Coverage of acute vascular injuries of the axilla and groin with transposition muscle flaps: case reports

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

For the patient-Evolution in the management of vascular trauma

There has been an evolution in the diagnosis and management of vascular trauma over the past 100 years. The primary stimulus to these changes has been the increased volume of patients with cervical, truncal, and peripheral vascular injuries during military conflicts and in civilian life. Patients with "hard" signs of a vascular injury are taken to surgery emergently with a few exceptions to be described. In contrast, patients with "soft" signs of a vascular injury undergo a careful physical examination including measurement of vascular index to determine if radiologic imaging is necessary. Computed tomography arteriography has become the most commonly used method of imaging, whereas duplex ultrasonography is used in some centers. Nonoperative management is now common for nonocclusive injuries diagnosed on computed tomography arteriography. Proximal tourniquets are commonly used to control exsanguinating hemorrhage from injuries to extremities, whereas balloons can be used to control hemorrhage from difficult to expose areas at operation. Temporary intraluminal shunts are now used in 3% to 9% of arterial injuries. Operative techniques of repair have been refined and contribute to the excellent results noted in modern trauma centers.

Vascular Injury in Orthopedic Trauma

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

Pedicled internal oblique rotational muscle flap for reconstruction of lateral pelvic defects: report of 4 cases

Various local and distant flaps have been used to repair pelvic defects, including sartorius, rectus abdominis, rectus femoris, tensor fascia lata, vastus lateralis, gracilis, and omentum, each with benefits and disadvantages. The pedicled internal oblique rotational muscle flap has been described to cover pelvic wounds but may be underutilized. We present our experience with 5 pedicled internal oblique flaps in 4 patients (3 male, 1 female). The mean patient age was 32 years (23-47 years), and the mean follow-up was 8 months. All patients required coverage of the lateral pelvis after failure of conservative measures. There were no major complications. One patient experienced decreased sensation in the lateral femoral cutaneous nerve distribution, which resolved fully within 3 months. The internal oblique muscle provides local soft-tissue coverage with a predictable blood supply, and its proximity to the pelvis offers an alternative for reconstruction of lateral pelvic defects, with minimal associated morbidity.