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


Early detection of vascular injury is critical; however, best practices for diagnosis remain controversial.[7] Historically, arteriography has been considered the benchmark of care but is associated with risk. After arteriography, up to 2% of patients have been reported to experience complications such as entry site hematoma, vessel thrombosis, embolization, and contrast reaction.[7,25] Other disadvantages to this diagnostic approach include delay in diagnosis when technicians are not readily available and cost of equipment.

Owing to the convenience and efficiency of CT angiography, it has become the most frequently used modality to localize vascular injuries. Another benefit is the ability for CT angiography to evaluate both bone and soft-tissue injury in addition to the vascular system. Accuracy of CT angiography has proven to be acceptable with missed injury rates as low as zero to 1.3%.[26] In addition, it is less costly and more efficient than direct angiography, limiting the use of angiography to situations where CT is either unavailable or limited by imaging artifacts. CT angiography has also become a standard part of the initial assessment at many centers because of its short acquisition time, high diagnostic accuracy, and avoidance of unnecessary intraoperative exploration, which decreases procedure time.[27]

Duplex ultrasonography is a noninvasive diagnostic modality option for suspected arterial or venous injuries in the extremities.[22] This method of vascular evaluation can detect complete arterial or venous disruption, main artery thrombosis, and reduced arterial blood flow. A disadvantage to this modality is its dependency on adequately trained technicians.[7] Compared with diagnostic modalities such as arteriography or CT angiography, duplex sonography is associated with fewer complications[7] but has been shown to be less accurate and often unreliable in the detection of arterial injuries in pelvic and extremity trauma.[28]