Frequency of Vascular Injury with Blunt Trauma-Induced Extremity Injury T.J. Bunt, MD, FACS, James M. Malone, MD, FACS, Mark Moody, MD, James Davidson, MD, Robert marpman, MD, FACS,Phoenix,Arizona
Vascular injury associated with select blunt traumainduced orthopedic injuries is thought to occur frequently enough to require angiography in most cases. We sought to establish the actual frequency of such vascular injuries by reviewing all orthopedic and vascular patients seen during 4 years at one institution. A total of 569 at-risk parajoint fractures or dislocations were seen with a 1.5% incidence of vascular injury; all were recognized on clinical examination and vascular consultation then obtained. Vascular injury in this setting is uncommon, associated with particular clinical presentations, and recognized by the orthopedic surgeon, without need for routine angiography or vascular consultation.
ascular surgeons are accustomed to an occasional consultation for repair of injured extremity vessels V after traumatic extremity fractures and/or dislocations,
during the 4 years from 1986 through 1989. Records of extremity fractures or dislocations that are commonly thought to be associated with vascular injury were extracted and reviewed for the incidence of vascular injury. At-risk cases were considered to be supracondylar humeral fracture and elbow dislocation in the upper extremity and supracondylar femoral fracture, tibial plateau fracture, and knee dislocation in the lower extremity. Other humeral fractures and tibia-fibula fractures were also reviewed as potential parajoint fractures causing potential vascular injury, although they are not commonly associated with same. All fractures and/or dislocations were due to blunt trauma and seen immediately after injury; penetrating injuries or delayed referrals were excluded from the review. All patients were managed by the Orthopedics Service and had baseline vascular examinations based on palpation or Doppler confirmation of pulses; angiogram and vascular surgical consultation were performed only when vascular compromise was suspected from such evaluations. Subsequent vascular examinations were performed after reduction and/or fixation, and the clinical status of the at-risk limb was assessed before the patient was discharged from the hospital or emergency room, and a crosscheck was made at a subsequent clinic followup visit.
and commonly associate such vascular injuries with a defined set of orthopedic injuries, e.g., supracondylar humerus fracture, tibial plateau fracture, or knee or elbow dislocation. They may not realize that a tremendous number of similar injuries are treated by the orthopedic service without need for a vascular consultation. A protocol for best patient management might then look at the role of the vascular surgeon and/or formal vascular consultation: Is one needed for all "at-risk" injuries? For certain select cases only? Or are the defining principles sufficiently coherent to allow the orthopedic surgeon to recognize the uncommon vascular injury when it occurs and then seek vascular consultation? This study sought to address these questions.
RESULTS Review of the Vascular Registry demonstrated that a total of 124 traumatic vascular injuries were managed by the Vascular Surgery Service over this interval, 70 of these in the extremities. Vascular injury due to nonpenetrating injury of the extremities represented 9% (6 of 70) of cases seen. Review of the Orthopedic Registry demonstrated 569 parajoint fractures, 9 (1.5%) of which involved vascular injury; 6 came to operation and were in the Vascular Registry. Table I tabulates the frequency of vascular injury seen with the various reviewed orthopedic injuries. There were no injuries associated with 108 humeral shaft fractures; there was a 3% (3 of 89) incidence with supracondylar humeral fracture in children. All three cases involved PATIENTS AND METHODS The charts of all patients admitted to or seen in the brachial artery spasm; none required documentation by emergency room and treated without admission by the angiogram; all responded to fracture reduction and all Orthopedics Service at Maricopa Medical Center were were clinically type III fractures. There was essentially no vascular injury following 345 retrospectively reviewed, and a crosscheck was made of the Vascular Registry for traumatic vascular injuries lower extremity fractures; none was seen with 55 supra'condylar femoral or 88 tibial plateau fractures. Of 202 From the Divisionsof Vascular and Orthopedic Surgery, Maricopa tibia-fibula fractures, the only 1 that resulted in vascular MedicalCenter,Phoenix,Arizona. injury was a grade IV open fracture with avulsion of the Requestsfor reprintsshouldbe addressedto T.J. Bunt,MD, Mari- tibioperoneal trunk and a semi-amputation of the limb. copa MedicalCenter,2601 East Roosevelt,Phoenix,Arizona85008. Presented at the 18th AnnualMeetingof the Societyfor Clinical Amputation was eventually required. Thus, limb salvage was obtained in eight of nine vasVascularSurgery,Palm Desert, California,March 7-11, 1990. 226
THE AMERICAN JOURNAL OFSURGERY VOLUME160 AUGUST 1990
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cular injuries (five of six operatively managed). Additional neurologic injuries included compartment syndrome in 6 of 203 tibia-fibula fractures and in 1 supracondylar femoral fracture; all were treated by fasciotomy with two permanent foot-drop syndromes. COMMENTS The peripheral vascular surgeon associates vascular injury following blunt orthopedic trauma with certain types of fractures or dislocations about major joints; an average service encounters a number of such injuries each year. For example, Meek and Robbs [1] noted 102 incidences of vascular injury in 83 lower extremities after orthopedic trauma over a 6-year period; O'DonneU and co-workers [2] recorded 28 cases of vascular injury after lower extremity fracture or dislocation over 12 years; and Wolman et al [3] noted 29 cases over 20 years. During the time frame of this review, 9% of 70 extremity vascular injuries were due to blunt orthopedic trauma. From the vascular surgeon's viewpoint, vascular injury after fracture and/or dislocation is a fairly frequent event; this logically leads to the concept that vascular consultation and/or angiography might well be warranted in all such injuries. The orthopedic surgeon, on the other hand, can demonstrate that there are literally hundreds of at-risk fractures and/or dislocations managed by the Orthopedic Service without vascular injury and could well maintain the position that vascular consultation is seldom warranted. This study sought to determine the actual frequency of recognized vascular injury occurring within a selected group of blunt trauma-induced fractures and/or dislocations occurring about the knee and elbow joints. The overall incidence of vascular injury in this 4-year series was low, only 1.5% (9 of 569). Fractures occurring on either side of the joint carried very little risk; even pediatric supracondylar humerus fractures were seldom associated with injury--3% (3 of 89). Major joint dislocations were more commonly associated with vascular injury: for open elbow dislocation, 66% (two of three); and for knee dislocation, 43% (three of seven). Furthermore, analysis of the exact type of fracture or dislocation reveals certain clinical patterns that indicate a high risk for associated vascular injury. Supraeondylar humeral fracture: This fracture is classified into three types based on fracture displacement. The most common types leave the brachialis muscle protecting the neurovascular bundle; in contrast, type III fractures may involve a medial spike that impales the brachialis muscle and displaces the brachial artery; the latter is tethered by the supratrochlear artery and may be kinked, contused, or go into intense spasm. Alternatively, a lateral spike uncommonly kinks the artery or the artery may get caught within the fracture itself. A type III fracture can be clinically recognized by a palpable anterior bone fragment and a visible subcutaneous hemorrhage in the anterior arm; there may also be a dimple in the overlying skin. Since type III fractures are uncommon, the overall incidence of Volkmann's ischemic contracture in supracondylar humeral fracture--0.5% of 4,520
TABLE I
Incidence of Neurovascular Injury Secondary to Blunt Trauma-induced Extremity Fracture/Dislocation No. of Patients
Vascular Injury (%)
Neurologic Injury (%)
Upper extremity Supracondylar humerus fracture Other humerus fracture Elbow dislocation Closed Open Lower extremity Supracondylar femur fracture Tibial plateaufracture Tibia-fibula fracture Knee dislocation Total
69
3 (3)
0
0
0
17 3
0 2 (66)
0 1 (33)
55
0
1 (2)
108
88 202 7 569
0 1 (0.5) 3 (43) 9 (1.5)
4 (5) 5 (2) 1 (14) 12 (2)
cases--is quite low; however, less severe vascular compromise may occur in as many as 5%. In our series, there was a 3% (3 of 89) incidence; all injuries were spasm relieved by fracture reduction [4-9]. Management of a type III supracondylar humeral fracture is sequential and increasingly invasive; initial fracture reduction may result in restoration of pulses; if not, angiography is indicated, which most investigators believe should be done at operation to avoid the hazards of percutaneous angiography in this age group. If pulses cannot be restored, exploration of the artery with lysis, local vasodilators, or correction of an intimal defect may uncommonly be indicated [4-9]. Elbow dislocation: Elbow dislocation is the second most common major joint dislocation; the dislocation is usually closed and posterior. Closed dislocations are rarely associated with vascular injury, whereas open and/or anterior dislocations are commonly associated with such injury. However, the open injury is itself rare. Grimes and Brooks [10] reported only 14 open dislocations in the literature as of 1985; Hofammann et al [11] reported 27 cases in a similar review of the literature in 1983; Linscheid and Wheeler [12] noted only 6 open cases in 110 consecutive elbow dislocations; Goldman and co-workers [13] noted 2 cases of vascular injury in a series of 23 dislocations; 1 occurred with open dislocation and 1 with closed dislocation. In open elbow dislocations, the brachial artery is usually disrupted by the forcible hyperextension of the joint, and recognition of the injury is straightforward. Collateral circulation of the forearm is often sufficient to maintain both viability and functions, so that ligation and reconstruction are equivalently reported. We would favor direct revascularization as was performed in both of our cases. Median nerve injury is commonly associated with such injuries and complicates rehabilitation [10-13]. Knee dislocations: Although the knee joint appears intrinsically unstable, it is actually remarkably sound and has no area of increased vulnerability (unlike the shoul-
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AUGUST 1990
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BUNTETAL
der). Consequently, it is dislocated less frequently than any other major joint. On the other hand, the highest rate of vascular injury occurs with knee dislocations. Injury occurs due to the extreme force required to dislocate the joint and may result in contusion, intimal flap, or complete disruption. The popliteal artery is relatively fixed at the adductor hiatus and soleus fascial triangles and has little room for movement. Vascular injury is equally likely with all directions of dislocation: Green and Allen [14] reviewed 204 dislocations, of which 30% (61 of 204) involved vascular compromise; 23 were anterior; 18 posterior; and 20 medial, lateral, or unspecified [1-3]. Recognition of the vascular injury may be hindered by delayed recognition of the dislocation, since many have been spontaneously or manipulatively reduced by the time of secondary consultation. Since the popliteal artery is poorly collateralized, and these collaterals are often interrupted by the trauma, distal ischemia is a significantly more frequent complication. Revascularization usually requires autologous interposition grafting; rehabilitation is complicated by concomitant neurologic inju-
ry [1-3,14]. Vascular injury with other parajoint fractures is exceedingly rare (supracondylar femoral, tibial plateau, or combined tibia-tibia in the lower extremity and with other humeral fractures in the upper extremity). A total of 463 such parajoint fractures were seen in this series; the only vascular injury was in a grade IV open tibia-fibula fracture with avulsion of the posterior tibial nerve and tibioperoneal trunk; the severity of the original injury precluded successful repair and amputation was necessary. There are a number of case reports in the literature detailing anecdotal experience with other vascular injuries due to other long bone fractures, but the incidence of each is rare. Thus, it seems reasonable to conclude from this study that vascular injuries are uncommon with blunt orthopedic trauma except knee dislocation (all types), type III supracondylar humeral fractures, and open elbow dislocations. Vascular consultation and/or angiography can, therefore, be limited to these situations. Conversely, the Orthopedic Service may safely manage all other parajoint fractures without formal vascular assistance; this entails thorough initial and follow-up vascular and/or Doppler examinations. Evidence of vascular injury on these examinations, or delineation of an impaired vascular state in the face of one of the three clinically delineated at-risk situations, would then entail vascular consultation. REFERENCES 1. Meek AC, Robbs JV. Vascular injury with associated bone and joint trauma. Br J Surg 1984; 71: 341-4. 2. O'Donnel TF, Brewer DC, Darling RC, Veen H, Waltham AA. Arterial injuriesassociatedwith fractures and/or dislocationsof the knee. J Trauma 1977; 17: 775-80. 3. Wolman FJ, Larrieu AJ, Alsop GC. Arterial injuries of the legs associated with fractures or dislocations. Am J Surg 1980; 140: 806-10. 4. RockwoodCA, Wilkins KE, King RE. Fractures of the distal
228
humerus. In: Fractures in children. Vol. 3. Philadelphia:JB Lippincott, 1984. 5. OttolenghiCE. Acute ischemicsyndrome:its treatment: prophylaxis of Volkmann's syndrome. Am J Orthop 1960; 2: 312-6. 6. RowellPJW. Arterial occlusionin juvenilehumeral supracondylar fracture. Injury 1974; 6: 254-6. 7. Sturm JT, RothenbergerDA, Strate RG. Brachial artery disruption followingclosedelbowdislocation.J Trauma 1978; 18: 364-7. 8. Broudy AS, Jupiter J, May J. Management of supracondylar fracture with brachial artery thrombosis in a child: use report and literature review. J Trauma 1979; 19: 540-4. 9. Friedman RJ, Jupiter J. Vascular injuries and closed extremity fractures in children. Clin Orthop 1984; 188: 112-20. 10. Grimes RJ, BrooksS. Brachial artery damage accompanying closed posterior dislocation of the elbow. J Bone Joint Surg [Br] 1985; 67: 378-81. 1 I. Hofammann KE, MovieimMS, Omer GE, Ball WS. Brachial artery disruption followingclosed posterior elbow dislocation in a child. Clin Orthop 1984; 184: 145-9. 12. LinscheidRL, Wheeler DK. Elbowdislocations. JAMA 1965; 194: 1171-2. 13. Goldman MH, Kent S, Schaumburg E. Brachial artery injuries associated with posterior elbow dislocation. Surg Gynecol Obstet 1987; 164: 95-100. 14. Green NE, Allen BL. Vascular injuriesassociatedwith dislocation of the knee. J Bone Joint Surg [Am] 1977; 59: 236-41. DISCUSSION John Corson (Iowa City, IA): I would stress some caution in accepting your conclusions, since a delay in recognizing vascular injury can be significant for both the patient and the surgeon. This is a highly litigious area. Nonvascular specialists are fallible in pulse palpation. Pulses may be present with significant arterial injury. Assessing whether limb-threatening ischemia is present is sometime difficult, especially in patients who have ingested drugs or alcohol or have associated nerve injuries. Significant soft tissue swelling, compartmental syndrome, plaster casts, and bulky dressings also make assessment difficult. I do have questions for you, Dr. Bunt. What is the role of noninvasive vascular examination, especially color duplex scan, in fracture and/or dislocation? What are the indications for arteriography in patients with dislocation of the knee? Should vascular surgeons be involved if a compartmental syndrome where the pulse disappears is believed secondary to that condition? Bruce J. Brener (Milburn, N J): Do you obtain arterial pressures using Doppler examination or do you just use the wave form? T.J. Bunt (closing): The orthopedist should not go unaided. The vascular surgeon should support him or her. At our institution, we attempt to educate orthopedists in vascular diagnosis, including the use of Doppler. They use it routinely on their service. Our incidence of missed vascular injury is so low that I believe a well-done physical examination and Doppler scan are sufficient. I have no experience with the color Doppler scan. All patients with dislocations undergo arteriography and, with a 40% incidence of arterial injury, it is worthwhile.
THE AMERICAN JOURNAL OF SURGERY VOLUME 160 AUGUST1990
Vascular injury associated with select blunt traumainduced orthopedic injuries is thought to occur frequently enough to require angiography in most cases. We sought to establish the actual frequency of such vascular injuries by reviewing all orthopedic and vascular patients seen during 4 years at one institution. A total of 569 at-risk parajoint fractures or dislocations were seen with a 1.5% incidence of vascular injury; all were recognized on clinical examination and vascular consultation then obtained. Vascular injury in this setting is uncommon, associated with particular clinical presentations, and recognized by the orthopedic surgeon, without need for routine angiography or vascular consultation.
ascular surgeons are accustomed to an occasional consultation for repair of injured extremity vessels V after traumatic extremity fractures and/or dislocations,
during the 4 years from 1986 through 1989. Records of extremity fractures or dislocations that are commonly thought to be associated with vascular injury were extracted and reviewed for the incidence of vascular injury. At-risk cases were considered to be supracondylar humeral fracture and elbow dislocation in the upper extremity and supracondylar femoral fracture, tibial plateau fracture, and knee dislocation in the lower extremity. Other humeral fractures and tibia-fibula fractures were also reviewed as potential parajoint fractures causing potential vascular injury, although they are not commonly associated with same. All fractures and/or dislocations were due to blunt trauma and seen immediately after injury; penetrating injuries or delayed referrals were excluded from the review. All patients were managed by the Orthopedics Service and had baseline vascular examinations based on palpation or Doppler confirmation of pulses; angiogram and vascular surgical consultation were performed only when vascular compromise was suspected from such evaluations. Subsequent vascular examinations were performed after reduction and/or fixation, and the clinical status of the at-risk limb was assessed before the patient was discharged from the hospital or emergency room, and a crosscheck was made at a subsequent clinic followup visit.
and commonly associate such vascular injuries with a defined set of orthopedic injuries, e.g., supracondylar humerus fracture, tibial plateau fracture, or knee or elbow dislocation. They may not realize that a tremendous number of similar injuries are treated by the orthopedic service without need for a vascular consultation. A protocol for best patient management might then look at the role of the vascular surgeon and/or formal vascular consultation: Is one needed for all "at-risk" injuries? For certain select cases only? Or are the defining principles sufficiently coherent to allow the orthopedic surgeon to recognize the uncommon vascular injury when it occurs and then seek vascular consultation? This study sought to address these questions.
RESULTS Review of the Vascular Registry demonstrated that a total of 124 traumatic vascular injuries were managed by the Vascular Surgery Service over this interval, 70 of these in the extremities. Vascular injury due to nonpenetrating injury of the extremities represented 9% (6 of 70) of cases seen. Review of the Orthopedic Registry demonstrated 569 parajoint fractures, 9 (1.5%) of which involved vascular injury; 6 came to operation and were in the Vascular Registry. Table I tabulates the frequency of vascular injury seen with the various reviewed orthopedic injuries. There were no injuries associated with 108 humeral shaft fractures; there was a 3% (3 of 89) incidence with supracondylar humeral fracture in children. All three cases involved PATIENTS AND METHODS The charts of all patients admitted to or seen in the brachial artery spasm; none required documentation by emergency room and treated without admission by the angiogram; all responded to fracture reduction and all Orthopedics Service at Maricopa Medical Center were were clinically type III fractures. There was essentially no vascular injury following 345 retrospectively reviewed, and a crosscheck was made of the Vascular Registry for traumatic vascular injuries lower extremity fractures; none was seen with 55 supra'condylar femoral or 88 tibial plateau fractures. Of 202 From the Divisionsof Vascular and Orthopedic Surgery, Maricopa tibia-fibula fractures, the only 1 that resulted in vascular MedicalCenter,Phoenix,Arizona. injury was a grade IV open fracture with avulsion of the Requestsfor reprintsshouldbe addressedto T.J. Bunt,MD, Mari- tibioperoneal trunk and a semi-amputation of the limb. copa MedicalCenter,2601 East Roosevelt,Phoenix,Arizona85008. Presented at the 18th AnnualMeetingof the Societyfor Clinical Amputation was eventually required. Thus, limb salvage was obtained in eight of nine vasVascularSurgery,Palm Desert, California,March 7-11, 1990. 226
THE AMERICAN JOURNAL OFSURGERY VOLUME160 AUGUST 1990
VASCULAR INJURY AND BLUNT ORTHOPEDIC TRAUMA
cular injuries (five of six operatively managed). Additional neurologic injuries included compartment syndrome in 6 of 203 tibia-fibula fractures and in 1 supracondylar femoral fracture; all were treated by fasciotomy with two permanent foot-drop syndromes. COMMENTS The peripheral vascular surgeon associates vascular injury following blunt orthopedic trauma with certain types of fractures or dislocations about major joints; an average service encounters a number of such injuries each year. For example, Meek and Robbs [1] noted 102 incidences of vascular injury in 83 lower extremities after orthopedic trauma over a 6-year period; O'DonneU and co-workers [2] recorded 28 cases of vascular injury after lower extremity fracture or dislocation over 12 years; and Wolman et al [3] noted 29 cases over 20 years. During the time frame of this review, 9% of 70 extremity vascular injuries were due to blunt orthopedic trauma. From the vascular surgeon's viewpoint, vascular injury after fracture and/or dislocation is a fairly frequent event; this logically leads to the concept that vascular consultation and/or angiography might well be warranted in all such injuries. The orthopedic surgeon, on the other hand, can demonstrate that there are literally hundreds of at-risk fractures and/or dislocations managed by the Orthopedic Service without vascular injury and could well maintain the position that vascular consultation is seldom warranted. This study sought to determine the actual frequency of recognized vascular injury occurring within a selected group of blunt trauma-induced fractures and/or dislocations occurring about the knee and elbow joints. The overall incidence of vascular injury in this 4-year series was low, only 1.5% (9 of 569). Fractures occurring on either side of the joint carried very little risk; even pediatric supracondylar humerus fractures were seldom associated with injury--3% (3 of 89). Major joint dislocations were more commonly associated with vascular injury: for open elbow dislocation, 66% (two of three); and for knee dislocation, 43% (three of seven). Furthermore, analysis of the exact type of fracture or dislocation reveals certain clinical patterns that indicate a high risk for associated vascular injury. Supraeondylar humeral fracture: This fracture is classified into three types based on fracture displacement. The most common types leave the brachialis muscle protecting the neurovascular bundle; in contrast, type III fractures may involve a medial spike that impales the brachialis muscle and displaces the brachial artery; the latter is tethered by the supratrochlear artery and may be kinked, contused, or go into intense spasm. Alternatively, a lateral spike uncommonly kinks the artery or the artery may get caught within the fracture itself. A type III fracture can be clinically recognized by a palpable anterior bone fragment and a visible subcutaneous hemorrhage in the anterior arm; there may also be a dimple in the overlying skin. Since type III fractures are uncommon, the overall incidence of Volkmann's ischemic contracture in supracondylar humeral fracture--0.5% of 4,520
TABLE I
Incidence of Neurovascular Injury Secondary to Blunt Trauma-induced Extremity Fracture/Dislocation No. of Patients
Vascular Injury (%)
Neurologic Injury (%)
Upper extremity Supracondylar humerus fracture Other humerus fracture Elbow dislocation Closed Open Lower extremity Supracondylar femur fracture Tibial plateaufracture Tibia-fibula fracture Knee dislocation Total
69
3 (3)
0
0
0
17 3
0 2 (66)
0 1 (33)
55
0
1 (2)
108
88 202 7 569
0 1 (0.5) 3 (43) 9 (1.5)
4 (5) 5 (2) 1 (14) 12 (2)
cases--is quite low; however, less severe vascular compromise may occur in as many as 5%. In our series, there was a 3% (3 of 89) incidence; all injuries were spasm relieved by fracture reduction [4-9]. Management of a type III supracondylar humeral fracture is sequential and increasingly invasive; initial fracture reduction may result in restoration of pulses; if not, angiography is indicated, which most investigators believe should be done at operation to avoid the hazards of percutaneous angiography in this age group. If pulses cannot be restored, exploration of the artery with lysis, local vasodilators, or correction of an intimal defect may uncommonly be indicated [4-9]. Elbow dislocation: Elbow dislocation is the second most common major joint dislocation; the dislocation is usually closed and posterior. Closed dislocations are rarely associated with vascular injury, whereas open and/or anterior dislocations are commonly associated with such injury. However, the open injury is itself rare. Grimes and Brooks [10] reported only 14 open dislocations in the literature as of 1985; Hofammann et al [11] reported 27 cases in a similar review of the literature in 1983; Linscheid and Wheeler [12] noted only 6 open cases in 110 consecutive elbow dislocations; Goldman and co-workers [13] noted 2 cases of vascular injury in a series of 23 dislocations; 1 occurred with open dislocation and 1 with closed dislocation. In open elbow dislocations, the brachial artery is usually disrupted by the forcible hyperextension of the joint, and recognition of the injury is straightforward. Collateral circulation of the forearm is often sufficient to maintain both viability and functions, so that ligation and reconstruction are equivalently reported. We would favor direct revascularization as was performed in both of our cases. Median nerve injury is commonly associated with such injuries and complicates rehabilitation [10-13]. Knee dislocations: Although the knee joint appears intrinsically unstable, it is actually remarkably sound and has no area of increased vulnerability (unlike the shoul-
THE AMERICAN JOURNAL O F S U R G E R Y
VOLUME 160
AUGUST 1990
227
BUNTETAL
der). Consequently, it is dislocated less frequently than any other major joint. On the other hand, the highest rate of vascular injury occurs with knee dislocations. Injury occurs due to the extreme force required to dislocate the joint and may result in contusion, intimal flap, or complete disruption. The popliteal artery is relatively fixed at the adductor hiatus and soleus fascial triangles and has little room for movement. Vascular injury is equally likely with all directions of dislocation: Green and Allen [14] reviewed 204 dislocations, of which 30% (61 of 204) involved vascular compromise; 23 were anterior; 18 posterior; and 20 medial, lateral, or unspecified [1-3]. Recognition of the vascular injury may be hindered by delayed recognition of the dislocation, since many have been spontaneously or manipulatively reduced by the time of secondary consultation. Since the popliteal artery is poorly collateralized, and these collaterals are often interrupted by the trauma, distal ischemia is a significantly more frequent complication. Revascularization usually requires autologous interposition grafting; rehabilitation is complicated by concomitant neurologic inju-
ry [1-3,14]. Vascular injury with other parajoint fractures is exceedingly rare (supracondylar femoral, tibial plateau, or combined tibia-tibia in the lower extremity and with other humeral fractures in the upper extremity). A total of 463 such parajoint fractures were seen in this series; the only vascular injury was in a grade IV open tibia-fibula fracture with avulsion of the posterior tibial nerve and tibioperoneal trunk; the severity of the original injury precluded successful repair and amputation was necessary. There are a number of case reports in the literature detailing anecdotal experience with other vascular injuries due to other long bone fractures, but the incidence of each is rare. Thus, it seems reasonable to conclude from this study that vascular injuries are uncommon with blunt orthopedic trauma except knee dislocation (all types), type III supracondylar humeral fractures, and open elbow dislocations. Vascular consultation and/or angiography can, therefore, be limited to these situations. Conversely, the Orthopedic Service may safely manage all other parajoint fractures without formal vascular assistance; this entails thorough initial and follow-up vascular and/or Doppler examinations. Evidence of vascular injury on these examinations, or delineation of an impaired vascular state in the face of one of the three clinically delineated at-risk situations, would then entail vascular consultation. REFERENCES 1. Meek AC, Robbs JV. Vascular injury with associated bone and joint trauma. Br J Surg 1984; 71: 341-4. 2. O'Donnel TF, Brewer DC, Darling RC, Veen H, Waltham AA. Arterial injuriesassociatedwith fractures and/or dislocationsof the knee. J Trauma 1977; 17: 775-80. 3. Wolman FJ, Larrieu AJ, Alsop GC. Arterial injuries of the legs associated with fractures or dislocations. Am J Surg 1980; 140: 806-10. 4. RockwoodCA, Wilkins KE, King RE. Fractures of the distal
228
humerus. In: Fractures in children. Vol. 3. Philadelphia:JB Lippincott, 1984. 5. OttolenghiCE. Acute ischemicsyndrome:its treatment: prophylaxis of Volkmann's syndrome. Am J Orthop 1960; 2: 312-6. 6. RowellPJW. Arterial occlusionin juvenilehumeral supracondylar fracture. Injury 1974; 6: 254-6. 7. Sturm JT, RothenbergerDA, Strate RG. Brachial artery disruption followingclosedelbowdislocation.J Trauma 1978; 18: 364-7. 8. Broudy AS, Jupiter J, May J. Management of supracondylar fracture with brachial artery thrombosis in a child: use report and literature review. J Trauma 1979; 19: 540-4. 9. Friedman RJ, Jupiter J. Vascular injuries and closed extremity fractures in children. Clin Orthop 1984; 188: 112-20. 10. Grimes RJ, BrooksS. Brachial artery damage accompanying closed posterior dislocation of the elbow. J Bone Joint Surg [Br] 1985; 67: 378-81. 1 I. Hofammann KE, MovieimMS, Omer GE, Ball WS. Brachial artery disruption followingclosed posterior elbow dislocation in a child. Clin Orthop 1984; 184: 145-9. 12. LinscheidRL, Wheeler DK. Elbowdislocations. JAMA 1965; 194: 1171-2. 13. Goldman MH, Kent S, Schaumburg E. Brachial artery injuries associated with posterior elbow dislocation. Surg Gynecol Obstet 1987; 164: 95-100. 14. Green NE, Allen BL. Vascular injuriesassociatedwith dislocation of the knee. J Bone Joint Surg [Am] 1977; 59: 236-41. DISCUSSION John Corson (Iowa City, IA): I would stress some caution in accepting your conclusions, since a delay in recognizing vascular injury can be significant for both the patient and the surgeon. This is a highly litigious area. Nonvascular specialists are fallible in pulse palpation. Pulses may be present with significant arterial injury. Assessing whether limb-threatening ischemia is present is sometime difficult, especially in patients who have ingested drugs or alcohol or have associated nerve injuries. Significant soft tissue swelling, compartmental syndrome, plaster casts, and bulky dressings also make assessment difficult. I do have questions for you, Dr. Bunt. What is the role of noninvasive vascular examination, especially color duplex scan, in fracture and/or dislocation? What are the indications for arteriography in patients with dislocation of the knee? Should vascular surgeons be involved if a compartmental syndrome where the pulse disappears is believed secondary to that condition? Bruce J. Brener (Milburn, N J): Do you obtain arterial pressures using Doppler examination or do you just use the wave form? T.J. Bunt (closing): The orthopedist should not go unaided. The vascular surgeon should support him or her. At our institution, we attempt to educate orthopedists in vascular diagnosis, including the use of Doppler. They use it routinely on their service. Our incidence of missed vascular injury is so low that I believe a well-done physical examination and Doppler scan are sufficient. I have no experience with the color Doppler scan. All patients with dislocations undergo arteriography and, with a 40% incidence of arterial injury, it is worthwhile.
THE AMERICAN JOURNAL OF SURGERY VOLUME 160 AUGUST1990
