Vascular Injury with Leg Fractures

J. Cone, Vascular Injury Associated With Fracture-Dislocations of the Lower Extremity, Clinical Orthopaedics and Related Research 243: 330 (1989)

All fractures and dislocations produce vascular injury. This is clearly demonstrated by hematoma formation and blood loss.

However, the thrombosis may not occur for hours or even days following the injury. Such injuries may demonstrate no initial findings on physical examination.

While the majority of vascular injuries may be diagnosed by careful history and physical examination, a totally negative history and physical examination are not sufficient to rule out the presence of a vascular injury in the high-risk trauma patient. The history will be of limited value, but it may disclose that the injury resulted from a high-energy impact.

The physical examination has traditionally been based on the six P’s of ischemic vascular disease: pulseless, pain, pallor, paresthesia (or anesthesia), paralysis, and poikilothermy (cool/cold extremity). Perfusion may be further assessed by checking the capillary refill time compared with an uninjured extremity. If one or more of these signs is present, one must assume there is a vascular injury.

Although the absence of pulses, Doppler signals, and capillary refill clearly and unequivocally establishes an ischemic extremity, normal pulses, signals, and refill do not rule out an injury that allows flow at the time of the test but that may either bleed or thrombose later. Doppler imaging does not rule out injury.

Thus, it can be concluded that while standard clinical techniques may allow assessment of the current status of distal perfusion, they cannot exclude vascular injury. One is left with the necessity of using angiography (or routine exploration) to exclude vascular injury. It is the gold-standard for ruling out subtle vascular injury. Fortunately, the well-perfused injured extremity allows the luxury of such careful evaluation.

Recent reports have led to a revision of the approach to the injured tibial artery in many centers. Particularly if there is significant musculoskeletal destruction, both tibial arteries should be repaired regardless of the apparent viability of the foot.

Vascular complications are virtually always the result of a missed or delayed diagnosis. They may include limb loss from ischemia due to an unrecognized vascular occlusion or compartment syndrome. Arteriovenous fistulas and pseudoaneurysms may result from missed nonocclusive vascular injuries. These fistulas and aneurysms are more common with injuries to the tibial or peroneal vessels.