Orthopaedic Injuries and Angiography
Ian Civil
Clinical Director, Trauma Service
Orthopaedic injuries and angiography
Ian Civil
Clinical Director
Trauma Services
We don’t need to discuss this
Haemodynamically unstable pelvic fracture
Angiography has an established therapeutic role here
We do need to discuss this
Severe (blunt) extremity injury
Poor/absent pulses
Variable alignment of the fracture
Possibility of significant vascular injury but probability low
EAST has no guidelines for blunt extremity vascular trauma, but for penetrating trauma -
III Recommendations
C. Level 3
Absence of hard or soft signs of vascular injury reliably
excludes surgically significant arterial injury and does
not require arteriography
Angiography for proximity is only necessary for shotgun
wounds
Hard signs of vascular injury
Active haemorrhage
Distal pulse deficit
Expanding or pulsatile haematoma
Distal ischaemia
Bruit
Thrill
Soft signs of vascular injury
Small stable haematomas
Injury adjacent to a nerve
Unexplained hypotension
Haemorrhage at scene
Proximity
How does that help?
That’s all very well but lots of patients with blunt
extremity trauma have “hard” signs. That’s why the
question has been asked.
Absent pulses?
Distal ischaemia?
are both common in blunt trauma but it is relative….
Soft signs such as those mentioned are seldom relevant
in blunt trauma.
Assessment options
Clinical
– Cap refill
– Colour
– Pulses
– Usually done and not normal, hence the ?
Doppler
– Nature of signals
– ABI
– Not always practical in the badly injured extremity
Angiography (OR or Radiology Dept)
– Do you need to know the answer to decide whether to go to the OR or not?
MRA
– Commonly used in vascular surgery but not practical for most trauma patients
Clinical examination
Comparison with other extremity vital
“Hands-on”
Consensus on presence and quality of pulses
Defer forming an opinion until limb splinted and dislocations reduced
Doppler
Mere presence of doppler signals not reassuring
Comparison with other side
Wave-form assessment usually not practical
ABIs crucial
Doppler assessment
100 limbs with blunt or penetrating trauma over 24/12 (only 22 blunt)
All had ABI and angio
75 with ABI >0.9 all had normal angios
20 with abnormalities had ABI <0.9
2 ABI < 0.9 but normal angios
3 ABI > 0.9 but abnormal angios
Sensitivity 0.87; Specificity 0.97; PPV 0.91; NPV 0.96; Accuracy 0.95
Lynch K, Johansen,K 1991
Doppler assessment
96 limbs with blunt or penetrating trauma over 6/12 (only 15 blunt)
Hard signs to OR; Patients with soft signs had ABI
ABI <0.9 to angio, remainder serial ABI, ultrasound, and some angios
17 normal perfusion, low ABI: 16 abnormal angios and 7 needing surgery
79 normal ABIs: 5 minor injuries not needing Rx
Johansen et al 1991
Angiography
Interventional radiology essential component of trauma assessment
Can the patient go to the department?
Is the extremity all that needs angio?
Good pics or none at all!!
MRA
Commonly used for vascular evaluation
Significant limitations in the acute evaluation of trauma patients
Essentially not practical for this form of evaluation
My approach
If there is arterial bleeding take the patient to the OR and sort the vascular problem out.
Otherwise take the patient to the OR and sort out the orthopaedics first (but simply and quickly)
If that resolves the arterial problem complete the ortho fix and consider need for definitive angio (to clear) later
If that does not resolve the vascular problem do an on table angio
If that confirms a vascular problem, fix it then, prior to definitive ortho fix (if one needs to be done)
Shunts are rarely needed in blunt trauma
Consider the overall injury complex and if fits the “mangled extermity” ? is amputation best
Is there any evidence to support this approach?
What sort of blunt extremity injuries lead to vascular problems?
How often is diagnostic angiography required and where should it be performed?
What proportion of vascular injuries require intervention?
What sort of extremity injuries lead to vascular problems?
62 (out of 12,005 blunt trauma) patients in 7 years
16 upper extremity; 46 lower extremity - all but one had a fracture or a dislocation
82% of lower extremity injuries location at the knee or below
Rozycki et al 2003
What sort of extremity injuries lead to vascular problems?
26 traumatic knee dislocations over 10 years in a University Hospital in Madrid, Spain.
2 popliteal artery occlusions (7.5%)
Rios 2003
Auckland Trauma Service experience
9195 blunt trauma patients over 7 years
3949 lower extremity injuries, 2503 upper
15 lower extremity vascular injuries, 9 upper
21 dislocated knees of which 4 resulted in vascular injury
How often is diagnostic angiography required?
300 angios in 297 patients suspected of having acute arterial injury
27% of patients suffered blunt trauma
Overall 28% had major angiographic abnormalities
Rose SC, Moore EE 1988
But only 27% of Gene Moore’s patients had blunt trauma!
However, Gene Moore says:
Specifically, a fracture, by itself is not an indication for angiography but rather should prompt a search for clinical signs of vascular injury. If an abnormal pulse, or secondary signs of vascular injury are present, then angiography should be performed. Joint dislocations, especially involving high risk joints such as the knee should serve as a separate indication for angiography.
Moore, Mattox and Feliciano
What does Grace Rozycki
(and David Feliciano) do?
Preoperative angios were obtained for 20 patients (out of 62)
Six of these were performed in the radiology suite, the remaining 14 were performed in the OR, all of which showed vessel occlusions
What proportion of vascular injuries require intervention?
Auckland Trauma Service experience
15 lower extrem injuries (8 SFA/pop, 7 infrapop)
4 dislocated knees, 2 open femur fractures, remainder tib/fib fractures or crush
7 grafts, 2 1o amps, 4 fasciotomies only, 1 ligation, 1 embolisation
9 upper extremity injuries (5 brachial, 3 axillary, 1 ulna)
2 dislocated elbows, 2 fx humerus, 1 clavicle, 1 ulna, rest crush
4 grafts, 2 direct repairs, 3 no Rx
Major vascular lesions associated with orthopaedic injuries
Karavias D, Korovessis P et al. J Orthop Trauma 1992 6:180-185
17 patients over 4 years
70% high energy, 88% open, 65% leg
Bones then vascular
3 amputations
Doppler imaging and “where necessary” angiography
Arterial injuries associated with lower extremity fractures
Andrikopoulos V, Anoniou I and Panoussis P
Cardiovascular Surgery 1995; 3:15-18
110 cases of vascular injury associated with lower extremity fractures over 5 years
74% RTC, remainder penetrating injury
No pulses in 83%, 57% nerve injuries
27 SFA, 48 popliteal, 35 infrapopliteal
Angiography was highly recommended in cases with a clinically suspected arterial injury at the infrapopliteal level AND a decrease in doppler signal or pressure.
Angiography before surgery in 55% and post-op in 15%
Arterial Injury in the Lower Limb from Blunt Trauma
Faris IB, Raptis S and Fitridge R. Aust NZ J Surg 1997;67:25
32 years of experience in Adelaide
Only 122 arterial injuries in 119 pts
Probable arterial injury -> angio but ? how many -ve angios
70 pre-op angios
Arterial injury fixed before sorting bones
Most patients had some form of mangled extremity with only 59 limbs salvaged
Orthopaedic injuries and angiography
Think of it whenever there is a fracture or crush injury and peripheral circulation is not normal
Check pulses and doppler in comparison with other side
ALIGN LIMB AND REDUCE DISLOCATIONS
For other than “check” angiography, OR expedites management
Embolisation and/or ligation have a role in some injuries
Fasciotomy commonly required
Vascular repair before definitive bony stabilisation
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Ministry of Health
