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


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

In This Article


Diagnosis of vascular injury in the setting of bony injury begins with physical examination and can be confirmed and localized with radiographic assessment. Initial trauma evaluation should start with Advanced Trauma Life Support protocols, followed by a secondary survey including a comprehensive clinical examination of all extremities and radiographic evaluation of the affected extremities.[7] Physical examination of the injured extremity includes observation of any obvious deformity, limb positioning, presence or absence of an open wound or bony crepitus, skin color inspection of the distal extremity, and capillary refill time in the distal digits. Serial neurovascular examinations in addition to ultrasonography and angiography should be used when there is a high index of suspicion for vascular injury.[7]

Patients presenting with a peripheral arterial injury generally have hard and/or soft signs of the injury. Examples of hard signs of an arterial injury include an absent distal pulse, pulsatile bleeding, pain, paralysis, palpable thrill, and a rapidly enlarging hematoma.[7,9] If a hard sign is present but localization of the vascular injury before the incision is still needed, a rapid ultrasonography or surgeon-done arteriogram in the operating room should be obtained.[21] Soft signs of an arterial injury include a history of arterial bleeding at the scene or in transit, diminished pulses, small nonpulsatile hematoma over an artery, proximity of the wound to a named vessel, and ipsilateral neurological deficit.[7] The distinction of a soft sign requires that patients still have an arterial pulse at the level of the wrist or foot on physical examination. Patients presenting with soft signs of vascular injury should undergo a thorough pulse examination and measurement of Doppler pressures such as the Ankle Brachial Index (ABI) or Arterial Pressure Index (API). The primary difference between the two studies involves which "normal" extremity is used for comparison with the injured extremity. In the ABI, the ankle pressure of the injured extremity is compared with the brachial artery pressure in the arm. The API is calculated by measuring the systolic pressure in the affected limb divided by the systolic pressure in the unaffected limb.[22] Regardless of which test is used, if the pressure index is less than 1.0, additional diagnostic workup is indicated.[9] Of note, inaccurate API results may occur in patients with pre-existing vascular disease, and some arterial injuries (profundal femora and peroneal) do not result in distal ischemia and are not picked with API or ABI.[7]

Surgeons should maintain a high suspicion for popliteus arterial injury in patients sustaining a knee dislocation, and if pedal pulses are diminished or absent postreduction, immediate arterial diagnostic imaging is required.[23] In addition, the incidence of compartment syndrome in blunt trauma with an associated vascular injury is as high as 59%,[24] and surgeons should closely monitor for signs and symptoms of compartment syndrome and be prepared to surgically release the affected compartments at the time of surgical intervention.