Principles in the Management of Arterial In juries

Associated with Fracture/Dislocations

MELVIN H. SHER, M.D.*

Ten out of 355 patients admitted with fracture and/or dislocations

of long bones secondary to blunt trauma had associated vascular
injuries. The clinical recognition of the associated vascular injury
and its verification by arteriography, Doppler study or surgical
exploration resulted in early vascular repair and limb salvage.
The controversial aspects of bone stabilization followed by vascular repair versus primary vascular repair, skeletal traction and
delayed internal fixation together with fasciotomy-fibulectomy
are discussed. Our results with the injuries seen justify the principle of bone stabilization followed by vascular repair, particularly
since a team effort resulted in little time lost prior to circulatory
restoration. The problems following vascular repair-namely anterior compartment syndrome, acute renal failure and cardiac
arrest are presented with their principles of management.

From the Framingham Union Hospital,

Framingham, Massachusetts

the popliteal artery as it is stretched across the popliteal

space with both superior and inferior fixation. Since experience with the management of this complex problem is
limited, 1,4,9,14,15,18,20 due to the infrequent combination of
arterial and orthopedic injury, we felt a review of the
problems posed in the diagnosis and treatment of these
lesions was appropriate.

Clinical Material
From August 1, 1968 to July 31, 1974, 16,931 orthopedic emergencies were seen at the Framingham
Union Hospital and 1,702 patients required hospital admission. From this latter group 355 patients had traumatic fracture of the long bones with or without associated
dislocation of the respective joint. There were 233 males
and 157 females. Ten patients, all males, had associated
arterial injuries for an incidence of 0.28%. Their ages
ranged from 18-46 years with a mean of 25 years.
Whereas the lower extremity was the most common site
of injury, three patients had injuries involving the upper
extremity (Table I). All patients suffered non-penetrating
blunt trauma and in three patients the blunt force was so
great it produced a compound fracture thereby resembling a penetrating injury.
All injuries were the result of vehicular accidents, six
motorcycle and three automobile; while one patient sustained his injuries from a fall of several feet (Table 2).
Surgery began within 8 hours from arrival in the Emergency Ward, an average of only 3 hours being used in
resusitation and/or diagnostic delay. The time from injury
to arrival in the Emergency Ward was not recorded in
these patients. Arteriography was employed in 6 patients
preoperatively, while in recent years the Doppler flow
study was used to support or establish the diagnosis of
arterial occlusion in three patients. In all patients the
Lincoln Street, diagnosis was suspected by the clinical signs of arterial
ischemia together with the absence of peripheral pulses.

amputation rate in acute

traumatic arterial injury during World War II was the
stimulant for surgeons during the Korean War to perform
direct arterial repair and realize a reduction in amputations from 49.6% to 10.8%.3.8 Depending upon the site of
an acute arterial injury, however, the amputation rate
may still be high. Thus failure to repair a damaged popliteal artery will usually result in loss of the extremity;
whereas arterial injury even when associated with a fracture about the elbow rarely requires amputation.6'7'1"3'19
The association of arterial injuries with fracture or dislocation secondary to blunt non-penetrating trauma has
been a relatively uncommon event. Effective management in these combined injuries requires recognition of
the arterial injury without delay and appropriate orthopedic management of the fracture or dislocation. Injuries to other body systems may be so severe they take
precedence over the vascular trauma or cause it to go
unrecognized. A high index of suspicion of arterial injury
should exist whenever arteries are in close proximity to
bone and held in a semi-fixed position.10 The arteries
most frequently involved are the subclavian artery beneath the clavicle, the brachial artery adjacent to the
humeral shaft and supercondylar portion of the humerus,
the femoral artery near the femoral shaft, and especially
T HE EXCEPTIONALLY HIGH

Submitted for publication April 25, 1975.

*Vascular Service, Framingham Union Hospital, 97
Framingham, Mass. 01701.

630

Vol. 182 No. S

MANAGEMENT OF ARTERIAL INJURIES

In one patient, Case 2, peripheral pulses were always

present but the sudden onset of shock and hemothorax 10
days following admission led to emergency exploration
and the diagnosis of subclavian vein laceration secondary
to the piercing of this vein by a fractured 1st rib segment.
Pulses were restored in all but one patient (Case 6). In
this latter patient a more vigorous attempt to restore
pulses was abandoned when no clots could be retrieved
from the distal tree and the hand was observed to be
warm with good capillary refill.
Arterial ischemia was the result of intimal tear and
secondary thrombosis in 5 patients, contusion and
thrombosis in two patients, and angulation with entrappment of the vessels by the fracture in two patients (Table
3). The latter two patients required no vascular procedure
but had restoration of peripheral pulses when the fractures were reduced and stabilized. Arterial continuity in
the remaining patients was obtained by resection of the
traumatized area and primary repair (2) or by autogenous vein grafts. (5) Four of the 7 patients requiring vascular
repair had distal thrombi extracted by the Fogarty catheter with resultant brisk back flow bleeding. In one patient
the vascular injury was a venous laceration and this was
controlled by primary venorrhaphy.
Internal fixation was employed as the primary method
of management in 6 patients, reduction and casting in 3,
and in the one patient with over-riding 1st rib fracture,
the rib was resected in order to control the acute vascular
accident (Table 4). Three patients whose injuries involved the knee joint had temporary footdrop, all with
recovery and a good functional result; whereas one patient who developed an anterior compartment syndrome
had a permanent footdrop. A below knee amputation
secondary to muscle necrosis and infection was required
in one patient; however, his final functional result with a
prosthesis was excellent. One patient with brachial
plexus avulsion and subclavian artery occlusion had a
flail arm and is classified as a poor result.

Discussion
Arterial injuries associated with fractures or dislocations are immediate or delayed. The immediate complications are: 1) Laceration of the vessel, either partial or
complete, 2) Occlusion, either partial or complete, which
may be due to (a) angulation, (b) extrinsic compression,
(c) intimal tears and disection with an intact adventitia,
(d) stretching and (e) spasm. The delayed complications
are: 1) False aneurysms, 2) AV fistula, 3) Thrombosis of
the vessel following reconstructive surgery, 4) Ischemic
muscle contractures. For successful management of a
patient with a combined vascular-orthopedic injury the
recognition of circulatory compromise is indispensible.
Poor results are not due to a more severe injury or one
which is less amenable to surgery, but to procrastination
and failure to appreciate signs and symptoms of arterial

631

TABLE 1. Arterial Injury Associated With Fracture andlor Dislocation.

16,931
Orthopedic cases seen in ER
1,702
Admissions from ER
Patients with long bone fracture
355
and/or dislocation
233
Male
157
Female
Associated arterial injury with long bone fracture
10
and/or dislocation
10
Male
0
Female
18-46 (mean 25)
Ages
Site of injury
7
Lower Extremity
3
Upper extremity

insufficiency when they accompany a fracture or dislocation. Valuable time has been lost by temporizing with
ancillary measures such as sympathetic nerve block, anticoagulation, and fasciotomy as primary treatment. The
safe time lag of 6-8 hours advocated by Miller and
Welch12 is arbitrary since adequate collateral circulation
provides a longer safe period and may account for the
lower incidence of limb loss following injury about the
elbow joint as compared to the knee joint when treatment
is either inadequate or delayed. While the time from
injury to surgery in our series was not recorded the delay
from arrival to surgery was well within the safe limit and
may account for our good overall result. The findings of
arterial ischemia when associated with a history of bleeding or a pulsating mass is diagnostic. On the other hand, if
the foot or hand is cool rather than cold, hypoasthetic
rather than anesthetic, pale rather than ashen, the diagnosis is more difficult especially when an operation will
convert a closed fracture into an open one with the potentials for osteomyelitis. Such a state may exist with reflex
arterial spasm; however, complete anesthesia or small
muscle paralysis is rare and the effect of this reflex vasospasm is diminished with the relief of pain, splinting of a
fracture, or intra-arterial Papaverine. If, however, the
spasm is not relieved, excision and reanastomosis of the
ends or interposition with a graft is the procedure of
choice. Extrinsic mechanical factors also cause the signs
and symptoms of arterial ischemia as experienced in Case
7. It is to this group that arteriography or Doppler study
is helpful and may prevent unnecessary surgery. Diminished or absent Doppler sounds or pulse waves support the diagnosis and lessen the need for arteriography;
however, if doubt exists and the patient's condition is
stable, arteriography or exploration should be performed.
If gentle closed reduction of a dislocation or fracture fails
to immediately improve circulation, arteriography or exploration should be done without delay. Arteriography
should be used prior to or during any re-exploration, and
upon completion of a repair to exclude technical errors
which may lead to subsequent failure. While arteriography establishes the exact location and extent of arterial
damage or extrinsic cause for pulselessness, it is a

632

SHER

Ann. Surg. * November 1975

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Vol. 182* No. 5

Cases
1. BD
2. TD
3. FP

4. BD

5. JL
6. CK
7. DM

8. JS
9. EB

10. GI

MANAGEMENT OF ARTERIAL INJURIES

TABLE 3. Arterial Injury and its Management.
Morbidity
Repair

Vascular Injury

Intimal tear and thrombosis

brachial artery, Contusion
4 cm long
Laceration right subclavian
Intimal tear popliteal artery
& thrombosis, Contusion 3.5
cm long, Transection of
popliteal vein
Occlusion of anterior and
posterior tibial arteries by
angulation, compression and
entrapment
Contusion & thrombosis of
popliteal artery 2.5 cm long
Intimal tear & thrombosis
left subclavian artery,
Contusion 2 cm long
Angulation of anterior and
posterior tibial arteries
Intimal tear & thrombosis of
popliteal artery, Contusion
5-7.5 cm long
Intimal tear & thrombosis of
popliteal artery, 3.5-4 cm
long contusion
Contusion & thrombosis of
superficial femoral artery
2.5 cm long

Resection and cephalic

vein graft

None

Primary suture repair

Resection of artery and
saphenous vein graft.
Primary anastomosis of
vein.
None-Reduction and
stabilization of
fracture

None
None

Muscle necrosis and

infection

633
Vascular Result
Restoration of all pulses
Good-No venous occlusion
Restoration of pulses.
No venous insufficiency.

Restoration of DP pulse

Resection & saphenous

vein graft
Resection & end to end
anastomosis

None

Restoration of pulses

None

None-Reduction and
stabilization of fracture
Resection and saphenous
vein graft, subcutaneous fasciotomies
Resection & saphenous
vein graft, subcutaneous fasciotomies
Resection & end to end
anastomosis

None

Poor-Pulses remained absent

but arm & hand warm with good
capillary refill
Restoration of pulses

None

Restoration of pulses

double-edged sword in that it is time consuming and the

delay may prove critical to limb survival.
Once a diagnosis is established the first question to be

Anterior compartment syndrome

None

Restoration of pulses
Restoration of pulses

answered is whether or not the limb is salvageable. Extensive tissue destruction resulting in a functionless or
useless extremity should undergo primary amputation

TABLE 4. Orthopedic Management, General Morbidity and Final Functional Result.

Cases
1. BD

2. TD
3. FP
4. BD

5. JL
6. CK
7. DM

8. JS
9. EB
10. GI

Orthopedic Injury
Comminuted supracondylar fracture left
femur
Fracture right femur
Fracture right humerus
Fracture right radius
Fracture right shoulder
Fracture left femur
Fracture 1st rib
Comminuted supracondylar fracture of
left femur
Comminuted fracture
proximal 1/3 tibia &
fibula
Dislocation left knee
Fracture transverse
process T, fracture
left pubic ramus
Fracture tibia and
fibular distal 1/3
Posterior dislocation
left knee
Comminuted posterior
displaced fracture of

proximal tibia
Fracture left femoral
shaft

Repair
Bar bolt & Rush rod

Result
Good

Morbidity
No orthopedic or

Final Functional Result

Good

vascular
Good
Good
Good
Good
Good
Good

Diabetes Insipitus

Laceration right
subclavian vein

Good

Good

Temporary footdrop

Good

cast

Poor

Reduction & cast

Good

requiring BK
amputation
Temporary footdrop
Avulsion brachial

None

Poor

plexus

Reduction & cast

Good

None

Good

Reduction & cast

Good

Temporary footdrop

Good

screw fixation

Good

syndrome

Compression plate

Poor

Angulation of fracture

Intramedullary rod
Intramedullary rod
Plate & screws
None

Intramedullary rod
Resection of 1st
rib

Compression plate

Muscle necrosis

Kirschman Rods &

Reduction, internal

Anterior compartment

site & compression

plate requiring delayed
rod fixation

Good with prosthesis

Good without brace
Poor-flail arm

Fair-permanent footdrop
requiring a brace
Good

634

Ann. Surg. * November 1975

SHER

with or without immediate postoperative prosthesis. If

salvage seems possible avoid unnecessary delay. Following proximal and distal arterial control, the fracture is
stabilized thereby safeguarding vascular repair. In challenging this standard approach, Connolly2 has demonstrated that the disruptive resistance of a typically sound
vascular repair to longitudinal traction is greater than a 40
pound pull. The infrequency with which the fracture
spears or disrupts the anastomosis versus the reality of
increased operating time, higher infection rate, and
further disruption of collateral circulation in an already
severely tramatized limb has led to the recommendation
of primary vascular repair and skeletal traction for
stabilization followed by delayed internal fixation 1-2
weeks after initial therapy.16'17 This approach seems acceptable for contaminated wounds, war injuries and prolonged delays prior to initial therapy, but in the community practice when most injuries are closed, uncontaminated and seen early, the standard approach of internal
fixation followed by vascular repair has provided good
results and with little time lost.
The traumatized vascular structures should be
adequately debrided to assure normal arterial structures
for reconstruction. Repair may be in the form of 1) Lateral suture, 2) Venous patch graft, 3) Resection with end
to end anastomosis, 4) Restoration by interposed autogenous reversed saphenous vein graft or synthetic dacron grafts, 5) Re-attachment of the intima if the tear is
circumferential and 6) Bypass grafting about the area of
trauma to relatively uncontaminated tissues. The distal
arterial tree should be perfused with a Heparin solution
and the graft placed under slight stretch. All clots should
be removed with a Fogarty catheter or, if not available,
by antegrade and retrograde flush prior to completion of
the reconstruction. Completeness of this part of the procedure should be checked with operative arteriography.
All major veins are repaired because without adequate
venous return the already elevated tissue pressure by the
edema and bleeding from the bone and soft tissues will be
further increased and with time the resultant damage
would be equivalent to that produced by direct interruption of a major artery. Subcutaneous fasciotomy of
adequate length and extent has been advocated by some
authors in all patients with traumatic injury; whereas
others believe both fascia and skin must be incised or
fibulectomy performed to prevent the anterior compartment syndrome.5 Simple elevation of the limb above
heart level postoperatively is helpful and possibly a preventative that should be carried out in all patients. Aggressive immediate re-exploration of the artery with or
without arteriography is mandatory if signs of ischemia
re-appear. Patients with prolonged delays prior to
surgery or who have had tourniquets applied for the
control of bleeding may develop postoperative renal failure secondary to the liberation and absorption of myo-

globin and other tissue breakdown products or cardiac

arrest due to the release and absorption of large amounts
of potassium. Manitol and good hydration preoperatively, intraoperatively, and postoperatively may help prevent these complications.
AV fistula, a late complication, is treated by excision
and restoration of arterial and venous continuity rather
than quadruple ligation; whereas a false aneurysm or a
nonessential artery may be treated by proximal arterial
ligation, but when the artery must be preserved vein
bypass grafting well removed from the site of the lesion is
preferable.
References
1. Bassett, F. H. and Silver, D.: Arterial Injuries Associated With
Fractures, Arch. Surg., 92:13-19, 1966.
2. Connelly, J.: Management of Fractures Associated with Arterial
Injuries, Am. J. Surg., 120:331, 1971.
3. DeBakey, M. E. and Simeone, F. A.: Battle Injuries of the Arteries
in World War II: An Analysis of 2,471 Cases, Ann. Surg.,
123:534-579, 1946.
4. Doty, D. B., Treemin, R. L., Rothschild, T. D. and Gaspar, M. R.:
Prevention of Gangrene Due to Fractures, Surg. Gynecol.
Obstet., 125:248-288, 1967.
5. Ernest, C. B. and Kaufer, J.: Fibulectomy-Fasciotomy An Important Adjunct In The Management of Lower Extremity Arterial
Trauma, J. Trauma, 11:365-380, 1971.
6. Hoover, N. W.: Injuries of the Popliteal Artery Associated With
Fractures and Dislocations, Surg. Clin. North Am., 41:109911112, 1961.
7. Huler, M. E. T. and Hirsch, M.: Popliteal Artery Occlusion Associated With Dislocation of the Knee Joint: Report of a Case
With Successful Repair, Br. J. Surg. 57:315-317, 1970.
8. Hughes, C. W.: Arterial Repair During the Korean War, Ann.
Surg., 147:555-561, 1958.
9. Julian, 0. C. and Hunter, J. A.: Vascular Injuries Occuring in
Relation to Bone and Joint Trauma, Clin. Orthop., 28:14-20,
1963.
10. Klingensmith, W., Otes, P. and Martinez, H.: Fracture With Associated Blood Vessel Injury, Am. J. Surg., 110:849-852, 1965.
11. Kurnn, R.: Elbow Dislocation and its Association With Vascular
Disruption, J. Bone Joint Surg., 4:756-758, 1969.
12. Miller, H. H. and Welch, C. S.: Quantative Studies on Time Factors in Arterial Injuries, Ann. Surg., 130:428-438, 1949.
13. Morton, J. A., Southgate, W. A. and DeWeese, J. A., Arterial
Injuries of the Extremities, Surg, Gynecol. Obstet., 123:611-627,
1966.
14. Pradhan, D. J., Juanteguy, J. M., Wilder, R. J. and Michaelson, E.,
Arterial Injuries of the Extremities Associated with Fractures,
Arch. Surg., 105:582-585, 1972.
15. Razek, M. S. A., Mnaymneh, W. and Yacoubian, H. D., Acute
Injuries of Peripheral Arteries With Associated Bone and Soft
Tissue Injuries, J. of Trauma, 13:907-910, 1973.
16. Rich, N. M., Matz, C. W., Hutton, J. E. Jr., Baugh, H. Jr., and
Hughes, C. W., Internal Versus External Fixation of Fractures
With Concomitant Vascular Injuries in Vietnam, J. of Trauma,
11:463-473, 1971.
17. Schweigel, J. F., and Gropper, P. T., A Comparison of Ambulatory
Versus Non-Ambulatory Care of Femoral Shaft Fractures, J. of
Trauma, 14:474-481, 1974.
18. Smith, R. F., Szilagyi, E., and Elliot, J. P., Fracture of Long Bones
With Arterial Injury Due to Blunt Trauma, Principles of Management, Arch. Surg., 99:315-324, 1969.
19. Sullivan, M. F., Rupture of the Brachial Artery From Posterior
Dislocation of the Elbow Treated by Vein Giaft, Brit. J. Surg.,
58:470-471, 1971.
20. Strum, J. T., et al, Blunt Trauma to the Subclavian Artery, Surg.
Gynec., Obstet., 138:915, 1974.