Vascular trauma associated with fractures / dislocations

North of Scotland major trauma guidelines
NHS Grampian

Fast and accurate diagnosis is paramount if limb salvage is to be successful. Early Orthopaedic and Vascular consultant referral and intervention is usually indicated.

The British Orthopaedic Association have published guidelines on the mangement of vascular injuries.

Management in the ED

  • Treat life threatening injuries ideally in conjunction with limb threatening injuries
  • Consider Code Red.
  • Apply direct pressure or a tourniquet (as distal as possible) to control active haemorrhage
  • Do not blindly clamp
  • Document neurovascular examination
  • Immediately re-align and reduce the pulseless deformed limb. Splint, reassess & image if appropriate
  • Identify direct/indirect signs of injury.
Direct signs Indirect signs
  • Pulsatile haemorrhage
  • Expanding haematoma
  • Absent palpable pulse
    Palpable thrill/bruit
  • Reduced or unequal pulse(s)
  • Non-pulsatile haematoma
  • History of significant haemorrhage
  • Injury near neurovascular structures
  • Mechanism e.g.: Knee dislocation/displaced tibial plateau, groin contusion from handlebar or mangled extremity
  • Paraesthesia
Do not use ‘pinkness’, capillary return, or Doppler signal to exclude injury.

In presence of direct signs

  • Urgent surgical exploration is indicated
  • Angiography should not delay revascularisation but may be considered if:
    • Multilevel injury
    • Peripheral vascular disease
    • Absent proximal pulse
    • Patient undergoing a WBCT for other indications and scan extended to include limb angiography.

In presence of indirect signs

CT Angiography should be performed as soon as possible.

Surgery

  • Orthopaedic and Vascular consultant should attend. Plastic Surgery should attend if open fracture
  • Patients should be aware of the substantial risk of amputation for some injuries
  • Two consultants should be involved in the decision to perform early amputation
  • Beyond 3-4 hours, warm ischaemia results in irreversible tissue damage and an increasing risk of amputation. Risks of delayed revascularisation include myoglobinuria and may be associated with increased mortality. Access incisions should be planned to facilitate soft tissue coverage
  • Vascular surgery ideally performed first.
  • Prioritise haemorrhage control and revascularisation. This may involve external fixation and temporary shunts.

Repair of identified nerve injuries is subsequently performed (delay if damage control).

  • Low threshold for post reperfusion fasciotomy.
    Admit all patients to a critical care environment post operatively.