Vascular trauma associated with fractures / dislocations

The British Orthopaedic Association have published guidelines on the mangement of vascular injuries.

Management in the ED

Treat life threatening injuries ideally in conjunction with limb threatening injuries
Consider Code Red.
Apply direct pressure or a tourniquet (as distal as possible) to control active haemorrhage
Do not blindly clamp
Document neurovascular examination
Immediately re-align and reduce the pulseless deformed limb. Splint, reassess & image if appropriate
Identify direct/indirect signs of injury.

Direct signs	Indirect signs
Pulsatile haemorrhage Expanding haematoma Absent palpable pulse Palpable thrill/bruit	Reduced or unequal pulse(s) Non-pulsatile haematoma History of significant haemorrhage Injury near neurovascular structures Mechanism e.g.: Knee dislocation/displaced tibial plateau, groin contusion from handlebar or mangled extremity Paraesthesia
Do not use ‘pinkness’, capillary return, or Doppler signal to exclude injury.

Urgent surgical exploration is indicated
Angiography should not delay revascularisation but may be considered if:
- Multilevel injury
- Peripheral vascular disease
- Absent proximal pulse
- Patient undergoing a WBCT for other indications and scan extended to include limb angiography.

CT Angiography should be performed as soon as possible.

Orthopaedic and Vascular consultant should attend. Plastic Surgery should attend if open fracture
Patients should be aware of the substantial risk of amputation for some injuries
Two consultants should be involved in the decision to perform early amputation
Beyond 3-4 hours, warm ischaemia results in irreversible tissue damage and an increasing risk of amputation. Risks of delayed revascularisation include myoglobinuria and may be associated with increased mortality. Access incisions should be planned to facilitate soft tissue coverage
Vascular surgery ideally performed first.
Prioritise haemorrhage control and revascularisation. This may involve external fixation and temporary shunts.

Repair of identified nerve injuries is subsequently performed (delay if damage control).

Low threshold for post reperfusion fasciotomy.
Admit all patients to a critical care environment post operatively.