Vascular injuries and amputation following limb fractures

Lower Extremity Amputations in Adults Less Than Forty Years of Age: An Underestimated Risk from Premature Atherosclerosis

Between 1987 and 1992, 57 patients aged twenty-five to forty (average, 34.0 ±4.5 years) underwent major lower extremity amputations in five community hospitals, including a Level II Trauma Center. Only 19 (33%) patients had traumatic amputations, 3 (5%) had malignant tumors, and 4 (7%) had juvenile-onset diabetes mellitus without atherosclerotic involvement of the large arteries. Thirty (53%) patients had premature atherosclerosis (PAS) of the lower extremities with end-stage renal disease (ESRD) present in half and related to diabetes in 12. All patients with ESRD required continuous dialysis therapy. Overall 19 (33%) patients in this study had diabetes. Of 32 patients < thirty-five years of age, 47% had traumatic amputations, and PAS was diagnosed in 28%. However, PAS was diagnosed in 84% of 25 patients > thirty-six years of age (OR= 14.3; P < 0.001). In total, 67 amputations were done. Twenty-one (68%) of 31 above-knee amputations (AKA) were performed in patients with PAS, and 26% of AKA were related to trauma. Of 10 bilateral amputations, 9 (90%) were done in patients with PAS. Patients with PAS had a high prevalence of risk factors for cardiovascular disease including smoking (87%), diabetes (50%), hypertension (50%), and hyperlipidemia (30%). Nine (30%) of the patients with PAS had hypercoagulable states. PAS was identified as the leading cause for major amputations among young adults in this community and was frequently associated with heavy smoking, diabetes, end-stage renal disease, and hypercoagulability.

Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management

OBJECTIVES

Review of limb arterial injuries associated with limb fractures.

DESIGN

Retrospective study.

SETTING

University Hospital.

MATERIALS AND METHODS

The clinical presentation, assessment and management of 25 patients with upper (seven) and lower (18) limb arterial injuries associated with limb bone fractures has been retrospectively reviewed.

MAIN RESULTS

Five patients presented with life threatening injuries and classic signs of acute limb ischaemia, 15 patients had an obvious limb arterial injury, and 5 presented with a suspected limb arterial injury. The site of arterial damage was: superficial femoral (4); popliteal (11); tibioperoneal trunk (3); anterior tibial (4); posterior tibial (3); peroneal (2); axillary (1); brachial (5); radial (4); and ulnar artery (4). The types of arterial repair were: autogenous vein interposition or bypass grafting (17); P.T.F.E. (2); end-to-end anastomosis (14); and ligation (8). The popliteal vein was injured in six cases, repaired in four and ligated in two; the superficial femoral vein was injured in four cases, repaired in three and ligated in one; and the axillary vein was injured in one case and was ligated. Primary nerve repair was employed in six out of seven injured nerves. Skeletal fixation preceded vascular repair in 21 patients and in four a Javid shunt was used. Intraoperative fasciotomy was performed in 12 out of 18 patients with lower limb ischaemia. Completion arteriography revealed residual thrombi in the distal foot of four patients, in whom intraarterial thrombolysis was effective. During the follow-up period of 1.5 to 2 years, the upper and lower limb preservation rate was 100 and 89%, respectively. The upper limb function was judged excellent in five patients, good in one and fair in one. In the lower limbs it was excellent in 11 patients, good in three, fair in one and poor in one.

CONCLUSIONS

To ensure life and functional limb salvage of patients with devastating vascular injuries, a well organised multidisciplinary approach is necessary.

Peripheral vascular injuries in children

We report 94 arterial injuries in 91 children treated at the Department of Thoracic and Cardiovascular Surgery, Medical School of Dicle University, between 1978 and 1988. The average age was 10.3 (range, 3 to 14) years. Stab wounds were seen in 37 patients (40%). Gunshot wounds were seen in 21 patients (23%), and two cases were caused by iatrogenesis. Vein damage was present in 39 patients (44.4%), and nerve loss was observed in 20 patients (21.2%). Twenty-one cases (23.3%) were associated with fractures. Diagnosis of arterial injury was made by clinical findings. Arteriography was used in 15 patients (16.5%) as the diagnostic method. The surgical interventions performed for arterial repair in our series were end-to-end anastomosis in 61 (64.5%), interposition of autogenous reversed saphenous vein grafts in 22 (23.4%), lateral suture in 8 (8.3%), and ligation in 3 (3.9%) patients. Four patients (5.3%) underwent limb amputation.