocations are particularly high risk for vascular injury.
- The time interval between injury and evaluation must be considered. "Warm" ischemia at body temperature for more than 6 hours results in irreversible nerve and muscle damage in 10% of patients. Cooling the extremity may avoid this complication.
- Previous history of vascular injury or disease
- Extensive or pulsatile external hemorrhage
- Anticoagulation therapy or impaired hemostatic function
- Prior venous thrombosis or embolism in the patient or a family member
Physical
Deciding whether the injury requires surgical intervention is a major priority of initial management.
- The presence of "hard" signs of vascular injury has a 92-95% sensitivity for injuries requiring intervention. The vast majority of patients exhibiting the following "hard" signs require intervention with a positive predictive value of 95%.
- Bruit or thrill is present in only 45% of patients with an arteriovenous fistula.
- Active or pulsatile hemorrhage
- Pulsatile or expanding hematoma
- Signs of limb ischemia and elevated compartment pressure including the 5 "P's" - Pallor, paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment. Pain on passive extension is the earliest and most sensitive physical finding.
- Diminished or absent pulses - This is not a sensitive prognostic finding, as up to 25% of patients with major vascular injuries requiring repair have normal pulses distal to the injury.
- The following "soft" signs are much less useful in predicting or excluding major vascular injuries that require intervention. The positive predictive value of "soft" signs indicating abnormal findings on an arteriogram is only 35%. The vast majority of these lesions do not require emergent repair.
- Hypotension or shock
- Neurologic deficit due to primary nerve injury occurs immediately after injury. In contrast, ischemic neuropathy is delayed in onset, developing within minutes to hours after injury.
- Stable, nonpulsatile or small hematoma
- Proximity of the wound to major vascular structures
Causes
Causes of peripheral vascular injuries include the following:
- Gunshot wounds, particularly high-energy rifle and close-range shotgun wounds, cause 70-80% of all vascular injuries that require intervention.
- Stab wounds - Only 5-10% of cases require intervention.
- Blunt trauma accounts for 5-10% of cases. The presence of a fracture or dislocation increases the risk. Blunt injuries are often more severe than penetrating injuries due to trauma to adjacent structures. The risk of eventual limb amputation is higher with blunt mechanisms of injury.
- Iatrogenic injury now accounts for more than 10% of cases. Endovascular procedures such as cardiac catheterization and central line placement are the two most common iatrogenic causes of vascular injury that require intervention. The incidence of iatrogenic injuries is growing in concert with the increased utilization of endovascular procedures.
More on Peripheral Vascular Injuries |
 Overview: Peripheral Vascular Injuries |
| Differential Diagnoses & Workup: Peripheral Vascular Injuries |
| Treatment & Medication: Peripheral Vascular Injuries |
| Follow-up: Peripheral Vascular Injuries |
| Multimedia: Peripheral Vascular Injuries |
| References |
| Next Page » |
References
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Further Reading
Keywords
peripheral vascular injury, penetrating trauma to the extremities, blunt trauma to the extremities, vascular injury, injury to arteries, injury to veins, injury to nerves, vascular trauma, crush injuries, gunshot wounds
