Arterial injury associated with skeletal trauma

Medial approach for the treatment of femur fractures in association with vascular injury

INTRODUCTION

To highlight an alternative method of treatment for femoral fractures associated with vascular injury, allowing both fracture fixation and vascular repair from the same surgical approach.

DESIGN

Retrospective case series.

METHODS

Twelve patients with arterial injury as a consequence of femoral fracture were treated by internal fixation. There were five femoral diaphysis, seven distal femoral including supracondylar and intercondylar fractures. Four patients had injury to the popliteal artery, whereas eight to the superficial femoral artery. Seven patients had a nerve injury. Medial femoral approach was used both for the fixation of the fracture and vascular repair. Fracture fixation was done by plate-screw in all patients, whereas vascular injuries were treated using saphenous vein interposition graft in ten patients and end-to-end repair in two patients. Nerve injuries were not dealt by exploration during the vascular repair.

RESULTS

All of the limbs were ultimately survived. Clinical and radiological union was observed in all patients at the last follow-up radiographs. Of the 4 total sciatic nerve palsies, 2 had developed total, one had tibial nerve recovery. One patient had no motor recovery. Of the 3 peroneal nerve palsies, 1 patient had recovery, 2 patients had no motor improvement.

CONCLUSIONS

A midlateral approach is traditionally used for fractures of femur when plates and screws are used for fixation. In association with vascular injury, this procedure requires two separate incisions. The added soft tissue disruption associated with open reduction and internal fixation by lateral incision can be reduced with the use of single medial approach, which allows bony stabilization under direct visualization of the repaired vessels.

Versatility of Taylor Spatial Frame in Gustilo-Anderson III C femoral fractures: report of three cases

Taylor Spatial Frame (TSF) combines a multiplanar external fixator and software accuracy for reduction of acute long-bone fractures. The frame gives stability, soft-tissue preservation, adjustability and functionality allowing bone to realize its full osteogenic potential. Three patients with multiple injuries and femoral Gustilo-Anderson type III C have been treated in our center. Initial surgery was performed within 6 h of injury with help of vascular surgeon. We used TSF as definitive fixation method. The results were assessed using the functional and radiological scoring system described by Paley and Maar. Fracture union occurred in all limbs and average fixation time was 151.6 days. All three patients had excellent outcome in terms of bony and functional ASAMI criteria. The TSF is a valuable tool. It is a definitive method of femoral Gustilo-Anderson type III C fracture care using external fixation with several advantages over previously used devices.

Late Recognized Vascular Injury after High-energy Fracture of the Proximal Tibia: a Pitfall to Know in Current Practice

Failure to recognize associated soft-tissue injuries after high-energy proximal tibia fractures is not uncommon. Despite the progress in managing these complex injuries, a prompt diagnosis of associated arterial injuries still remains difficult. A high index of suspicion for arterial damages is nevertheless mandatory in these severe fractures. Treatment protocols have been developed to reduce the previously reported high rates of amputation and permit an optimal management of soft-tissue and an acceptable functional outcome. We report here a well-documented case of a severely displaced proximal tibia fracture that illustrates the problem of diagnosing and managing the associated vascular injuries.

[Dislocation of the knee joint with lesion of the popliteal artery. A case report]

Complete dislocation of the knee is rare but frequently associated with popliteal artery disruption. Prompt recognition and early revascularisation are paramount for a successful and functional result. We report on a case of anterior dislocation of the knee complicated by concomitant popliteal artery injury. The value of pre-operative diagnostic methods including pre-operative arteriography and Doppler-sonography is discussed. Review of literature is presented.

Vascular injury with associated bone and joint trauma

The clinical presentation and management of 102 vascular injuries associated with bone and joint trauma, in 100 patients over a 6-year period, is reviewed. Eighty-three injuries involved the lower limbs. Amputation became necessary in 16 patients. In 12 this was directly attributable to delay in revascularization or the extent of the soft tissue injury with consequent sepsis. Early graft occlusion in an otherwise salvageable limb occurred in four patients (3.9 per cent). Successful therapy involves close co-operation between vascular and orthopaedic surgeons with the vascular injury taking priority. The orthopaedic injury should be treated on its merits. In contaminated or comminuted fractures skeletal traction (or in suitable cases exoskeletal fixation) can be employed without adversely affecting the vascular repair. A plea is made for early diagnosis of concomitant vascular injury in patients with bone and joint injuries; this depends on clinical awareness and careful and repeated examination.

Arterial injuries in two Bristol hospitals from 1974 to 1980

Fifty-eight patients with 63 peripheral arterial injuries coming to the Bristol Royal Infirmary and Frenchay Hospital, Bristol over a six-year period from 1974-1980 were studied. The majority followed road traffic accidents, and over 70 per cent occurred in teenagers and young adults. Arterial reconstructions were undertaken in 51 cases (81 per cent) with concomitant fasciotomy in 3. Pulse volume recordings and on table arteriograms were used to detect and correct 2 reconstructions which were initially less than ideal. Forty-eight of 51 reconstructions were patent at follow up.

Major arterial trauma: review of experience with 267 injuries

Experience with 267 arterial injuries treated over a 3--4-year period is reported. Vessels in the lower limb were involved most commonly (43 per cent), but there was also a relatively high incidence of carotid (13 per cent) and subclavian (9 per cent) injuries in this series. Penetrating wounds (stab and gunshot) were most commonly responsible. We found that serious distal ischaemia is uncommon in upper limb injuries, but expanding haematoma at the root of the limb is a cause of mortality and serious morbidity. Selective use of preoperative angiography is recommended. Successful results follow liberal use of interposition grafts after wide excision of doubtful vessel, rigorous wound excision, delayed primary closure and fixation of associated fractures. Repair of concomitant venous injuries should always be attempted but is more important in the lower than the upper limb. Late revascularization in the presence of critical ischaemia yields a 50 per cent limb salvage rate, but great care must be taken to avoid renal insufficiency and, if it occurs, energetic treatment is necessary for survival.