Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3594_Библиотеки_им_академика_М_И_Перельмана
.pdf
26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 325
https://t.me/medicina_free
Table 26.2 Functional Motor and Sensory Assessment of the Extremities.
Nerves Motor Sensory Significance
UPPER LIMB
Musculocutaneous nerve Elbow flexion Radial border
Median nerve Wrist flexion, abduction of thumb.
Ulnar nerve Abduction of fingers Little finger May also have ulnar artery injury
Radial nerve Extension of elbow, wrist, and
LOWER LIMB
Saphenous nerve (terminal
branch of femoral nerve)
Tibial nerve (sensory medial
and lateral plantar nerves)
Sural nerve (branch of common
peroneal nerve)
Common peroneal nerve Ankle eversion (lateral
Superficial branch peroneal
nerve
Deep branch peroneal nerve Dorsiflexion of the foot First web
(Thumb can be brought out at
90 degrees from palm.)
fingers at metacarpophalangeal
joints
Plantar flexion of the foot Sole of foot Posterior compartment of leg injury or compartment
compartment)
of forearm
Thumb Consider flexor compartment syndrome.
First web Consider extensor compartment syndrome.
Medial border
of foot
Lateral border
of foot
Dorsum of
foot
space
Injury in axilla/upper arm; risk of axillary/brachial artery injury
Thigh injury or anterior thigh compartment syndrome.
Femoral artery/vein may be injured.
syndrome. Posterior tibial artery may also be injured.
Popliteal fossa injury
Indicates injury before division into deep and superficial
branches (sensory loss in both superficial and deep branches).
Lateral compartment injury or compartment syndrome
Lateral compartment injury or compartment syndrome
Anterior compartment injury or compartment syndrome.
Anterior tibial artery may also be injured.
in Chapter 8. However, it should be appreciated that routine
preoperative angiography is not indicated in single-level
injuries. In this scenario, the vascular injury is invariably
at the same level as the soft-tissue and bony injuries. Glass
et al. found that angiography had no impact on limb-salvage rates, regardless of the time interval to revascularization (intervals less than 6 hours: 85% and 90% limb-salvage
rates with and without angiography, respectively; intervals
greater than 6 hours: 61% and 67% limb-salvage rates with
and without angiography, respectively).24 We advocate judicious use of angiography and only in the scenario of multilevel soft-tissue or skeletal injury where the site of vascular
injury is not clear. This approach is also advocated by the
various UK national organizations.
Much of the debate regarding the value of routine angiography in patients with open fractures has been made
nugatory by the ubiquity of multidetector computed tomography (CT). CT angiography (CTA), performed as part of the
CT series assessing other aspects of the limb injury (e.g.,
the positions of bony fragments) or other injuries to other
bodily areas (head, axial skeleton, torso), may be utilized to
avoid the need for formal digital subtraction angiography.
However, if CTA has not been performed but angiography
is still indicated, an on-table study may be the most expeditious way of obtaining the necessary information.
INITIAL SURGICAL MANAGEMENT
The rst steps in the surgical management of the poly traumatized extremity are as follows:
1. Pre-scrubbing of the limb
While the patient is in the anesthetic room, the limb
should be prescrubbed with a soap solution and a surgic al
scrub brush. This is termed a “social clean” and does not
involve scrubbing the wound itself. A pneumatic tourniquet should be placed on the proximal limb if the wound
permits. The decision to inate will be inuenced by the
degree of control of hemorrhage at the start, with further
appraisal of the hemorrhage once surgical exploration of
the wound has begun. The bloodless eld afforded by a
tourniquet allows easier identication of important structures, but the aggregate tourniquet time must be monitored carefully with the goal of minimizing the ischemic
insult to vulnerable tissues. The limb should be prepped
and draped in the standard fashion.
2. Reestablishment of circulation via a shunt and reassessment
The rst step is to rapidly identify the injured vascular
axis, to apply local control measures, and then to judiciously shunt arterial and venous structures. The selection and use of temporary vascular shunts as damage
control adjuncts in this setting are reviewed in detail in
Chapter 23. Once perfusion has been reestablished with
temporary vascular shunt(s), further assessment of
options for limb salvage should be made by swift examination of the wounded tissues. This may involve the use
of a “trial of débridement” using a combination of limited débridement and surgical exposure of deeper tissues
lying within and bordering on the injury zone to gain
more information on the extent of disruption and the
likelihood of functional recovery.
3. Surgical débridement of injured tissues
Denitive débridement should be systematic and
meticulous but should not be so radical as to resect
frankly uninjured and uncontaminated tissue bordering the wound. Where the degree of functional recovery
may hinge on preservation of tissue volume, an overly
aggressive approach is not correct.
326 SECTION 4 • The Management of Vascular Trauma
https://t.me/medicina_free
The normal sequence is to work superficial-to-deep
and peripheral-to-central. Where there has been significant anatomical disruption, it can be prudent to
identify the main neurovascular structures first to
avoid inadvertent injury during débridement. The
skin edge of the traumatic wound should be excised.
The wounds usually need to be extended to allow
access to all damaged tissues. In the lower limb, extensions are performed along fasciotomy lines to limit the
additional damage of débridement. All overtly devitalized and contaminated tissue should be débrided.
The layers and tissues should be worked through systematically. Assessing the viability of different tissues
can be difficult and requires experience. For skin, the
best assessment is bleeding from a cut edge. Fat can
appear discolored if devascularized. Muscle is assessed
by the “four Cs”: contractility (muscle twitches when
lightly gripped with forceps); consistency (does not
tear when gently handled); color (red-pink color; not a
dusky purple); and capacity to bleed. However, studies
have shown even using these signs is not an accurate
way of confirming viability and there is a risk of overdébridement.25 Bone may be difficult to assess, but a
combination of intact periosteum and bleeding from
the bone ends suggests viability. All nerves should be
preserved. Note that absence of bleeding is unreliable
as a marker of unviability if the patient is hypotensive or hypothermic or if a tourniquet is being used.
If there is a suggestion that tissue may be viable but
underperfused, it should be left for subsequent review
when perfusion has been optimized.
As discussed previously, degloving injury occurs when
tissue, particularly skin, is sheared away from its underlying structures. This leads to damage of the perforating vessels and subsequent tissue death, although this
may only manifest itself after 3 to 5 days. Making an
assessment of the viability of degloved tissue is difcult,
and incisions close to an area of degloving may lead to
further compromise of perfusion and may precipitate
the death of tissue that may have otherwise survived.
Degloved skin is more fragile than normal skin, must be
handled delicately, is intolerant of tension when used to
close wounds, and should be used with caution when
fashioning amputation aps.
Multiplanar degloving occurs when muscles and
neurovascular structures are sheared in different tissue
planes (Fig. 26.1). This signies a more severe injury
and a poorer chance of limb salvage. The main issue
with degloving is that the extent of the soft-tissue defect
may not be apparent immediately and it may take up to a
week for all non-viable tissue to declare. This means that
reconstruction may need to be delayed until it is clear
what has survived and what has not.
Once the soft-tissue débridement has been completed,
bony débridement is begun. The bone ends should
be delivered and again assessed for viability and contamination. All grit and debris should be removed by
scrubbing, by bone excision, or with a burr. Any loose
bony fragments that do not have soft-tissue attachment
should be removed. Larger fragments, particularly if
they comprise the articular surface of a joint may be
preserved, although they risk becoming sequestra
Fig. 26.1 Multiplanar degloving of a lower limb following being run
over by a truck. Looking into the popliteal fossa, the posterior aspect of
the leg is visible. The vessels were intact, but the severity of the bony
and soft-tissue injury were not compatible with salvage.
if vascularity is poor. Once the soft-tissue and bony
débridement has been completed, the wound should be
irrigated and washed with low-pressure saline lavage
of between 3 and 6 L depending on wound size. There is
no evidence to support the use of additional antimicrobial agents.26 Hydrogen peroxide does not confer any
benet but acts solely to damage tissues. It should not
be used.
At any stage in this process of concurrent débridement and wound assessment, it may become apparent
that tissue loss is catastrophic and that there is no reasonable hope of limb salvage. Depending on the nature
and the degree of injury, as well as the experience of the
operator, this position may be reached within minutes
of surgical exposure and débridement, or it may become
apparent only after a more thorough and prolonged
assessment of deeper structures within the wound. In
these circumstances, the decision to amputate a limb
depends on multiple factors, but patient physiology is a
consistent variable. In the polytraumatized and critically
ill individual, there is nothing to be gained from delaying
limb ablation. However, where physiology permits—and
unless the situation demands urgent separation of the
limb from the body—a decision concerning amputation
should be explored with the patient and consent obtained
as appropriate. It is often wise to defer amputation until
a later second-look opportunity, 24 to 48 hours after the
initial surgery, in order to counsel the patient and to set
expectations accordingly.
4. Stabilization of the fracture site
Operative stabilization eliminates fracture move-
ment, protects the vascular repair, and reduces the
risk of infection.9 In one of the earliest reports, Rich
et al. reviewed the results of open fractures that
required a vascular repair during the war in Vietnam, and reported that 50% of all intramedullary
(IM) nails required removal for complications directly
related to the implant.27 The most common complication was infection, and the authors concluded that,
26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 327
https://t.me/medicina_free
in the military environment, external splints with the
use of transxion pins was a safer option for the stabilization of fractures associated with vascular injury.
In his 1979 series, Romanoff reported on patients of
whom the majority had internal xation with screws
or plates.6 Internal xation was associated with a
lower rate of amputation (30%) than external xation
(45.3%), but the authors acknowledged that this was
likely to be related to injury factors rather than the chosen technique. However, the authors concluded that
infection rates were directly inuenced by the method
of xation, with higher rates associated with internal
xation (45% versus 27.2%).
Plate xation of open fractures of the lower limb fell
out of favor in the 1980s. Bach and Hansen reported
a prospective trial of plate versus external xator for
severe open tibial fractures in 1989. Of 26 fractures
treated by plate xation, 9 (35%) developed wound
infections and 5 (19%) developed chronic osteomyelitis. Of the 30 fractures treated by external xation,
4 (13%) developed wound infections and only 1 (3%)
developed chronic osteomyelitis. At nal follow-up,
all tibial fractures had healed, but the conclusion of
the authors was that plate xation had little role in
the stabilization of severe open tibial fractures.28 Most
contemporary sources agree that plate stabilization of
open femoral fractures is rarely indicated and that IM
nails have been more commonly used. A 2006 review
has also concluded that IM nailing is the treatment of
choice, although the authors admit that there are few
prospective studies of open femoral fracture.29 IM nails
were associated with a deep infection rate of 3.3%,
compared with 13.3% with denitive external xation;
the latter was also associated with a malunion rate of
23.3% and a reoperation rate of 17% (outcomes poorer
than reported with traction).
Despite the apparent superiority of IM nailing for
internal fixation, it should be noted that few of the
patients included in these studies had sustained a
vascular injury. In such cases, where timely limb
reperfusion is a prerequisite to successful outcome,
the advantage of definitive IM fixation is often outweighed by the expediency of external fixation. The
latter facilitates concurrent activity such as vein harvest, and requires less specialist equipment and, arguably, less technical expertise. Furthermore, external
fixators can be used to span a disrupted joint and to
maintain stability of fractures involving the articular
surfaces. In effect, external fixation can be effectively
used as a damage control technique before definitive
vascular repair and, from there, IM fixation and softtissue cover. Complications such as pin-site infection
must be guarded against through rigorous care of
the fixator–skin interface and minimization of delay
to definitive IM fixation in order to prevent long-term
infective sequela.
5. Denitive vascular repair with autologous graft
Denitive vascular repair establishing adequate perfu-
sion to the mangled extremity is a key tenet of management. The use of autologous vein (e.g., great saphenous)
as a vascular conduit is preferred in nearly all cases of
mangled extremity.
6. Coverage of repair with soft tissue
The vascular repair will be threatened if the extent
of injury means that soft-tissue cover is not possible.
Negative pressure wound therapy (NPWT) dressings are
commonly used to seal open fractures associated with
a soft-tissue defect, but they may contribute to anastomotic breakdown if they are placed directly in contact
with exposed vessels. If NPWT is used in this scenario,
a double sheet of silicone dressing should be placed over
the vessels for protection. The pressure should be kept
low (50 mm Hg) to prevent compromise of perfusion.
Ideally, viable soft tissue must be placed over the repair
and, if this is not possible through local apposition, local
aps must be mobilized (Fig. 26.2). Sartorius, if available, is a good option for covering the common femoral
vessels. Other types of ap coverage are discussed later
in this chapter.
7. Performance of fasciotomies
Fasciotomies of the calf should be two-incision fasci-
otomies (to enable full access to all four compartments).
The most critical aspect of performing calf fasciotomies
is accurate placement of the incisions. Medially, there
are three perforating vessels that arise from the posterior tibial vessels at 5, 10, and 15 cm above the medial
joint line of the ankle and reach the skin 1.5 to 2 cm
posterior to the medial subcutaneous border of the
tibia. These perforators are important in open fractures
because they provide the blood supply for the distally
based local fasciocutaneous aps that can be used to
cover open fractures. Preservation is assured by making the medial incision 1.5 cm posterior to the medial
subcutaneous border of the tibia. This distance should
be measured and marked before making the incision.
By following this method, all potential reconstructive
options are preserved. If there has been extensive vascular disruption and these perforators are no longer
intact, the placing of the incision is less critical, but it
is important not to expose the subcutaneous border of
the tibia. The lateral incision is placed 2 cm lateral to
the lateral subcutaneous border of the tibia. The anterior compartment is opened, and the intermuscular
septum between it and the lateral/peroneal compartment is identied and released. When extending the
incision, proximally care should be taken to protect the
common peroneal nerve.
RECONSTRUCTION
Orthopedic interventions should be planned and then executed at the same time as denitive soft-tissue reconstruction. When it is not possible to approximate soft tissue over
the defect, appropriate reconstructive options must be considered. It should be remembered that adequate and timely
débridement must be performed before reconstruction: it is
the quality of this initial débridement that sets the foundation for success.
Timing of Reconstruction
There has been much emphasis on the timing of bony and
soft-tissue reconstruction. The argument is the sooner the
skeleton is stabilized and the soft-tissue defect closed, the
lower the risk of infection.
328 SECTION 4 • The Management of Vascular Trauma
AB
https://t.me/medicina_free
Fig. 26.2 (A) A reversed vein
graft to manage a brachial artery
defect following a high-energy
gunshot wound to the antecubital fossa. There are few local
cover options for the graft. (B) A
proximally based adipofascial flap
raised from the forearm and covering the vessel.
The “x and ap” approach consists of near simultaneous skeletal xation and soft-tissue coverage with a ap.
This technique is predicated on the evidence that early
wound closure decreases the risk of deep infection.30 Godina
et al.'s 1986 series of 532 patients treated with microsurgical reconstruction for extremity trauma revealed a postoperative infection rate of 1.5% for patients treated within
72 hours of injury, compared to 17.5% in those who
received delayed operations.31 Byrd and Spicer (1985) also
found that reconstructions performed within 5 days had a
lower incidence of osteomyelitis (5%) than those covered
later (40%).32 Delay leads to technical difculty (the tissues
are more friable and planes often brosed) and is associated
with higher ap failure rate and predisposition to long-term
infection.
32,33
Furthermore, extremity fractures covered by
free aps—fully transposed blocks of vascularized tissue
that are grafted onto a local vascular axis in order to remain
viable—heal faster when the ap is performed within
15 days.34 Achieving early x and ap may be difcult if
the patient is unstable secondary to their polytrauma or
if institutional factors make timely work-up very difcult.
Naique et al. reported a deep infection rate of 8.5% for an
average coverage time of 6.8 days, which suggests that a
threshold of 7 days to x and ap is a clinically appropriate
time frame.
33
The current UK standard is to attempt coverage within
72 hours. However, it should be noted that in the literature series with the lowest bone infection rate, 25% of the
patients had coverage after 7 days.
11
Choice and Type of Reconstruction
The nature of the tissue defect is the principal factor that
determines the choice of reconstructive technique. Bare
bone and joint tissue do not tend to granulate so split skin
grafts will not work. Where there are large complex defects
with substantial loss of volume or where the tissues overlying bone are thin (as is the case with the tibia), a ap is
often required. Where possible, and in low-energy transfer
wounds, a local ap may be possible assuming the local vascular supply (as mediated by perforating vessels) is robust.
Formal intraarterial angiography, obtained post-vascular
reconstruction, may help in this determination. There is
much debate about what type of aps should be used, e.g.,
muscle aps versus fasciocutaneous aps. There is little
clinical evidence to argue the superiority of one ap over
another; the choice will come down the defect, the patient,
and the surgeon.
Flap Reconstruction
For lower limb trauma, the choice of local aps, that is, aps
raised from tissue bordering the defect, is contingent on the
site of the injury:
n Upper-third tibia/knee
The upper third of the tibia can be covered using a gastrocnemius muscle ap. The medial and/or lateral heads
are mobilized and pedicled on their supplying vessel, the
sural artery. The muscle can be completely detached and
can be used to cover defects as high as the suprapatellar region. The ap relies on the sural artery being intact
and extensive vascular disruption around the knee may
preclude this option. Alternately, a proximally based
saphenous artery fasciocutaneous ap can be utilized for
upper-third defects. This vessel, a branch of the descending genicular artery, should be intact unless the vascular
injury is midthigh.
n Middle-third tibia
Distal fasciocutaneous aps based on the medial perforators from the posterior tibial artery are best suited to
cover defects here. The perforators tend to arise 5, 10,
and 15 cm above the medial joint line of the ankle. A
vascular injury to the posterior tibial vessels or a medial
fasciotomy incision placed too posteriorly may compromise these perforators and preclude use.
26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 329
https://t.me/medicina_free
n Distal-third tibia/ankle
Few local fasciocutaneous ap options are available
for use in this zone. A fasciocutaneous ap based on
the posterior tibial perforators may be raised and then
rotated through 180 degrees around the axis of the
perforator to bring the ap into the defect ("propellor"
ap). Such aps have a tenuous venous drainage and
a concordantly higher complication rate. Other local
options include a ap based on the sural neurovascular bundle that allows tissue from the posterior aspect
of the calf to be pedicled in a reversed fashion to cover
defects around the ankle. Such aps tend to have a
higher complication rate with partial ap loss, though
Parrett et al. suggest that the evidence is skewed by
comorbidity and that sural aps are reliable in t,
healthy patients.
35
Free Flaps
Distal defects are frequently treated with free tissue transfer
aps due to the lack of local ap options. Free aps can be
used when the defect is too large for local aps or when local
vascular compromise precludes the use of a local ap. After
the free ap is raised, its native blood supply is disconnected
and the ap is moved to the distal leg, with reanastomosis of
the ap vascular pedicle to local vessels using microsurgical
technique. Free tissue transfer relies on the presence of patent vessels outside of the injury zone in order to secure both
ap perfusion and venous outow. Vessel segments chosen
as targets for ap inow should not have been traumatized
in the injury. Normally vessels proximal to any injury are
used, though it is possible to use vessels distal to the injury if
they are of good quality. Vein loops can be used if the length
of the free ap pedicle is too short to reach good native vessels but a better option might be to select a free ap with a
long pedicle. A less-optimal solution is to perform an end-toside anastomosis on the vein graft used to restore perfusion
after vascular injury, though this risks compromising both
the limb and ap perfusion. Free tissue transfer in the face
of vascular reconstruction always requires careful evaluation of the best inow/outow vessel option.
When free ap extremity surgery is being considered, the
patient must be physiologically stable and able to withstand
uid shifts/circulatory changes. Late amputation should be
considered if it is anticipated that the patient will be unable
to tolerate the process of free tissue transfer in a timely
fashion. However, late coverage of open fractures, despite
having a higher risk of infection, may still be a reasonable
option in polytraumatized patients due to the potential of
overall better functional outcome.
taken as a thin ap (or thinned after being raised) to
provide a low-prole solution to tissue defects around
the foot and ankle. Other commonly used fasciocutaneous free aps include the radial forearm (for smaller
defects), the scapular aps, and the parascapular aps
(raised around vessels close to the axilla). The latter are
commonly used around the ankle but can be bulky due
to the thickness of the dermis (Fig. 26.4).
n Muscle aps
The latissimus dorsi (LD) ap is used when a large
area of cover (up to 20 cm × 40 cm) is required because
it is based on the largest muscle in the body. It has a long
pedicle (6 to 16 cm; average 9 cm) and can be quick to
raise. LD aps are raised with the patient in the lateral
position, which requires an intraoperative change in
patient position, and are associated with postoperative
shoulder dysfunction. The latter may retard rehabilitation, the ability to transfer from wheelchair to bed, and/
or the proper use of crutches. Alternative aps include
serratus anterior muscle ap and gracilis muscle ap
(the latter suitable for long, narrow defects).
Commonly Used Flaps for Upper Limb Wounds
Options include radial forearm aps for smaller defects or
ALT aps for larger defects. Local aps include reversed
radial forearm, posterior interosseous artery, and lateral
arm aps. All of these can be pedicled on their supplying
vessels to cover various defects from the elbow downward.
As with lower limb local aps, a vascular injury and repair
will compromise the choice of vessel used, and a formal
angiogram is often required to conrm the local options.
Where necessary, the upper limb can be moved to the
area of a potential ap raised from the groin or abdomen,
a maneuver not permissible for the lower limb. Such aps
can be raised and left connected to the native blood supply
and from there grafted onto the limb defect. After 3 weeks,
the blood supply of the ap integrates with that of the
Commonly Used Flaps for Lower Limb Wounds
n Fasciocutaneous aps
The anterolateral thigh (ALT) ap (Fig. 26.3) is a very
popular ap for lower limb reconstruction for several
reasons. It is based on an area of skin and fascia on the
anterolateral aspect of the thigh supplied by perforators of the descending branch of the lateral circumex
femoral artery. This provides a very large ap (15 cm
× 35 cm) with a long pedicle (up to 12 cm) providing
a coverage solution for most defects of the lower limb.
The ALT ap can be raised from the contralateral leg
without any intraoperative repositioning and can be
Fig. 26.3 An anterolateral thigh flap with a block of vascularized muscle (chimeric flap) to cover a lower limb open fracture. There is experimental evidence that the muscle may be beneficial for faster fracture
union.
330 SECTION 4 • The Management of Vascular Trauma
AB
https://t.me/medicina_free
Fig. 26.4 (A) Anterolateral thigh flap being raised on the right thigh. (B) Flap raised to show the feeding vessel, perforators from the descending branch
of the lateral circumflex femoral artery.
upper limb; and the connection to the donor site is surgically divided to leave an island of torso tissue covering the
upper limb defect. No microsurgical vascular anastomosis is
required, and there is no need to formally evaluate or utilize
the axial vessels of the upper limb, unlike free-ap or local
fasciocutaneous techniques.
Outcomes of Limb Salvage
Saddawi-Konnefka and colleagues reviewed 28 observational studies concerning the treatment of tibial fractures
and observed that the most common complications after
limb salvage were the following: osteomyelitis (17.9%) and
fracture nonunion (15.5%) with secondary (late) amputation in 7.9%.36 The authors were able to compare the secondary amputation rate between those without vascular
injuries (5.1%) and those with vascular injury (28.7%).
Taking the groups together, 63.5% of salvage patients
returned to work, compared to 73% of amputees.
In 1997, Lin et al. reported on 36 lower extremity revascularizations performed on 34 patients. After the revascularization, seven (19.4%) patients with IIIC fractures
underwent secondary amputation within 1 week. At the
2-year follow-up, the overall secondary amputation rate had
risen to 25% (9 of 36). Of 29 salvaged limbs among their
27 patients, 23 limbs (79.3%) required secondary coverage
procedures that included 12 free ap transfers (41.4%). All
27 patients required further surgery to improve functional
outcome.
shunts are used,24 although the protective nature of shunting may be of far less benet in more-distal and highergrade fractures such as Gustilo IIIC injuries.
energy transfer, gross contamination, and delay in denitive treatment. In Brown et al.'s series of 35 combat-injured
and devascularized limbs, 29 had an associated fracture and
6 did not.4 Of the patients who had an associated fracture,
37
Outcome seems to improve when temporary vascular
5
Wartime injuries are typically characterized by high-
15 (52%) underwent primary amputation, 13 of which
were damage control procedures in critically ill patients. In
the remaining two patients (both of whom had experienced
a time interval from point of injury to surgery of greater
than 6 hours), the injured limbs were deemed anatomically
unsalvageable. Fourteen limbs had vascular repairs undertaken, with a much higher incidence of postoperative complications in patients with an associated fracture.
Summary
The management of a devascularized extremity with a
signicant bone and soft-tissue injury is challenging. The
complexity of these cases requires a team approach in order
to ensure that unfeasible options are rejected and that the
optimal route to maximal functional recovery is selected.
It can be appreciated that there are numerous reconstructive options and that the eventual choice will depend on
the patient, the nature of the defect, and the surgical preference. Finally, it should be remembered that amputation
of the mangled extremity may be the best reconstructive
option for the patient in some cases.
References
1. National Institute for Health and Care Excellence. Fractures (Complex): Assessment and Management. London: Nice; 2016. https://
www.nice.org.uk/guidance/ng37/resources/fractures-complexassessment-and-management-pdf-1837397402053.
2. Miranda F, Dennis J, Veldenz H, Dovgan PS, Frykberg ER. Conrma-
tion of the safety and accuracy of the physical examination in the
evaluation of knee dislocations for injury of the popliteal artery: a
prospective study. J Trauma. 2002;52:247–252.
3. Young K, Aquilina A, Chesser TJS, etal. Open tibial fractures in major
trauma centres: a national prospective cohort study of current practice. Injury. 2019;50:497–502.
4. Brown K, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC.
Complications of extremity vascular injuries in conict. J Trauma.
2009;66:S145–S149.
5. Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E,
Feliciano DV. A decade’s experience with temporary vascular shunts
at a Level 1 trauma centre. J Trauma. 2008;65:316–326.
26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 331
https://t.me/medicina_free
6. Romanoff H, Goldberger S. Combined severe vascular and skeletal
trauma. J Cardiovasc Surg. 1979;20:493–498.
7. Green N, Allen B. Vascular injuries associated with dislocation of the
knee. J Bone Joint Surg Am. 1977;59-A:236–239.
8. Patterson B, Agel J, Swiontkowski M, Mackenzie EJ, Bosse MJ. Knee
dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) study LEAP Study Group. J Trauma.
2007;63:855–858.
9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of
one thousand and twenty-ve open fractures of long bones. J Bone
Joint Surg Am. 1976;58-A:453–458.
10. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on
the management of open fractures of the tibial shaft. Clin Orthop.
1998;350:18–25.
11. Wordsworth M, Lawton G, Nathwani D, etal. Improving the care of
patients with severe open fractures of the tibia: the effect of the introduction of major trauma networks and national guidelines. Bone Joint
J. 2016;98:420–424.
12. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial
fractures with severe soft-tissue loss. Limb salvage compared with belowthe-knee amputation. J Bone Joint Surg Am. 1993;75:1431–1441.
13. Fairhurst MJ. The function of below-knee amputee versus the
patient with salvaged grade III tibial fracture. Clin Orthop Relat Res.
1994;301:227–232.
14. MacKenzie EJ, Bosse MJ, Pollak A, et al. Long-term persistence of
disability following severe lower-limb trauma. J Bone Joint Surg Am.
2005;87-A:1801–1809.
15. Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of
mangled lower extremities. J Trauma. 1993;34:99–104.
16. Fochtmann A, Binder H, Rettl G, etal. Third degree open fractures
and traumatic sub-/total amputations of the upper extremity: outcome and relevance of the mangled extremity severity score. Orthop
Traumatol Surg Res. 2016;102:785–790.
17. Fowler J, MacIntyre N, Rehman S, Gaughan JP, Leslie S. The impor-
tance of surgical sequence in the treatment of lower extremity
injuries with concomitant vascular injury: a meta-analysis. Injury.
2009;40:72–76.
18. McHenry T, Holcomb J, Aoki N, Lindsey RW. Fractures with major
vascular injuries from gunshot wounds: implications of surgical
sequence. J Trauma. 2002;53:717–721.
19. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith
adjunct in the management of wartime vascular injury. J Trauma.
2006;61(1):15–21.
20. Gifford SM, Aidinian G, Clouse WD, etal. Effect of temporary vas-
cular shunting on extremity vascular injury: an outcome analysis
from the GWOT vascular initiative. J Vasc Surg. 2009;50(3):
549–555.
21. Hancock HM, Stannard A, Burkhardt GE, etal. Hemorrhagic shock
worsens neuromuscular recovery in a porcine model of hind limb
vascular injury and ischemia/reperfusion. J Vasc Surg. 2011;53
(4):1052–1062.
22. https://www.boa.ac.uk/standards-guidance/boasts/trauma-boasts.
html
23. Kwasnicki R, Din A, Hettiaratchy S. The use of pulse oximetr y to diagnose
limb ischaemia. J Plast Reconstr Aesthet Surg. 2018;71:1816–1834.
24. Glass G, Pearse M, Nanchahal J. Improving lower limb salvage follow-
ing fractures with vascular injury: a systematic review and management algorithm. J Plast Reconstr Aesthet Surg. 2009;62:571–579.
25. Sassoon A, Riehl J, Rich A, etal. Muscle viability revisited: Are we
removing normal muscle? A critical evaluation of dogmatic debridement. J Orthop Trauma. 2016;30:17–21.
26. Anglen JO. Comparison of soap and antibiotic solutions for irrigation
of lower-limb open fractures: an experimental study. J Orthop Trauma.
2005;19:591–596.
27. Rich NM, Metz CW, Hutton JE, Baugh JH, Hughes CW. Internal versus
external xation of fractures with concomitant vascular injuries in
Vietnam. J Trauma. 1971;11:463–473.
28. Bach AW, Hansen ST. Plates versus external xation in severe open
tibial shaft fractures. Clin Orthop. 1989;241:89–94.
29. Giannoudis PV, Papakostidis C, Roberts C. A review of the manage-
ment of open fractures of the femur and tibia. J Bone Joint Surg Br.
2006;88-B:281–289.
30. Gopal S, Majumdar S, Batchelor A, Knight SL, De Boer P, Smith RM.
Fix and ap: the radical orthopaedic and plastic treatment of severe
open fractures of the tibia. J Bone Joint Surg Br. 2000;82:959–966.
31. Godina M. Early microsurgical reconstruction of complex trauma of
the extremities. Plast Reconstr Surg. 1986;78:285–292.
32. Byrd HS, Spicer TE, Cierney 3rd G. Management of open tibial frac-
tures. Plast Reconstr Surg. 1985;76:719–730.
33. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial
fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006;88:351–357.
34. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ.
Microvascular soft-tissue transplantation for reconstruction of acute
open tibial fractures: timing of coverage and long-term functional
results. Plast Reconstr Surg. 1992;98:478–487.
35. Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP.
Risk analysis for the reverse sural fasciocutaneous ap in distal leg
reconstruction. Plast Reconstr Surg. 2009;123:1499–1504.
36. Saddawi-Konnefka D, Kim H, Chung K. A systematic review of
outcomes and complications of reconstruction and amputation
for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg.
2008;122:1796–1805.
37. Lin C, Wei F, Levin S, Su JI, Yeh WL. The functional outcomes of
lower-extremity fractures with vascular injury. J Trauma. 1997;43:
480–485.
Bibliography
Howard PW, Makin GS. Lower limb fractures with associated vascular
injury. J Bone Joint Surg Br. 1990;72:116–120.
Nanchahal J, Nayagam S, Khan U, etal. Standards for the Management of
Open Fractures of the Lower Limb. London: RSM Press Ltd; 2009.
27
https://t.me/medicina_free
Vascular Surgery in the Austere
Environment
DAVID M. NOTT
Introduction
Vascular surgery is normally conducted in a highly technical environment with a full complement of specialized
equipment including noninvasive ultrasound technology, state-of-the-art computed tomography (CT), modern
uoroscopy, specialized instruments for open surgery, and
postoperative intensive care units and wards staffed with
experienced vascular nurses and junior doctors. Performing vascular surgery in an austere environment is the
antithesis to this. Faced with major vascular injury, the
surgeon will nd few tasks more demanding of his or her
wisdom, especially with regard to decision making. The primary principles are always control of life-threatening hemorrhage and prevention of end-organ ischemia. However,
time, resources, and the patient's physiology are pressing
factors that require constant consideration. The diagnosis
and management of arterial and venous injury are performed by careful clinical examination supplemented with
a continuous-wave Doppler probe. In the austere setting,
there are rarely other, more elaborate diagnostic modalities. Correct clinical decisions are paramount with limited
equipment, inexperienced intensive care staff, and a limited
means to transfer patients to a higher level of care.
It is vitally important to begin the task with the right
mindset and to approach all vascular injuries in damage
control mode. Blood loss alone will have altered the patient's
physiology, and the overriding necessities are to stop bleeding, to reestablish blood ow using shunts combined with
fasciotomy or to ligate, and, if necessary, to perform amputation. One must also be prepared to make quick decisions.
This is not the environment in which to spend a long time
performing extensive and difcult vascular reconstructions.
In general, one should not entertain the idea of performing
a complex vascular anastomosis at the rst operation. If the
decision is to shunt the injured vessel, one must make sure
all the bleeding has stopped and bring the patient back the
following day for a more denitive operation. That strategy
will allow time for the patient to warm up, will allow for
adequate resuscitation to take place, and will allow time to
source blood donors if blood is still required.
The single surgeon working in a relief or humanitarian
aid scenario requires a multiplicity of skills. Apart from
knowledge pertaining to vascular anatomy and surgical
techniques, including extraanatomic bypass, it is also necessary to be able to perform nerve and tendon repairs, to
undertake orthopedic trauma management (reduction
of fractures, external xation), and to be able to perform
elements of plastic surgery (which entails knowledge of
the blood supply to muscles and skin necessary to cover
332
vascular repairs). The aim of this chapter is to review the
management of the patient with vascular and associated
injuries from the perspective of marked resource constraint and
to highlight areas of differences and commonality with
trauma surgery as it is practiced in replete, developed-world
settings.
Fundamentals
Fig. 27.1 demonstrates much of the basic equipment that
should be taken on austere missions in which extensive
injury management is anticipated: a handheld Doppler
machine, magnifying loops, an operating headlight with
batteries, 20 or so umbilical vein catheters (size 4 and size 6),
and four boxes of 5-0 Prolene. Most nongovernmental organization (NGO) operating theaters are well provisioned, but
lighting is usually a limitation, and the instruments tend to
be fairly large and cumbersome.
In general, clinical evidence of an arterial injury is manifested in one of the following four ways: external bleeding,
end-organ or extremity ischemia, pulsatile hematoma, or
internal bleeding accompanied by signs of shock. Patients
present very early, early, late, or very late. Those who present late are a self-selected group, often hemodynamically
normal but with mummied limbs (if in hot, dry climates).
In this scenario, there is no role for revascularization; and
amputation is the necessary option (Fig. 27.2).
Sometimes the patient may not understand the consequences of an arterial injury, therefore, making the rational
argument for the amputation in order to save the patient's
Fig. 27.1 Important tools for the austere vascular surgeon.
27 • Vascular Surgery in the Austere Environment 333
https://t.me/medicina_free
Fig. 27.2 A 14-year-old girl who fell off a tree while picking mangos in
Chad and presented to the hospital 2 weeks later.
Fig. 27.3 Discussions pertinent to the level of amputation.
life can be extremely challenging. The patient in Fig. 27.3
did not appreciate that his leg was beyond salvage. When
he did agree to an amputation 4 days later, he consented
only to a below-knee amputation (though the whole of the
below-knee compartment was necrotic). It took another
week of intense discussion before the patient agreed to the
denitive procedure, and by that time sepsis was present. In
these instances, even if the patient understands that a limb
is not viable, culture and religion sometimes decree that a
person must die with his/her body in toto or intact. In such
difcult circumstances, the surgeon must rely on his or her
understanding and empathy for the patient's personal and
religious beliefs. The patient in South Sudan (Fig. 27.4) was
otherwise very t and well, but he chose to return to his village with a wooden splint and died 2 weeks later.
The decision to operate on vascular trauma is based on
hard and soft signs of injury. Hard signs of vascular injury
include the absence of distal pulses, active external hemorrhage, signs of ischemia, expanding or pulsatile hematoma,
and a bruit or thrill (in the case of an arteriovenous stula).
Fig. 27.4 This patient had absent distal Doppler pulses due to a gunshot wound to the leg and refused treatment on religious grounds.
Soft signs of vascular injury consist of a stable hematoma,
diminished distal pulses, injury in the proximity of a major
vessel, or neurological decit. The most common arterial
injury associated with hard signs is either a partial laceration or a complete vessel transection. In general, complete
transection leads to retraction and thrombosis of the proximal and distal ends of the vessel with subsequent ischemia.
In contrast, partial laceration causes persistent bleeding or
pseudoaneurysm formation. In the austere environment,
only those patients with hard signs undergo treatment. The
diagnostic equipment is generally not available to accurately diagnose vascular injury presenting only with soft
signs. Repeat examinations or serial clinical monitoring
and pressure measurements (i.e., injured extremity index
[IEI]) with the handheld Doppler will often reveal a trend in
patients who initially present with soft signs and then go on
to develop hard signs.
1
Neck Injuries
CAROTID INJURIES
In austere environments, the only indication for surgery
in the neck is penetrating trauma with hard signs. Blunt
carotid injuries resulting in intimal disruption with
subsequent dissection or thrombosis may present with catastrophic neurological symptoms that develop some time
after the injury was sustained. Such patients do not normally
present to the surgeon. In cases of penetrating trauma, the
method of exposure and treatment of injuries to the vascular structures of the neck is determined in large part by
the precise location of the injury and the anatomy of blood
vessels and surrounding structures. The neck has been
classically divided into three zones (Fig. 27.5). Zone I is from
below the cricoid cartridge to the superior border of the
clavicle; zone II lies between the cricoid cartilage and the
angle of the jaw; zone III extends above the angle of the jaw
to the base of the skull. Hard signs include external or intraoral bleeding, an expanding (arterial) or stable (venous)
334 SECTION 4 • The Management of Vascular Trauma
https://t.me/medicina_free
Zone III
Zone III
Zone II
Zone II
Zone I
Zone I
Fig. 27.5 Zones of the neck. (Redrawn from Bagheri et al. Penetrating
neck injuries. Oral Maxillofacial Surg Clin N Am. 2008;20:393–414.)
hematoma, stridor and air bubbling from the wound, and a
palpable thrill or audible bruit. In the absence of hard signs,
assessment of the neck is by careful clinical examination,
which must be repeated serially. Without clinical signs of a
vascular- or aerodigestive injury (such as pain on swallowing, subcutaneous emphysema, or soft tissue air on a lateral
neck radiograph), nonoperative management should be fol-
2–4
lowed.
If facilities for a barium/Gastrogran swallow are
available, that should be performed.
Nonoperative management does not equate with conservative management, and these patients should be regularly
reviewed. Any change in status may mean a change in the
management plan is needed. There has been considerable
debate in the literature regarding whether it is mandatory
to explore any wound in the neck that has penetrated the
platysma. This author's policy is to not explore the neck in
the absence of hard signs.
5–7
If it is bleeding from the external carotid artery or its
branches, ligation is the preferred option. An injury to the
common carotid artery below the bulb, if deemed unreconstructible, can be managed with ligation. In these challenging cases, one must accept that perfusion of the brain
on the injured side will occur via retrograde ow from the
posterior circulation and the contralateral side. Other injuries of the bulb and internal carotid artery can be reconstructed with a vein patch and segmental defects managed
with an interposition vein graft. In all cases, the long saphenous vein should be harvested from the groin because there
are reports of carotid patch disruption if the vein is taken
from the ankle.
8,9
Resection of the internal carotid with
external-to-internal carotid artery transposition is a good
option when treating proximal internal carotid artery (ICA)
injuries in children.10 Injuries involving the jugular veins
can be ligated with impunity, and this is the preferred option
over reconstruction in the austere setting.
11
There has been debate about the use of a cervical collar
in penetrating neck injuries. In the author's opinion, most
patients with penetrating neck injuries will not survive if
they have cervical spine trauma because they are already tetraplegic or have associated major head injury. Those with no
neurological signs rarely have a spinal injury, so using a collar
may potentially obstruct the airway and mask other injuries.
12
The patient with a hard sign or signs of cervical vascular
trauma should be taken urgently to the operating theater
because rapid expansion of a hematoma may occur, resulting in deviation of the trachea and elevation of the oor of
the mouth. In this circumstance, one must be prepared to
perform an emergency tracheostomy or cricothyroidotomy
if the anesthetist is having any difculty with intubation.
One must also be sure to prepare the neck and chest, in case
of the requirement for proximal control, and to prepare the
proximal thigh for vein harvesting (Fig. 27.6). If needed,
suction drains can easily be made by creating a vacuum in a
50-mL syringe and then using plungers from 20-mL syringes
to maintain the plunger in the suction position (Fig. 27.7).
Preoperatively, it is very important to assess the neurological status of the patient using the Glasgow Coma
Scale (GCS). An adverse outcome is more likely to occur in
a patient with a GCS of less than 8, and in this situation,
the ICA should be ligated if it is found to be the cause of
the bleeding. In this scenario, no attempt at carotid repair
should be made, even if there is antegrade ow, due to the
risks of causing propagation of thrombus and, on restoration of perfusion, converting an ischemic infarct into a
hemorrhagic one.
13,14
Those not in coma or with only a mild
neurological decit should be considered for carotid repair
using a vein patch or reversed vein. Because only 35% of
patients have an intact circle of Willis, there is a risk of signicant neurological insult if the ICA is ligated.
15
Carotid–jugular stulae are rare. In 1994, during this
author's mission to Sarajevo, a 13-year-old girl with a fragment wound to the neck presented for care. The penetrating
wound had become swollen and there was a readily palpable
thrill over the enlarged neck mass. Unlike arteriovenous stulae in the limbs, carotid–jugular stulae are particularly
prone to complications such as intractable high-output
cardiac failure, atrial brillation, and embolization.16 In the
case of the 13-year-old girl, the common carotid artery was
clamped, and perfusion of the internal carotid relied on ow
from the external carotid. Having isolated the stula, both
the internal jugular vein and the common carotid artery
were repaired with 5-0 Prolene.
It is recognized that internal carotid artery stump pressures are highly variable, but, on the whole, the ICA back
pressure may be augmented by 10 to 15 mm Hg if the external carotid artery is maintained in continuity. If this can be
maintained, it may augment internal carotid artery stump
pressures to the degree that repair of some carotid injuries
may not be necessary.17 Although some surgeons advocate
using a shunt in isolated common carotid artery injuries,
this author has not used one in this situation, and there are
no studies to support its role in this setting.
18
Соседние файлы в папке Библиотека им академика М.И. Перельмана