Chapter 184 - Extremity trauma Flashcards
Incidence of extremity trauma vs all vascular injuries
0.5-1% of all injuries 20-50% of all vascular injuries
Mortality after vascular trauma in extremities
Blunt 2-5% Total 2.8% (78% penetrating)
Amputation rate after extremity trauma
7-30% (higher with blunt
Most common areas of extremity vascular trauma in UE and LE
UE: forearm LE: popliteal (blunt); SFA (penetrating)
Associated injuries with extremity vascular injuries (fracture, venous, nerve, soft tissue)
Fracture: 80-100% blunt; 15-40% penetrating Venous: 15-35% Nerve: LE 10%; UE 40-50% Soft tissue: LE 30%; UE 40-70%
Hard signs of extremity arterial injury
1) Absent distal pulse 2) Palpable thrill or audible bruit 3) actively expanding hematoma 4) Active pulsatile bleeding
Soft signs of extremity arterial injury
1) Diminished distal pulse 2) History of significant hemorrhage 3) Neurologic deficit 4) Proximity of wound to named vessel
Physical exam for extremity arterial injury: PPV and NPV
PPV 100% NPV 99%
Injury extremity index calculation and SEN/SPE
Distal / proximal Sensitivity 82-86%; specificity 40%
In extremity injury, what if only soft signs and doppler index is normal
no further investigation needed
CTA for extremity vascular injury SEN/SPE
Sensitivity 95% Specificity 90%
Non-operative management in extremity vascular injury
1) success in > 70% 2) for injuries distal to axillary and femoral
Dogma of harvesting conduit vein from non-injured limb
No evidence
Key points to open repair in extremity vascular injury
1) longitudinal incision 2) tournequet 3) endoballoons 4) localized heparin 5) venous conduit preparation
Temporary shunts uses in extremity injury
1) good in larger arteries and veins 2) poor in small forearm and tibial vessels
Venous repair types
1) end-to-end 2) lateral venorrhaphy 3) patch 4) interpositional graft 5) ligation
Ligation of injured vein key points
1) increase DVT but no change in PE rate 2) If cannot tollerate additional OR time for repair then ligate
Management of venous injury to avoid edema
1) elevation 2) compression
Axillary artery injury
1) mostly penetrating 2) all segments have similar rate 3) 1/3 have plexus injury 4) 2/3 have pulse deficit 5) open repair with interpositional graft given difficulty near thoracic outlet
Brachial artery injury
1) 3/4 have pulse deficit 2) associated with # and dislocation 3) end-to-end or interpositional
Radial/ulnar artery injury
1) 80% have pulse deficit 2) soft tissue trauma associated 3) Doppler based Allen test is key 4) end-to-end
Doppler based allen test for radial/ulnar injuries
1) if patent palmar –> ligate 2) if not patent –> repair 3) if both injured –> repair ulnar
Femoral artery injury
1) 90% pulse deficit 2) CTA needed to see PFA 3) PFA can be ligated in unstable patients with its branches embolized IR
Popliteal artery injury
1) 100% diminished pulses 2) Type IV tibial plateau fractures associated with popliteal injury 3) medial approach to repair and avoid dissecting behind knee 4) highest amputation of all injuries 5) interpositional graft needed
Risk factors fo amputation following popliteal artery injury
1) severe soft tissue injury 2) deep tissue infection 3) pre-operative ischemia 4) no systemic anticoagulation use 5) not primarily repaired 6) no pedal pulses within 24 hours
Tibial artery injury
1) pulse deficit 2) high impact injuries 3) single tibial –> leave alone 4) repair at least 1 tibial vessel
Compartment syndrome
1) 40% LE injury get fasciotomies 2) fasciotomy associated with LE #, dislocation, venous and nerve injury and multiple arteries 3) fasciotomy associated with UE # and multiple arteries 4) 20% brachial artery injury get compartment syndrome
Mangled extremity severity score (MESS) cut off for primary amputation
7 or higher
Intraarterial drug injection treatment
1) systemic anticoagulation with heparin 2) Dexamethasone 4 mg IV q6h 3) Dextran 40 IV at 20ml/hr 4) pain control 5) elevation 6) physio
Frostbite
1) tpa if < 24 hr and shown not to due to vasospasm 2) 0.5-1.0 mg/hr TPA total via all ports 3) heparin 500 U/hr via each port/sheath
Mangled extremity severity score
Schatzker classification of tibial plateau fractures
