1
|
Stahel PF, Kaufman AM. Contemporary management of open extremity fractures: What you need to know. J Trauma Acute Care Surg 2024; 97:11-22. [PMID: 38374531 DOI: 10.1097/ta.0000000000004288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
ABSTRACT Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the Lower Extremity Assessment Project and the Major Extremity Trauma Research Consortium have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within 3 hours of injury, preferably within 1 hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical debridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopedic Surgeons provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient's physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.
Collapse
Affiliation(s)
- Philip F Stahel
- From the Department of Surgery (P.F.S.), Brody School of Medicine, East Carolina University, Greenville, North Carolina; College of Osteopathic Medicine (P.F.S.), Rocky Vista University, Parker, Colorado; and Mission Health, HCA Healthcare (P.F.S., A.M.K.), North Carolina Division, Asheville, North Carolina
| | | |
Collapse
|
2
|
Brachial Artery Embolectomy in a Polytrauma Patient: A Case Report. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2022. [DOI: 10.2478/jce-2022-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: The upper extremity is a frequent site of injury. Upper limb arterial thromboembolism, a rare complication of such injuries, may be missed if typical signs, such as pain, pulselessness, and sensory loss, cannot be ascertained or are overlooked by physicians, especially in the case of polytrauma or comatose patients.
Case presentation: In this report, we present the case of a left brachial artery thromboembolism in a polytrauma patient for which brachial artery embolectomy was performed. Before surgery, the diagnosis was established with doppler ultrasonography of the upper limb vessels, performed upon suspicion of thrombus formation. Brachial artery arteriotomy and thrombo-embolectomy were performed using a size 6 Fr Fogarty catheter, after which 500 IU heparin was flushed to ensure adequate back and forward flow. Limb function and blood flow were restored immediately after the procedure.
Conclusion: A high index of suspicion, timely assessment, and a prompt intervention can significantly reduce the rate of limb ischemia and/or amputations in polytrauma patients, especially in resource-limited settings.
Collapse
|
3
|
Kawatani Y, Hori T. Rare brachial artery injury caused by blunt trauma; a case of the brachial artery laceration in an amateur volleyball player. Trauma Case Rep 2021; 37:100570. [PMID: 34917737 PMCID: PMC8669432 DOI: 10.1016/j.tcr.2021.100570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
Low-energy blunt brachial artery injury is very rare and can be easily missed. Moreover, brachial artery injury in an amateur volleyball player is extremely rare. A 33-year-old woman was referred to our emergency department with swelling on her left upper arm after playing volleyball. Paresis or paralysis was not observed. The pulse of the left brachial artery was palpable, but relatively weak. An ultrasound examination and a computed tomography, both, revealed a pseudoaneurysm on the posterior wall of the left brachial artery in the antecubital fossa. A massive hematoma was also observed beneath the artery. The examination ruled out any concomitant injuries such as fracture and dislocation of the joints. An emergency surgery was performed. A hockey stick skin incision was made from the distal brachium to the antecubital fossa. The left brachial artery was detected in the hematoma. A 15 mm-long laceration was observed on the posterior wall of the artery. The condition of the vessel wall around laceration was poor. Therefore, we resected the injured lesions. The defect was so long that the lesion was interposed by a reversed saphenous vein graft. Heparin was administered one day after the surgery, which was later changed to apixaban on the sixth day after the surgery. Apixaban was discontinued after a month post-surgery. During the follow-up period, the patient did not report any complications and the graft was unobstructed.
Collapse
Affiliation(s)
- Yohei Kawatani
- Department of Cardiovascular Surgery, Kamagaya General Hospital 929, Hatsutomi, Kamagaya-Shi, Chiba-Ken, Japan
| | - Takaki Hori
- Department of Cardiovascular Surgery, Kamagaya General Hospital 929, Hatsutomi, Kamagaya-Shi, Chiba-Ken, Japan
| |
Collapse
|
4
|
[Neurovascular complications in fractures of the extremities, part 1 : Vascular lesions]. Unfallchirurg 2019; 122:555-572. [PMID: 31270552 DOI: 10.1007/s00113-019-0682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neurovascular injuries in fractures threaten at least the function of extremities. The timely interaction between diagnosis and treatment of vascular injuries helps to avoid a poor outcome or even fatal complications. An important parameter is to "think about it" for injuries under strain. An ankle-brachial index (ABI) of <0.9 is an indicator. Massive bleeding, manifest and long-lasting peripheral ischemia and a rapidly expanding hematoma necessitate an immediate surgical intervention. Endovascular techniques are recommended on the extremities of stable patients with circumscribed vascular lesions. The debate about the sequence of repair (vascular vs. osseous) has to be decided on an individual basis; however, when in doubt vascular repair should be given priority. Vessel reconstructions should be performed without tension and must be covered by vital soft tissues, the indications for fasciotomy should be liberally interpreted. The prognosis with respect to preservation of the extremity and long-term functional outcome substantially depends on the quality of treatment of accompanying injuries.
Collapse
|
5
|
Axillary artery laceration after anterior shoulder dislocation reduction. Turk J Emerg Med 2019; 19:87-89. [PMID: 31073545 PMCID: PMC6497926 DOI: 10.1016/j.tjem.2018.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction Glenohumeral dislocation is the most commonly encountered dislocation in the emergency department. The most frequent complications of glenohumeral dislocation are rotator cuff tears and an increase in the risk of recurrent dislocation. Less common acute complications include fractures, neurological complications and vascular injuries. The incidence of axillary artery injury associated with shoulder dislocation is reported to be about 1–2%. Case An 81-year-old male presented to the emergency department with pain in the right shoulder after a fall. On physical examination, the shoulder was in slight abduction and external rotation. Shoulder movements were painful and there was a swelling in the axillary region which was tender to palpation. There was no sensory or motor deficit and the peripheral pulses were equal and palpable. Following the administration of analgesics, shoulder reduction was performed using the flexion-adduction-external rotation method. After reduction, the patient started complaining of axillary pain. On control examination, the patient did not have any motor or sensory deficits, but peripheral pulses were not palpable on the right arm. The right upper extremity computed tomography angiography, which was performed with the suspicion of vascular injury, revealed a right axillary artery rupture. Conclusion Axillary artery injury accompanying anterior shoulder dislocation is a rare but serious condition which may result in limb loss and death.
Collapse
|
6
|
Nam MH, Tsai MH, Fang YW, Lin MC. Spontaneous bleeding of thoracoacromial artery mimicking tunneled cuffed catheter-related complication: A case report. Medicine (Baltimore) 2019; 98:e14986. [PMID: 30921209 PMCID: PMC6456088 DOI: 10.1097/md.0000000000014986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE The chronic complications caused by the tunneled cuffed catheter in chronic dialysis patients are infection and catheter dysfunction. While bleeding due to this access can occur occasionally. PATIENT CONCERNS We present a 92-year-old woman with a 6-year history of regular hemodialysis (HD). For the past 2 years, she has been receiving HD via a tunneled cuffed catheter placed in the right internal jugular vein. She suffered from a right chest subcutaneous hematoma near the catheter without recent trauma. The increasing size of hematoma after dialysis, and the oozing from the outlet of the catheter were also observed. DIAGNOSIS Computed tomography of chest and angiography were done and showed that the hematoma was caused by thoracoacromial artery bleeding, which was near the puncture site of the tunneled cuffed catheter. INTERVENTIONS Fluid resuscitation, blood transfusion, surgical drainage, and parenteral antibiotics were prescribed. OUTCOMES Patient recovered fully without any further sequelae. LESSONS Spontaneous bleeding of thoracoacromial artery is rare and clinicians should keep in mind as a differential diagnosis in patient with new-onset hematoma over anterior chest wall. Early diagnosis and treatment are important in such cases.
Collapse
Affiliation(s)
| | - Ming-Hsien Tsai
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan (R.O.C)
| | - Yu-Wei Fang
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan (R.O.C)
| | - Mi-Chu Lin
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital
| |
Collapse
|
7
|
Phang ZH, Miskon MFB, Ibrahim SB. Blunt trauma to the antecubital fossa causing brachial artery injury and minor fractures around the elbow joint, an easily missed diagnosis with potential devastating consequences: a case report. J Med Case Rep 2018; 12:211. [PMID: 30016981 PMCID: PMC6050690 DOI: 10.1186/s13256-018-1751-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background Blunt trauma causing brachial artery injury in a young patient is very rare. Cases of brachial artery injury may be associated with closed elbow dislocation or instability. Elbow dislocation may not be evident clinically and radiologically on initial presentation. Case presentation This is a case of a 37-year-old, right-hand dominant, Malay man who fell approximately 6 meters from a rambutan tree and his left arm hit the tree trunk on his way down. He was an active tobacco smoker with a 20 pack year smoking history. On clinical examination, Doppler signals over his radial and ulnar arteries were poor. He proceeded with emergency computed tomography angiogram of his left upper limb which showed non-opacification of contrast at the distal left brachial artery just before the bifurcation of the left brachial artery at his left elbow joint. Radiographs and computed tomography scan also showed undisplaced fracture of left lateral epicondyle and radial head with no evidence of elbow dislocation. He subsequently underwent left brachial to brachial artery bypass which was done using reversed saphenous vein graft and recovered well. His fractures were treated using 90 degree long posterior splint for 2 weeks and he was then allowed early range of motion of the left elbow. This patient developed left elbow dislocation 6 weeks postoperatively. Closed manipulative reduction of his left elbow resulted in incomplete reduction. The functional outcome of his left elbow was limited with a range of motion of left elbow of 0–45 degrees. However, he was not keen for surgery to stabilize his elbow joint during his last follow-up 6 months post injury. Conclusions This is an uncommon case of brachial artery injury in a civilian caused by blunt trauma associated with occult elbow instability/dislocation and minor fractures around the elbow joint. The treatment of brachial artery injury with clinical evidence of distal ischemia is surgical revascularization. The possibility of elbow instability and dislocation need to be considered in all cases of brachial artery injury because early radiographs and computed tomography scans may be normal. Short-term posterior splint immobilization is not sufficient to prevent recurrent dislocations.
Collapse
Affiliation(s)
- Zi Hao Phang
- Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas, Tmn Mount Austin, 81100, Johor Bahru, Malaysia.
| | - Mohd Fadhli B Miskon
- Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas, Tmn Mount Austin, 81100, Johor Bahru, Malaysia
| | - Sa'adon B Ibrahim
- Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas, Tmn Mount Austin, 81100, Johor Bahru, Malaysia
| |
Collapse
|
8
|
Lebowitz C, Matzon JL. Arterial Injury in the Upper Extremity: Evaluation, Strategies, and Anticoagulation Management. Hand Clin 2018; 34:85-95. [PMID: 29169600 DOI: 10.1016/j.hcl.2017.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Trauma to the upper extremity can present with an associated arterial injury. After patient stabilization, thorough assessment with physical examination and various imaging modalities allows accurate diagnosis of the specific arterial injury. After diagnosis, efficient treatment is necessary to allow limb salvage. Treatment options include ligation, primary repair, graft reconstruction, endovascular repair, and amputation. The final treatment rendered is frequently dependent on injury location and mechanism. With any of the treatment options, complications may occur, including thrombosis. Currently, no validated anticoagulation protocol has been established for managing arterial injuries in the upper extremity.
Collapse
Affiliation(s)
- Cory Lebowitz
- Department of Orthopedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ 080084, USA
| | - Jonas L Matzon
- Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107, USA.
| |
Collapse
|
9
|
Utility of Multidetector Computed Tomography Angiography in evaluation of post traumatic neglected vascular injuries of the upper extremity. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
10
|
Pezeshki Rad M, Mohammadifard M, Ravari H, Farrokh D, Ansaripour E, Saremi E. Comparing color Doppler ultrasonography and angiography to assess traumatic arterial injuries of the extremities. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e14258. [PMID: 25785180 PMCID: PMC4347799 DOI: 10.5812/iranjradiol.14258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 04/20/2014] [Accepted: 06/01/2014] [Indexed: 11/17/2022]
Abstract
Background: Traumatic events are one of the major causes of arterial injuries. Physical examination is not a good predictor of the extent of injuries and arteriography is considered as the gold standard for this purpose. In the recent years, noninvasive modalities are increasingly replacing diagnostic arteriography. Color Doppler ultrasonography (USG) is an excellent method to investigate arterial diseases. Objectives: The present study aimed to evaluate the diagnostic value of color Doppler USG compared to conventional angiography in traumatic arterial injuries of extremities. Patients and Methods: Seventy-five patients with extremity trauma suspicious for arterial injury were examined by color Doppler USG just before angiography. Doppler pattern and flow states were assessed, then angiography was performed. The results of duplex USG were compared with angiography. Results: Color Doppler USG had a sensitivity of 95% and specificity of 98% in diagnosis of arterial injury. Positive and negative predictive values of Doppler USG were 92.5% and 94.2%, respectively. Conclusions: Color Doppler USG can be used as a reliable modality with acceptable sensitivity and specificity values to screen hemodynamically stable patients with limb trauma suspicious for arterial injury.
Collapse
Affiliation(s)
- Masoud Pezeshki Rad
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahyar Mohammadifard
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran
- Corresponding author: Mahyar Mohammadifard, School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran. Tel: +98-5118414499, Fax: +98-5612226898, E-mail:
| | - Hassan Ravari
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Donya Farrokh
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Emad Ansaripour
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elena Saremi
- School of Medicine, Vascular and Endovascular Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
11
|
Nour M, Zerhouni H, Bensaid B, Khaloufi S, Ouazzani L, Aqquaoui L, Elhami I, Oubejja H, Erraji M, Ettayebi F. [Axillary artery pseudo-aneurysm secondary to shoulder dislocation in children]. ACTA ACUST UNITED AC 2013; 38:377-80. [PMID: 24042011 DOI: 10.1016/j.jmv.2013.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022]
Abstract
Axillary artery injury following anterior dislocation of the shoulder in children is a rare complication often considered as iatrogenic. We report the case of a pseudo-aneurysm of the axillary artery in a 5-year-old boy that appeared four months after a shoulder dislocation that was reduced in an ambulatory setting. Although this is an uncommon vascular complication, we emphasize the need for short-term and long-term follow-up in these children to avoid missing a pseudo-aneurysm of the axillary artery.
Collapse
Affiliation(s)
- M Nour
- Service des urgences chirurgicales pédiatriques, hôpital d'Enfant-Rabat, Rabat, Maroc.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Zaiton F, Ahmed AF, Samir AM. Value of multislice computed tomography angiography (MCTA) in neglected post traumatic vascular injuries of the extremities. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2013.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
13
|
Delayed Axillary Artery Pseudoaneurysm as an Isolated Consequence to Anterior Dislocation of the Shoulder. Ann Vasc Surg 2012; 26:279.e9-12. [DOI: 10.1016/j.avsg.2011.05.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/22/2011] [Accepted: 05/15/2011] [Indexed: 11/22/2022]
|
14
|
Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM. Imaging vascular trauma. Br J Surg 2011; 99:494-505. [DOI: 10.1002/bjs.7763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 01/06/2023]
Abstract
Abstract
Background
Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.
Methods
A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.
Results
Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.
Conclusion
Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
Collapse
Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK
| | - M Cleanthis
- Imperial College Regional Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N Tai
- Trauma Clinical Academic Unit, Barts and the London NHS Trust, London, UK
| | - T Carrell
- National Institute for Health Research Comprehensive Biomedical Research Centre of Guy's and St Thomas' NHS Foundation Trust and Department of Vascular Surgery, King's College London, London, UK
| | - T M Loosemore
- St George's Vascular Institute, St George's University of London, London, UK
| |
Collapse
|