Hard signs
Soft signs
Arterial/pulsatile bleeding
History of hemorrhage in the field
Persistent hemorrhage with shock
Small, stable, non-pulsatile hematoma
Expanding or pulsatile hematoma
Unexplained hypotension
Palpable thrill
Penetrating wounds in proximity to major vessels
Audible bruit
Associated nerve deficit
Absent pulse
Diminished or unequal pulses
What Are the 6 Ps of Limb Ischemia?
These physical exam findings include pain, pallor, paresthesias, paralysis, pulselessness, and poikilothermia. Of the 6 Ps, only pulselessness is considered a hard sign of vascular injury. These findings may be found in patients with both acute and chronic limb ischemia from a variety of causes.
What Is the Implication of an Audible Bruit/Palpable Thrill Near an Artery in Association with Trauma?
It is highly suggestive of a traumatic arteriovenous fistula.
What Are the Principles of the Physical Examination of an Injured Extremity?
Examination of injured extremity must assess vascular, neurologic, musculoskeletal, and soft tissue integrity of the entire limb, including the joints above and below the site of injury (Table 43.2). Comparison of potentially abnormal findings to the contralateral extremity is recommended.
Table 43.2
Physical examination of the injured extremity
Vascular |
Peripheral pulses above and below the site of injury |
Perfusion of skin (warmth, color, and capillary refill) |
Hard and soft signs of vascular injury |
Neurologic |
Sensation, strength, reflexes |
Musculoskeletal |
Fracture or gross deformity |
Joint exam (passive and active range of motion, joint instability, effusion) |
Soft tissue |
Intact |
Degree of contamination |
Pathophysiology
What Is the Mechanism of Popliteal Artery Injury?
The popliteal artery is susceptible to traction and transection injuries due to its fixed course across the knee joint. The artery is tethered at both its superior border, as the superficial femoral artery exits the adductor hiatus, and its inferior border at the tendinous arch of the soleus. Along its course, the popliteal artery forms an anastomotic network around the knee by giving off paired geniculate branches. Posterior dislocation of the knee compresses the popliteal artery against the posterior aspect of the tibial plateau resulting in arterial injury. The most common presentation of popliteal artery injury is thrombosis with acute distal limb ischemia.
What Are the Classic Orthopedic Fractures/ Dislocations That Are Associated with Arterial Injury ?
The Classic Orthopedic Fractures/Dislocations That Are Associated with Arterial Injuries are Detailed in Table 43.3.
Table 43.3
Common skeletal and associated arterial injuries
Injury | Artery involved | Features |
|---|---|---|
Shoulder girdle dislocation | Axillary artery | Posterior dislocations result from seizures and have an increased risk of axillary nerve injury. Anterior dislocations are more common and present with axillary artery injuries |
Clavicle fracture | Subclavian artery | Patients may have associated pneumothorax and/or hemothorax |
Supracondylar fracture | Brachial artery | Occurs more commonly in children; may result in Volkmann’s contracture if left untreated |
Pelvic fracture | Branches of internal iliac artery (superior gluteal and internal pudendal) | Arterial bleeding in the presence of severe posterior fractures is more likely to be due to an injury to the superior gluteal artery. Severe anterior fractures may result in injury to the internal pudendal artery; both can result in hemorrhagic shock (major source of blood loss) |
Hip dislocation | Femoral artery | Posterior dislocations present with an internally rotated and adducted leg with an increased risk of sciatic nerve injury. Anterior dislocations present with externally rotated and abducted legs with an increased risk of femoral artery injury; risk of avascular necrosis if combined with femoral head fracture |
Knee dislocation | Popliteal artery | Arterial injuries occur more frequently in patients with posterior dislocation and less with anterior |
Tibial plateau fracture | Popliteal artery | Arterial injuries occur more frequently in patients with medial injuries and less with lateral |
Why Is It Important to Promptly Reduce a Dislocation?
Dislocations that are left unreduced for a prolonged period of time are associated with poorer long-term outcomes including limited functional recovery. In the short term, these injuries are associated with significant pain and discomfort which are improved with reduction. Prompt reduction will allow for near-normal range of motion and use. Furthermore, dislocations associated with arterial injuries increase the risk of osteonecrosis of the involved bone.
Watch Out
Always reexamine a patient’s vascular and neurological status after performing reduction.
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