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25 • Management of Pediatric Vascular Injury 315
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For more complex injuries in the setting of tissue loss,
interposition grafting is required (Fig. 25.3). Management
in these situations includes débridement of the injured
artery back to healthy tissue and reconstruction with an
interposition graft. Concomitant orthopedic injury, soft
tissue defects, and injuries to adjacent nerves and veins
often accompany these severe injuries.25 GSV is generally the preferred conduit as it is the most size-appropriate and easily available arterial replacement.
19,26–28
As in
adults with extremity injuries, the ipsilateral GSV should
be avoided to avoid compromise of venous outow of the
injured extremity.27 Lesser saphenous and upper extremity
veins may be used provided they are size-appropriate. Synthetic conduits are generally avoided in the management of
pediatric vascular trauma because of concerns over infection, patency, and relative stenosis over time due to lack of
conduit growth.
Long-term follow-up of extremity and other arterial
reconstructions has historically been extremely poor.
10,15,29
Despite reports of vein bypasses for renal artery reconstruction as having a high rate of aneurysmal degeneration, no
such reports exist for the peripheral vasculature.
27,28
Injured deep veins of the proximal extremities – including
the femoral, popliteal, and axillary veins – should undergo
repair or reconstruction whenever possible. Vein repair is
particularly important for alleviating limb edema, improving patency of concomitant arterial repairs and improved
functional outcomes. Primary repair, lateral venorrhaphy,
C
E
D
Fig. 25.3 (A) Penetrating wound to the right thigh of a 5-year-old girl.
(B and C) The right foot had a weakly palpable pulse. There was a Doppler
signal, but the injured extremity index was diminished at 0.35. The right
foot and great toe manifested a noticeable pallor when compared with
the uninjured left extremity. (D) The wound was hemostatic, so heparin (75 units/kg) was bolused in the emergency department. The right
leg was explored, and the injured superficial femoral artery (SFA) was
exposed. The injured segment was 4 cm distal to the takeoff of the deep
femoral artery. (E) (Arrows) A reversed greater saphenous vein interposition graft was used to replace the injured segment of the SFA. Interrupted 6.0 monofilament expanded polytetrafluoroethylene sutures
were used for both the proximal and distal anastomosis. (From Cannon
JW, Villamaria CY, Peck MA. Pediatric vascular injury. In: Rasmussen TE, Tai
NRM, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia, PA: Elsevier; 2016.)
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non–reversed vein interposition and synthetic interposition
bypasses have all been described. Early patency of all types
of vein reconstruction is excellent.
26
CERVICAL AND TORSO VASCULAR INJURIES
Special discussion is warranted for management of penetrating trauma to the great vessels. Similar to other large vessel
injury, primary repair, patch angioplasty, and interposition
grafting with autologous vein are acceptable methods of
repair. Ligation of the distal internal carotid artery may be
required when injuries are too distal for operative repair. Distal extracranial (zone III) carotid pseudoaneurysm may be
excluded with a percutaneously placed endovascular stent
graft for injuries that extend up to the base of the skull. All
proximal carotid artery (zone I) injuries may be reached
through a median sternotomy with extension of the incision
to the traumatized side of the neck. Although operative intervention is appropriate for these zone I injuries, endovascular
stenting may be possible although outcomes in pediatric
patients are unknown. Interestingly, in infants cannulated for
ECMO with subsequent ligation of the right common carotid,
there is detectable blood ow to the right middle cerebral
artery within 15 minutes.30 However, longer-term cognitive
and overt neurologic decits may result.
the long-term implications of unilateral compromise to cerebral perfusion is necessary to discern the implications of ligation as a therapeutic option for penetrating carotid injuries.
In contrast to penetrating cerebrovascular injuries, blunt
injuries rarely benet from surgical intervention as medical
management with systemic anticoagulation or antiplatelet
therapy has been met with a low rate of stroke or bleeding.33
Although there is no screening recommendation for blunt
cerebrovascular injuries (BCVI) in children, adaptation of
adult screening protocols have exposed the incidence of BCVI
in children who present to the trauma bay with neurological
compromise. Given the importance of stroke prevention in
these children, widespread implementation of BCVI screening programs is paramount to prevent long-term disability.
Access to the innominate and proximal right subclavian
arteries generally require median sternotomy to achieve
proximal control in the setting of penetrating injury. Supraclavicular incisions are required for more distal subclavian
artery injuries bilaterally. The left subclavian is accessed via
a high left anterior-lateral thoracotomy; however, combination incisions (i.e., trap door) may be necessary to improve
exposure to complex left-sided injuries.
Most cases of pediatric thoracic aortic injuries are managed with open repair – often in a delayed fashion – using
an interposition graft. Delayed repair with early initiation
of β-blocker therapy has been shown to be a survival benet
to patients.35 Disruption of aortic ow is treated with the
clamp-and-sew technique utilizing a synthetic interposition graft. Although complete thoracic aortic transection is
rarely survivable, for children who reach the hospital alive,
survival is estimated at 80% with very low rates of paraplegia. Most deaths in these patients who survive to the hospital are a result of concomitant head trauma or associated
cervical, abdominal, or extremity hemorrhage.
The distribution of abdominal vascular injury is often
divided into aortic, renal, visceral, and iliac injuries. These
vascular injuries are often associated with concomitant
31,32
Further study of
34
abdominal organ injuries and major abdominal venous
injuries, and they carry a high mortality.
24,36
Like cerebrovascular and thoracic injury, management is dictated by the
hemodynamic stability of the child and the severity of associated injuries. Methods of repair include aortic replacement with synthetic graft, use of the greater saphenous
vein or hypogastric artery for other arterial injuries, and lateral venorrhaphy, ligation, or, in some instances, panel graft
reconstruction of the inferior vena cava or iliac veins.
37
PEDIATRIC VASCULAR ANASTOMOTIC
TECHNIQUE
Numerous classic studies have supported the recommendation of performing an interrupted suture technique for arterial anastomoses in growing vessels.
recent animal models that have compared various repair
methods and materials. Titanium clips, running dissolvable
suture, and interrupted permanent suture anastomoses have
been evaluated to determine the optimal anastomotic technique. In these studies, a running-type anastomosis using
permanent suture was shown to impede vessel growth and is
more commonly associated with stricture.
To date, different anastomotic techniques have not been
directly compared in pediatric patients, however. Although
a running-type anastomosis with absorbable suture may
be considered, absorbable suture is more thrombogenic
than a permanent monolament suture. Thus, an interrupted technique using permanent suture (e.g., Prolene)
will both minimize the risk of thrombosis while also permitting future vessel growth
for interposition grafts, both the conduit and native vessel
should be spatulated to create a functionally enlarged communication that permits vessel growth without narrowing
(Fig. 25.4).
Fig. 25.4 On-table angiogram in a 13-year-old who fell off her bicycle
and suffered a blunt injury to her right superficial femoral artery (SFA)
and vein (SFV). The SFV was able to be repaired primarily. The SFA was
transected and completely occluded requiring reconstruction with
reversed saphenous vein from the contralateral leg. The anastomoses
were performed with interrupted 6-0 Prolene sutures. (A) (Arrow) The
initial completion angiogram demonstrated a significant stenosis at
the distal anastomosis. (B) (Arrow) The anastomosis was revised with
more extensive spatulation of the vein graft resulting in a widely patent
distal anastomosis on repeat imaging. The patient subsequently had a
full recovery with normal perfusion to her foot. (Images courtesy Venkat
Kalapatapu, MD.)
26,28,42,43
38–40
There are now more
26,40,41
(see Fig. 25.3). Finally,
25 • Management of Pediatric Vascular Injury 317
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ENDOVASCULAR OPTIONS
The use of endovascular techniques as a minimally invasive operative approach to pediatric vascular injuries has
recently gained some momentum. Although data supporting endovascular therapy in acute pediatric vascular trauma
are mostly limited to case reports,
29,44,45
more recent observational research supports an increased use of endovascular
technique in pediatric vascular arterial trauma, especially in
children with severe blunt injuries.9 Based on these limited
reports, it appears that children who underwent endovascular treatment had comparable outcomes to those who underwent open surgical intervention; however, the authors note
signicant differences in demographic characteristics among
children offered endovascular procedures including older
age, higher prevalence of thoracic injury, and higher injury
severity score (ISS). Limitations to the broader application of
endovascular therapies in pediatric vascular trauma include
the size ranges of available stents and grafts and the inability
of endovascular implants to grow with the child. These limitations highlight the need for further endovascular innovation to enable more routine use in pediatric patients.
ADJUNCTS TO MANAGEMENT:
ANTICOAGULATION, PAPAVERINE,
THROMBOLYSIS, AND SHUNTS
Although the use of heparin as a stand-alone therapy for
most vascular injuries has fallen out of favor because of suboptimal outcomes, its systemic or regional use is essential,
particularly in the setting of extremity trauma with vascular reconstruction.46 Intraoperatively, heparinized saline
should be infused both proximally and distally once the
injury has been isolated and any thrombus extracted.47 A
bolus of therapeutic heparin should also be strongly considered intraoperatively to improve postoperative patency of
the vascular reconstruction. Continuation of heparin therapy may have a role following repair of small arteries and
when vasospasm is present. Low-dose aspirin should also
be considered postoperatively following arterial reconstruction to mitigate platelet aggregation at the anastomosis.
There is a very limited role for thrombolytic therapy in
arterial trauma because concurrent injuries often contraindicate their use. The greatest utility may be when there is
a delay in diagnosis following blunt or iatrogenic injury to
the distal lower extremity tibial arteries, although in these
situations, thrombectomy is usually adequate. Catheter
directed intraarterial administration at the proximal extent
of the occlusion is the preferred methodology. Tissue plasminogen activator is currently the only available agent at
a dose of 0.25 to 1.5 mg/h. Fibrinogen levels are trended
to ensure lysis of the thrombus with discontinuation of the
infusion once systemic brinogen levels decrease, suggesting clot dissolution. Heparin infusion is used post-thrombolysis to prevent clot propagation. Follow-up angiography
is then performed through the existing catheter to identify
residual luminal defects that need additional management,
such as angioplasty and surgical reconstruction.
Given the incidence of vasospasm in the injury pediatric
vessel, pharmacomanipulation is often employed to prevent
occlusion.48 Multiple studies support the use of papaverine
containing solutions to prolong vessel patency in children
with indwelling arterial catheters.
49–51
Both topical 2% lidocaine and papaverine have also been described as intraoperative adjuncts to mitigate vasospasm; however, their use
has not been systematically studied in children.
52
The use of temporary vascular shunts has gained increased
attention as an important adjunct in patients undergoing
damage control surgery. Their use has been shown to reduce
overall ischemic time and can serve as a bridge to denitive
repair.53 The reduction in ischemia time may result in lower
rates of compartment syndrome, nerve injury, and muscle
loss, which may improve the overall quality of limb salvage
and in turn prevent later amputations resulting from poor
limb function.
53–56
Both military and civilian experience indicate that proximal extremity arterial shunts remain patent
in 85% to 95% of cases; however, more distal shunts have
poor patency and likely do not improve limb salvage. Given
these experiences, a similar approach should be considered in
pediatric patients in the setting of severe hemorrhagic shock
or devastating associated injuries requiring complex reconstruction. Balloon catheter thrombectomy should be performed both before placement and after removal of a shunt.
Heparinized saline should be liberally infused locally. Finally,
an appropriately sized device should be selected to balance
between maintained patency and preventing an unwanted
arterial dissection (Fig. 25.5).
Special Situations
ECMO
ECMO cannulation is associated with pediatric vascular
injury; however, even without direct vascular injury, the
relative occlusion of the carotid artery has been implicated
in both cognitive and motor neurologic decits.
evidence, comparable to the long-term limb length discrepancies previous described, has led some centers to perform
carotid artery reconstruction after decannulation. This
approach has resulted in increased carotid arterial patency
as well as favorable neurologic outcomes compared with
controls.
57
Fig. 25.5 Options for temporary vascular shunts in pediatric trauma.
Top, 8-Fr Argyle straight shunt. Bottom, modified 14-Ga angiocatheter
(approximately 6 Fr).
31,32
Such
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SUPRACONDYLAR HUMERUS FRACTURES AND
BRACHIAL ARTERY INJURIES
Supracondylar humerus fractures are associated with
vascular injury in up to 20% of fractures with signicant
displacement.58 Angulation and displacement of the proximal fragment puts the brachial artery, as well as both the
median and radial nerve, at risk. Vascular injury typically
results from either stretch leading to intimal disruption or
from vascular impingement. Because of the rich network of
collateral vessels around the pediatric elbow, the hand may
appear pink, even with absent distal pulses. If urgent closed
or open reduction of the fracture does not improve distal
perfusion (Doppler signal or palpable pulse present), surgical exploration is indicated.59 In cases of vessel impingement, release of the vessel may re-establish normal distal
ow. Otherwise, arteriotomy with embolectomy should be
the initial maneuver if an injury is identied. If the vessel
is severely injured with intimal disruption, reconstruction
with reversed GSV should be performed.
Like supracondylar fractures, posterior elbow dislocations can also result in vascular injury. Management strategies include reduction of the dislocation and evaluation of
distal perfusion. Evidence of continued malperfusion after
fracture reduction warrants surgical exploration.
COMPARTMENT SYNDROME AND FASCIOTOMY
Prophylactic lower extremity four-compartment fasciotomy is indicated in the setting of prolonged arterial ischemia, combined arterial and venous injuries, and vascular
injury with hemorrhagic shock. Similarly, therapeutic fourcompartment fasciotomy should be performed immediately upon the diagnosis of compartment syndrome. These
principles are well-established in the adult literature and
can also be applied to pediatric patients.28 Similarly, upper
extremity fasciotomy should also be performed for the indications outlined (Fig. 25.6). Though there is little research
on post-fasciotomy outcomes, these interventions likely
improve incidence of ischemic limb salvage.
Postinjury Surveillance and
Outcomes
Little is known of the outcomes of pediatric vascular injuries. As noted previously, the mortality rate in these patients
is high at approximately 10%.
Regarding limb-specic outcomes, in one case series of
iatrogenic vascular injury, successful restoration of a palpable pulse after surgical intervention was achieved in 10
of 14 patients (71%, age 6 months to 9 years) with acute
femoral ischemia.15 In another retrospective series of noniatrogenic trauma, 11 of 58 children (19%) with distal vascular injury has subsequent limb-loss and an additional 2
children were diagnosed with limb length discrepancy during longer-term follow-up.11 A 2019 case series from a large
pediatric level 1 trauma center indicated superior extremity
outcomes in 23 patients with a restoration of in-line ow
as compared with 3 patients who did not undergo vascular
intervention. In this series, there were no deaths at 30 days
and no secondary amputations over a 43-month follow-up
29
period.
7,10,11
Future Directions
The vast majority of the recommendations included in this
review are based on evidence from case series and expert
opinion. Although there has been recent increased attention to pediatric vascular trauma, the existing evidence
remains limited due to small sample sizes, only short-term
follow-up, and lack of uniform approaches to management.
Given the small numbers of pediatric vascular trauma
cases at any one institution, to move beyond this low level
of evidence, multiinstitutional collaboration is imperative.
Future collaborative efforts to systematically evaluate the
short- and long-term outcomes of neonatal and pediatric
vascular injuries should be high priority, as these injuries
have the greatest associated costs in terms of disability. Dedicated adult vascular injury registries such as the American
Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT)
registry demonstrate the value of multicenter collaboration
to better understand the demographics of vascular injury
and to identify optimal treatment approaches.60 A similar
registry with long-term outcomes should be developed for
pediatric vascular trauma as well.
Importantly, survey of providers caring for children with
vascular injury has exposed the relative discomfort of most
vascular surgeons in the care of pediatric vascular disease.61 Given the complex nature of these injuries and their
infrequent occurrence, after control of life-threatening
hemorrhage, further management should be centralized in
tertiary referral centers with pediatric specialists in general/
vascular surgery, plastic/reconstructive surgery, orthopedic
surgery, and interventional radiology.
62
Fig. 25.6 Upper extremity fasciotomy in a 2-year-old girl following a
crush injury to the left arm.
Conclusions
Pediatric vascular injuries result from iatrogenic complications, penetrating injuries, and blunt trauma. Although
25 • Management of Pediatric Vascular Injury 319
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historical approaches to these injuries have emphasized
nonoperative management, modern experience indicates
that both open operative repair and select endovascular
intervention is both feasible and safe in children. Results
from vascular trauma management in combat suggests
that a comprehensive approach, including damage control resuscitation with selective shunting, use of interposition graft for reconstruction with interrupted sutures, use
of perioperative regional and systemic anticoagulation
and liberal use of fasciotomy result in good short-term
outcomes. Future directions should focus on multiinstitutional collaboration with long-term follow-up to optimize
study sample size and to determine the benet of various
management options in this vulnerable and poorly studied
population.
Disclaimer
The opinions expressed in this document are solely those
of the authors and do not represent an endorsement by or
the views of the United States Air Force, the Department of
Defense, or the United States Government.
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adjunct in the management of wartime vascular injury. J Trauma
Acute Care Surg. 2006;61(1):8–15.
54. Borut LJ, Acosta CJA, Tadlock LM, Dye JL, Galarneau M, Elshire CD.
The use of temporary vascular shunts in military extremity wounds:
a preliminary outcome analysis with 2-year follow-up. J Trauma Acute
Care Surg. 2010;69(1):174–178.
55. Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E,
Feliciano DV. A decade's experience with temporary intravascular
shunts at a civilian level I trauma center. J Trauma Acute Care Surg.
2008;65(2):316–326.
56. Taller J, Kamdar JP, Greene JA, etal. Temporary vascular shunts as ini-
tial treatment of proximal extremity vascular injuries during combat
operations: the new standard of care at Echelon II facilities? J Trauma
Acute Care Surg. 2008;65(3):595–603.
57. Desai SA, Stanley C, Gringlas M, etal. Five-year follow-up of neonates
with reconstructed right common carotid arteries after extracorporeal membrane oxygenation. J Pediatr. 1999;134(4):428–433.
58. Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovas-
cular injury and displacement in type III supracondylar humerus
fractures. J Pediatr Orthop. 1995;15(1):47–52.
59. Delniotis I, Ktenidis K. The pulseless supracondylar humeral frac-
ture: our experience and a 1-year follow-up. J Trauma Acute Care Surg.
2018;85(4):711–716.
60. DuBose JJ, Savage SA, Fabian TC, etal. The American Association for
the Surgery of Trauma PROspective Observational Vascular Injury
Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care
Surg. 2015;78(2):215–223.
61. Bonasso PC, Dassinger MS, Smeds MR, Moursi MM. Pediat-
ric vascular surgical practice patterns. Ann Vasc Surg. 2019;54:
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62. Bonasso PC, Gurien LA, Smith SD, Gowen ME, Dassinger MS. Pediatric
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J Trauma Acute Care Surg. 2018;84(5):758–761.
26
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Soft-Tissue and Skeletal Wound
Management in the Setting of
Vascular Injury
SHEHAN HETTIARATCHY and JON CLASPER
Introduction
Extremity injuries involving signicant trauma to bone,
soft tissue, and major vessels are relatively uncommon outside of the wartime setting. This constellation of injuries
may also be referred to as the mangled extremity. Much
of the difculty encountered in managing patients with a
mangled extremity is due to the fact that few surgeons gain
much experience in dealing with this challenging injury
pattern. In order to meet this challenge, such injuries are
best dealt with by a multidisciplinary team that combines
the subject-matter expertise of vascular, plastic, and orthopedic specialists.1 The purpose of this chapter is to consider
the nature of the extravascular component of severe limb
trauma, the priorities in reconstruction, and the sequencing of interventions in order to furnish the vascular surgeon with the key imperatives of soft-tissue and skeletal
management as understood by their orthopedic and plastic
surgical colleagues.
Epidemiological Factors
The likelihood of fracture-associated extremity vascular
trauma depends on the nature of the associated orthopedic
injury, with an overall incidence estimated to be less than
1%.2 However, certain orthopedic injury patterns, such as
posterior knee dislocation, mandate a higher index of suspicion. Young et al.3 found an incidence of 9% of vascular
injuries in a series of 661 civilian open tibial shaft fractures.
These had an amputation rate of 38% compared to a rate
of 5% in open fractures without vascular injuries. Vascular
injuries may also be more commonly associated with fractures in the high-energy ballistic and blast environments of
military trauma. From a database of 679 patients with military extremity trauma, Brown et al. identied 34 patients
and 37 limbs with vascular injury.4 In only nine of these
limbs was the vascular trauma not associated with a corresponding fracture. The authors of this study noted that
outcome was worse in patients with combined orthopedic
and vascular injury, and this was attributed to the unfavorable soft-tissue sequelae of energy transfers sufciently
large to cause bone fracture. This nding is also consistent
with examples of high-energy extremity wounds reported
in the civilian literature.5 In an Israeli report of 35 casualties, both military and civilian, Romanoff revealed that of
35 combined orthopedic and vascular injuries, 14 (40%)
involved the femoral vessels, 9 (26%) compromised the
popliteal vessels, and 8 (23%) involved the brachial artery.6
Upper limb injury complexes were often related to gunshot
wounds compared to lower limb injuries. In Brown's series
(reporting experience from the British military), 11 injuries
(30.5% of all cases) involved the upper limb, with 7 involving the brachial artery, and 4 involving the radial and/or
ulnar arteries.
The orthopedic injury most commonly associated with a
vascular injury is dislocation of the knee, particularly when
the dislocation is posterior in nature. The orthopedic injury
is of relatively low priority in the initial management of
the patient as the knee will usually be easy to reduce and,
in some cases, may have been reduced before the vascular
injury is appreciated. In general, the majority of these will
be closed injuries. In a literature review totaling 245 knee
dislocations with a 32% incidence of vascular injuries, time
to revascularization was the most important factor in determining outcome. The authors described a salvage rate of
89% when this was carried out in less than 8 hours, compared to an amputation rate of 86% when the delay was
greater than 8 hours.7 A prospective report, undertaken as
part of a multicenter study depicting the outcome of severe
lower limb injuries described 18 patients, of whom 4 (22%)
required amputation (a gure that is relatively consistent in
the literature). Despite successful salvage, patients still had
a moderate to high level of disability 2 years after the injury;
the knees were stiffer and weaker; and only two were stable
in all directions.
8
Grading of Open Fractures
Open fractures represent a heterogeneous group of injuries,
but the relationship between extent of tissue damage and
likelihood of limb salvage and functional recovery has been
recognized for decades. As such, a formal system for grading the severity of open fractures was introduced by Gustilo
and Anderson in 1976 (Table 26.1).9 This remains a universally accepted classication of the wound associated
with an open fracture, relating especially well to the risk of
infection. For Gustilo type I fractures, an infection rate of
1% or less can be expected, and for type II fractures, a rate
of approximately 3% has been reported.10 Since the original
description, it has been recognized that those with type III
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Table 26.1 Gustilo-Anderson Classification of Open
Tibial Fractures.
Type I An open fracture with a wound less than 1 cm long and
clean
Type II An open fracture with a laceration more than 1 cm long
without extensive soft-tissue damage, flaps, or avulsions
Type III An open segmental fracture, an open fracture with exten-
sive soft-tissue damage, or a traumatic amputation
fractures are a large and heterogeneous group, and, to
reect this, a modication to the original grading was made
with subdivision of type III fractures as follows:
n Type IIIA—Adequate soft-tissue cover of the bone despite
extensive laceration
n Type IIIB—Extensive soft-tissue loss, with periosteal
stripping and exposed bone. Usually associated with
massive contamination
n Type IIIC—Open fracture with vascular injury that
needs repair
For type IIIA fractures, an infection rate of 17% has been
reported, and for type IIIB, 26%. However, lower infection
rates are achievable. Wordsworth et al. reported a 1.6%
infection rate in a series of 65 patients with IIIB open tibias.11 Type IIIC fractures have a variable infection rate,
depending on the soft-tissue injury and the time to revascularization. A proportion of IIIC injuries require amputation
due to lack of reconstructive options, and late infection is
of less relevance as an outcome measure in this group. A
series of 661 open tibial shaft fractures showed an amputation rate of 38% for IIIC injuries compared to a of rate 5% in
IIIB injuries.3 The relative rarity of these injuries, combined
with their heterogeneous nature, means that meaningful
comparison of outcomes (either between different papers
or even between patients reported in the same paper) is difcult, if not impossible.
Salvage Versus Amputation
In essence only the following three decisions are available
to the surgeon managing an extremity injury where limb
ischemia is present: perform primary amputation, defer primary amputation to a later date, or attempt surgical intervention with a view to limb salvage. The latter may involve
a lengthy or complex revascularization procedure, denitive fracture xation, and soft-tissue coverage extending to
microvascular tissue transfer. There are inherent risks of
attempted limb salvage as the procedures may be costly in
terms of patient reserve and risk of mortality, need for multiple operative procedures, and prolonged rehabilitation.
“Successful limb salvage” is a subjective phrase: outcomes
can be variably dened according to patient factors such as
pain, function, return to work, and satisfaction. Expectation of recovery varies according to the individual. Younger
patients tend to have higher levels of preinjury activity, and
rehabilitation will be concordantly longer in order to ensure
recovery to previous functional capability. In contrast, the
older, less-mobile population may have lower expectations.
Expectation management forms a key part of the duty
of the multidisciplinary team in cases of limb salvage or
amputation, with regular and consistent counseling of the
patient and their relatives in order to allow realistic but positive interpretations of recovery potential.
Studies have reported the long-term outcomes and
quality of life in limb-salvage patients with open tibial
shaft fractures and severe soft-tissue loss compared to
amputees.12 Limb-salvage patients took longer to achieve
full weight-bearing status, were less willing or able to
work, and had a signicant loss in range of movement at
the ankle. Fairhurst et al. demonstrated that early amputees had higher functional scores, fewer operations, and
returned to work and sporting activities within 6 months.
They concluded that early amputation was better when
confronted with a borderline salvageable tibial injury.13
However, reports from a prospective multicenter trial of
556 patients (the Lower Extremity Assessment Project
[LEAP]), reported no difference in functional outcomes
between patients who either underwent limb-salvage surgery or early amputation at 2-year and 7-year follow-up
points.14 The level of amputation was a further predictor of outcome. Further analysis of the difference in cost
analysis of limb salvage, and amputation has shown that
the latter is signicantly more expensive if the ongoing
maintenance and replacement costs of the prostheses are
included.
Several scoring systems have been developed to help
guide the decision as to whether or not to amputate after
severe lower limb trauma, and they have been designed
to augment subjective clinical impression with objective
assessment based on specic criteria. In their retrospective
review of 58 severely injured limbs, Bonanni et al. showed
low sensitivities of Mangled Extremity Severity Score
(MESS) (22%), limb-salvage index (61%), and predictive
salvage index (33%).15 The LEAP study assessed MESS,
predictive salvage index, limb-salvage index, nerve injury;
ischemia/soft tissue contamination; skeletal; shock; age
(NISSA); and Hannover Fracture Scale (HFS)-97. The
authors reported a high specicity but much lower sensitivities for the scores than those reported by the developing authors. The performance decreased further when
immediate amputations were excluded.14 A further study
from the same group suggested that lower limb extremity scores do not predict short- or longer-term functional
outcome. Overall, scoring systems have not proven to be
useful for prospective clinical decision making and are not
widely used for this purpose—the nal decision to salvage
a limb must be tailored to the patient, their injury, and
their future functional goals.
16
Strategies in Managing
the Severely Injured Limb
SEQUENCING OF INTERVENTIONS
Considerable debate has centered on the sequencing of
operative steps in the management of the mangled extremity. The following elements of treatment are necessary for
26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 323
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most limbs that exhibit an open fracture associated with
major vascular injury:
n The extent of soft-tissue damage, vascular compromise,
and skeletal instability must be systematically assessed.
n The wound should be débrided so that all unviable tissue
is removed.
n Vascular repair/reconstruction should be performed.
n Skeletal stabilization must be performed.
n Mitigation of complications—such as infection or com-
partment syndrome—must be undertaken proactively.
Determining the optimal sequence of reperfusion versus
stabilization of the limb may be difcult because the following two competing imperatives have to be reconciled: the
period of warm ischemia must be as limited as possible (and
should never extend beyond 6 hours from time of injury),
yet skeletal stability must be achieved in a timely fashion
without compromising any vascular repair. Deciding on the
best sequence has attracted much debate since the 1980s.
A metaanalysis of the data concluded that amputation
rates are not affected by the sequencing of revascularization, whether undertaken before or after fracture stabilization.17 The authors acknowledged the retrospective nature
of the cohort studies analyzed, and outcomes other than
amputation were not considered in their review.
McHenry, in 2002, retrospectively studied a cohort of
27 limbs with orthovascular injury secondary to gunshot
wounds and concluded that revascularization (whether
denitive or via a shunt) should be carried out before skeletal
stabilization, on the basis of a nonsignicant trend toward
higher fasciotomy rates in ve cases where stabilization was
prioritized.18 The cohort included brachial, femoral, and
popliteal injuries; but the authors did not include patients
with crural vessel injury. Furthermore, 13 of the 14 internal xations were carried out in the group that had initial
revascularization, suggesting possible selection bias. Initial
revascularization followed by skeletal xation was not associated with damage of the vascular repair, contradicting an
often-quoted rationale that orthopedic manipulation and
fracture xation in the setting of a freshly repaired vessel
carries a major risk of disruption.
The debate around sequencing has been blunted by the
development of temporary vascular shunting as a means of
ensuring early restoration of ow and facilitation of a window of opportunity for orthopedic intervention. Extensive
experience with the use of vascular shunts during the wars
in Afghanistan and Iraq includes clinical data suggesting that
this damage control adjunct extends the window of limb salvage in the most severely injured extremities.
19,20
Translational
large animal data, also stemming from investigation during the
wars, has shown improved extremity neuromuscular recovery
and function with shorter ischemic times (less than 3 hours).21
Whichever strategy is chosen, it is worth reiterating that these
injuries are infrequently seen and often require individualized
solutions. Some cases merit early stabilization, others shunting, and some early denitive vascular repair.
In the United Kingdom, the sequencing debate has been
largely settled by national evidenced-based guidance. Protocols were developed jointly by the British Orthopaedic
Association and The Vascular Society of Great Britain and
Ireland.22 These formed the basis for UK Department of
Health guidance issued by the UK's National Institute for
Clinical Excellence (NICE, Box 26.1).1 This suggests that the
sequence of shunt, skeletally stabilize, and then perform
vascular repair is usually best. It should be remembered
that the skeletal stabilization may not be denitive so care
must be taken of the vascular repair if further orthopedic
procedures are performed.
MAJOR LIMB AMPUTATION FOR TRAUMA
Amputations undertaken for the acutely injured and unsalvageable extremity offer a set of challenges that differ from
those regularly encountered by vascular surgeons managing
patients with unreconstructible peripheral vascular disease. In
particular, patients with limbs that have been rendered unsalvageable by blast have very specic requirements. In such
circumstances, guidelines developed by UK Defence Medical
Services may prove helpful (and are applicable to the patient
with non–blast-mangled extremity) as set out in Box 26.2.
In assessing the viability of the distal soft-tissue envelope
(which will dene the level of amputation), medial and lateral longitudinal incisions along fasciotomy lines should
be used to extend the wounds in order to allow adequate
exposure if the preexisting wounds do not afford this assessment. At initial débridement, all viable tissue should be preserved even if bone length appears excessive or if excess soft
tissue is present. This is to avoid compromising denitive
closure, particularly if further skin or soft-tissue necrosis
occurs. Denitive aps should not be performed at the initial débridement. This may result in the excision of viable
tissue, which could be required for denitive wound closure,
particularly if further excision is required or if nonstandard
aps are necessary. Denitive aps are created at the time of
wound closure, usually 2 to 5 days later.
Essentially, a trauma amputation should be considered
an extension of débridement, rather than a denitive procedure in its own right. By adopting this attitude, the limb is
removed as part of the débridement of nonviable tissue, the
tissues are excised at the most distal point possible, and the
temptation to fashion formal aps is avoided.
Box 26.1 Vascular Injury
1. Use hard signs (lack of palpable pulse, continued blood loss, or
expanding hematoma) to diagnose vascular injury.
2. Do not rely on capillary return or Doppler signal to exclude
vascular injury.
3. Perform immediate surgical exploration if hard signs of
vascular injury persist after any necessary restoration of limb
alignment and joint reduction.
4. In patients with a devascularized limb following long bone
fracture, use a vascular shunt as the first surgical intervention before skeletal stabilization and definitive vascular
reconstruction.
5. Do not delay revascularization for angiography in people with
complex fractures.
6. For humeral supracondylar fractures in children (under
16 years) without a palpable radial pulse but with a wellperfused hand, consider observation rather than immediate
vascular intervention.
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Box 26.2 UK Defence Medical Services
Guidelines Concerning Trauma Amputation
1. The examination findings, together with the indications to
amputate the limb, should be documented.
2. Existing limb salvage scores should NOT be used to determine the need for amputation.
3. Whenever possible, the decision to amputate a limb should
be confirmed by a second surgeon.
4. All wounds should be photographed.
5. Radiographs should be obtained before amputation.
6. Neurological dysfunction (particularly numbness of the sole
of the foot) should NOT be part of the criteria used to decide
amputation.
7. The site of amputation should be at the lowest level possible.
8. Guillotine amputations should not be performed.
9. There should be no fashioning of flaps at initial débridement.
10. Bone should be cut at the most distal soft-tissue levels.
11. Amputation should not be carried out at the level of any
fracture unless this is the appropriate skin/soft-tissue level.
12. No part of the wound is to be closed at initial surgery.
13. No attempt is to be made to prevent skin retraction.
14. Through-knee amputation is acceptable if appropriate.
ASSESSMENT OF THE INJURED EXTREMITY
The patient with a severely injured or mangled extremity
should be managed within trauma protocols based around
Advanced Trauma Life Support guidelines or their equivalent. The limb injury, no matter how severe, should not
detract from or delay any lifesaving interventions that need
to be undertaken to ensure that major hemorrhage is controlled and that the airway is secured. Bleeding from the
limb should be controlled: direct pressure applied through
sterile dressings, combined with elevation, is appropriate. If
unsuccessful, the application of a tourniquet is indicated.
Ideally this should be a pneumatic tourniquet but a military-style combat application mechanical tourniquet with
a windlass mechanism will sufce.
Each tissue type, skin, muscle, and nerve should be considered and assessed separately. The zone of injury (i.e., the
part of the limb that has received the energy transference
from the wounding mechanism) should be determined.
This zone can vary in size depending on how the injury
was induced, but, irrespective of size, all tissues within the
injury zone will have been affected to a lesser or greater
extent. Certain tissues, such as skin, are more robust and
can tolerate a degree of injury, whereas others (fat, muscle)
are more likely to suffer irreparable damage.
For extremities, it is important to determine whether a
degloving component is present. This is when the skin has
been sheared off the deep fascia, leading to thrombosis or
avulsion of the skin perforating vessels and subsequent
skin death. Degloving occurs in traction or shearing injuries and is often observed if a limb has been run over by a
vehicle. Degloving also occurs in blast injuries, where the
blast mechanism strips the skin away from the underlying
tissues. Detecting the presence of a degloving injury can be
difcult but should always be considered given a suspicious
mechanism of injury. Soft-tissue appraisal should occur in
conjunction with the orthopedic assessment. This should
include an assessment of limb-length discrepancy, abnormal
bony contour, joint function, and axial stability according
to the usual “look/feel/move” paradigm.
A full neurovascular examination should be performed,
although a depressed level of consciousness will not permit a full assessment of motor and sensory functions. The
peripheral nerves of the extremity should be examined
(Table 26.2). In the foot, these are saphenous nerve (instep)
medial and lateral plantar nerves (sole), sural nerve (outer
border), supercial peroneal nerve (dorsum), and deep
peroneal nerve (rst web-space dorsum). In the hand, these
are the median nerve (index nger), the ulnar nerve (little
nger), and the supercial branch of the radial nerve (rst
web space).
Motor examination may be limited by pain from the
injury or mechanical disruption of the muscles being
tested. In the lower extremity, the tibial nerve (ankle plantar
exion) and deep branch of the peroneal nerve (ankle dorsiexion) are examined. In the upper extremity, the following
nerves should be tested: the median nerve (thumb abduction); the ulnar nerve (nger abduction); the radial nerve
(elbow/wrist/nger at metacarpophalangeal joint extension); and the musculocutaneous nerve (elbow exion).
Detailed examination of the individual muscle groups may
also be performed.
The vascular examination should be performed before
and after any reduction of fractures or joint dislocations.
Hard signs of vascular injury can be difcult to elicit in a
severely distorted limb and pulse oximetry can be a useful
adjunct. Absence of an arterial waveform or different waveform from a contralateral uninjured limb should be taken as
a suggestion of vascular injury.23 Compartment syndrome
should be actively excluded. The wounds are then inspected
via careful removal of overlying dressings. At this stage,
only visual inspection may be possible, so the assessment
will not be as informative as the exploration or denitive
assessment performed in the operating theater. The location
and size of the wounds should be documented. Tire marks
or abrasions on the skin may seem innocuous but may be
the result of a shearing force and hence important indicators of degloving. The exposure of any fractures or joints
should be documented.
Large, loose particles of gross contamination should be
removed, but formal irrigation of wounds within the emergency department (ED) is not required as this is best undertaken in the operating theater. ED irrigation risks ushing
contaminants deeper into the wound, worsening of patient
hypothermia, and delaying denitive surgery. Similarly,
there is no indication for wound exploration in the ED as
this can be achieved in a far more comprehensive and controlled fashion in the operating room. Once the soft-tissues
have been assessed, the wounds should be photographed
and then dressed with a saline-moistened gauze covered by
an occlusive dressing. The limb should then be splinted as
close to the anatomical position as is possible.
All patients should receive tetanus prophylaxis if there is
doubt about native immunity. A stat dose of antibiotics should
be administered intravenously (e.g., Co-amoxiclav 1.2 g or
cefuroxime 1.5 g). (If the patient has a documented penicillin
allergy, clindamycin 600 mg IV can be used instead.)
If there is doubt about vascular integrity (e.g., if pulses
are not restored following an early attempt at traction and
splinting), further investigation may be merited as discussed
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