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

Outcomes

Sequelae of fracture-associated vascular injuries are highly area specific. Gilbert et al[45] found notable differences in overall mortality rate by the location of vascular injury with associated fracture—3.3% in lower extremity, 6.3% in upper extremity, and 20% in the pelvis. Vascular injury severity is closely correlated with patient outcomes, even more than the mechanism or type of fracture. Wu et al showed that severe vascular injuries were associated with poorer hemodynamics, higher injury severity scores, more blood transfusions, and longer intensive care unit (ICU) and total hospital stays. It is also well established that the presence of vascular injury independently influences long-term limb function in lower extremity fractures.[46] Limb salvage outcomes are dependent on the time to diagnosis, limb warm ischemia time, and the nature of the injury. Unfavorable patterns such as crush injuries and segmental fractures have consistently demonstrated inferior outcomes when salvage was pursued over amputation.[7] Even nonischemic arterial injuries seem to negatively affect reconstructive outcomes in open tibial fractures and are associated with increased complications such as flap failures and unplanned return to the operating room (OR).[47]

Although it is a common practice to proceed directly with vascular repair initially, some studies have challenged this notion and showed that temporary intravascular shunts may improve patient morbidity and decrease the risk of compartment syndrome.[5] In a study of 24 patients with ballistic femur fractures and an associated vascular injury, Rehman et al[48] showed that surgical sequence did not seem to affect the outcome regarding limb loss, compartment syndrome, or mortality. They did find, however, that orthopaedic intervention after revascularization is a risk for disruption of the vascular repair.

The physician and patient discussion surrounding limb salvage versus amputation in limb-threatening injuries should be individualized and nuanced, and final shared decision making depends on injury factors, patient comorbidities, and psychosocial factors. Because time is of the essence in the setting of fractures with vascular injuries, these discussions can rarely be addressed before the initial vascular repair, and as a result, there are some patients who decide to have amputation after a successful vascular repair. This should not be viewed as a failure of treatment but instead should be described as giving the patient the ability to make the decision for limb salvage or amputation with all options available and a more complete understanding of what each choice entails.

Overall, the risk of amputation in combined orthopaedic and vascular injuries varies widely and is influenced by factors such as >8 hours to repair, arterial transection, extent of soft-tissue damage, associated peripheral nerve injury, and presence of compartment syndrome.[7] Clinical scenarios exist in which the vascular injury is straight-forward and easily addressed, but the bony or soft-tissue damage associated with these complex extremity injuries is deemed nonreconstructable. In these cases, it is best to have the multiple physicians (orthopaedic, vascular, and plastic surgery) involved discussing these findings, and after consensus is reached, early amputation may be the best treatment option. Limb salvage is associated with a higher number of procedures and hospitalizations, and in some cases, early amputation can be considered to optimize patients' functional capacity.[7,49] Early amputation may also be the best treatment option in patients in physiologic extremis with dysvascular limbs to preserve life over limb. Some previous reports evaluating lower limb fractures with vascular injuries have found amputation rates to be as high as 43%;[49] other series have shown more encouraging results. In a recent study of 196 patients with major vascular injuries associated with traumatic extremity fractures, limbs were able to be salvaged in greater than 90% of cases.[50] This demonstrates that a well-organized and consistent approach to treatment is the key to achieving improved clinical outcomes and good functional recovery.

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