Assessment and Interventions for Vascular Injuries Associated With Fractures

Clay A. Spitler, MD; David A. Patch, MD; Graeme E. McFarland, MD; Walt R. Smith, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(9):387-394. 

In This Article

Etiology

The rate of vascular injury depends on the type of injury and varies widely by population, geographic location, and blunt versus penetrating trauma.[7] The incidence of vascular injuries accompanied with long bone fractures is uncommon, <1%.[8] However, certain fracture patterns have demonstrated a propensity for vascular compromise including open fracture, tibial-fibula fracture, comminuted tibial plateau fracture, severely displaced fractures, and segmental shaft fractures, as well as patients presenting with blunt trauma, crushed injury, floating joint, and dislocation.[9] Vascular injury associated with blunt fractures in the lower extremity can be devastating carrying notable morbidity and mortality, with higher rates of complication than penetrating vascular injuries.[9] Acute limb ischemia after a vascular injury and lower extremity fractures can result in reperfusion injury, soft-tissue necrosis, and amputation.

Although vascular injury can occur in both upper and lower extremity trauma, most of the literature focuses on outcomes of vascular injury associated with lower extremity trauma. Displaced fractures of the distal femur, proximal tibial fractures, and dislocations of the knee are at the highest risk for vascular insult because of the high-energy nature of these injuries and proximity to arterial structures.[10] Femur fractures associated with vascular compromise of the superficial femoral artery have been reported to range from 1.0% to 2.0%.[11] Injuries to the popliteus artery occur in 1.5 to 2.8% of all tibial fractures (Figure 1); however, open tibial fractures accompanied by arterial injuries have an incidence of nearly 30%.[4] Vascular injuries in the setting of knee dislocations have been reported as high as 22 to 32% (Figure 2).[12] In talar neck fracture dislocations, the dislocated talar body can cause impingement or even transection of the posterior tibial artery. These fractures require urgent surgical reduction. The combination of pressure-induced necrosis on the skin and posterior tibial artery injury can lead to extensive local soft-tissue death or critical ischemia to the plantar foot.[13]

Figure 1.

Three-dimensional reconstruction of a CT angiogram demonstrating a popliteus artery injury and a proximal tibial fracture. The patient underwent a below knee popliteus to tibioperoneal trunk bypass with the saphenous vein. The fracture was then treated with an intramedullary nail and required a medial gastrocnemius flap and split thickness skin graft for coverage of the graft and fracture site on the following day.

Figure 2.

Intraoperative angiogram of a popliteus artery demonstrating dissection and occlusion after Salter Harris three tibial plateau fracture-dislocation. A, Popliteus artery occlusion. B, Angiogram after popliteus artery bypass with saphenous vein graft. C, Some residual distal vasospasm after bypass. The patient was treated with percutaneous reduction and fixation of the articular component of the injury and external fixation. Prophylactic fasciotomies were done and later able to be primarily closed.

Notable patterns of upper extremity trauma associated with vascular injuries that have been described in the literature include scapulothoracic dissociation, fractures of entire length of the humerus (Figure 3), and fractures of the radius and/or ulna. Scapulothoracic dissociation is a rare and potentially life-threatening injury with 80% to 90% of cases associated with rupture of subclavian or axillary vessels.[14] These injuries require careful physical examination and assessment of radiographic findings to avoid diagnostic omission in the setting of high-energy shoulder girdle injuries. Axillary or brachial artery injury can be seen with shoulder dislocations or fractures of the humerus because of the proximity of the vessel to the bone. In pediatric populations, vascular injuries associated with fractures of the supracondylar humerus are well documented, with Gartland type III fractures being at high risk for vascular injury.[15] Both blunt and penetrating traumas to the forearm and wrist can be associated with radial or ulnar artery injuries, and because of collateral circulation, the need for repair depends on the presence of adequate perfusion to the hand.[16,17]

Figure 3.

Three-dimensional reconstruction of a CT angiogram demonstrating a humerus fracture with a brachial artery transection. The patient underwent urgent axillary to brachial artery bypass, forearm fasciotomy, and carpal tunnel release, followed by the placement of an external fixator. The patient was treated with an intramedullary nail to avoid additional soft-tissue stripping and the morbidity of another surgical approach. Local soft-tissue rearrangement and split thickness skin grafting were required for wound coverage.

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