An 18-year-old male was stabbed in the right axilla with pulsatile bleeding. Paramedics arrive at the trauma resuscitation bay with direct pressure on the axilla.
BP 70/40, HR 120, Resp 28, temperature 37°C, GCS 12. Absent pulses, paralysis, and paresthesias in right arm with active arterial bleeding when direct pressure released from wound in right axilla. This is an isolated injury.
Obvious axillary artery injury with hard signs present. Significant volume loss has occurred. Patient needs protection of the airway, direct control of hemorrhage, and immediate operation. Permissive hypotensive is indicated with immediate infusion of type O-negative packed red blood cells to raise systolic BP to no higher than 80–90 mm Hg. This may begin on the way to the operating room, but should not cause any delay. Proximal vascular control will require access to the axillary artery in the infraclavicular region. Saphenous vein interpostition graft may be required.
Sterile prep and drape right arm with senior team member keeping direct pressure on injury site to control bleeding. Prep right shoulder and chest wall, and entire right leg to give access to saphenous vein if needed. First incision in the infraclavicular region carried down by muscle-splitting pectoralis major muscle. Pectoralis minor tendon divided at coracoid process to expose axillary artery and vein that are encircled with double-passed silastic vessel loops. Systemic heparin given in view of isolated injury and temporary control and gently occluded. Attention turned to axilla where longitudinal incision made while direct pressure held on upper arm to occlude venous inflow and arterial backflow. Lacerated axillary artery identified; take care to avoid median and ulnar nerves. Vein found to be intact. Small vascular clamp placed proximally and distally to injured artery and vessel loops in proximal vessels and pressure on upper arm released. No other injuries present (Fig. 41-13).
Incisions for proximal control axillary artery in the infraclavicular region and exposure of brachial artery injury in the upper arm and axilla.
One centimeter segment of proximal brachial artery lacerated longitudinally. Local Fogarty catheter thrombectomy performed and heparinized saline (10 U heparin/mL) flushed, taking care to limit infusion volume and avoid air and debris flush into level of vertebral origin. Debridement and spatulation of proximal and distal artery leads to over 2 cm defect with undue tension when approximation assessed with tension on clams. Saphenous vein segment harvest from left ankle region and interposition graft placed (Fig. 41-14).
Saphenous vein interposition graft for repair of brachial artery laceration.
Distal pulses and Doppler flow assessed and found to be normal. Wound closed primarily. Thin sponge and tape dressing applied.
Serial right arm pulse examinations, neurologic examinations, and assessment muscle compartments in addition to inspection of right axillary wound site for presence of hematoma.
Fully recovered without neurologic deficit and with normal upper extremity blood flow.
A male in his 70s presents to the emergency department with a dog bite in the left arm. This occurred 2 hours ago and he reports rapid onset of severe pain and inability to move his arm. His pit bull has bitten him on two other extremities within the last 2 weeks. The patient has a history of hypertension, hyperlipidemia, cigarette smoking, and coronary artery disease.
BP 180/90, HR 80, Resp 20, temperature 37°C. Nonbleeding puncture wounds in left medial aspect upper arm. Absent pulses below the level of the puncture wounds, paralysis, and paresthesias in right arm. Superficial wounds in left arm and left leg with normal neurovascular examination (Fig. 41-15).
Right upper arm puncture wounds from pet pit bull bite.
Obvious brachial artery injury with thrombosis and occlusion occurred. Now 2 hours of ischemia with limb threat to right arm. Patient needs expeditious restoration of blood flow. Physical examination indicates extent of injury and further imaging unnecessary and time consuming, increasing risk of prolonged ischemia and risk of limb loss. Patient needs to go directly to the operating room. Comorbidities place him at increased risk and the anesthesiologist needs to be alerted regarding patient’s medical history.
Sterile prep and drape right arm, shoulder, and right leg for possible saphenous vein harvest. Incision made along medial aspect of arm from above to below; puncture wounds made avoiding including wounds to reduce wound infection risk. Vessel injury site and sufficient uninjured proximal and distal brachial artery exposed. Thrombosis of brachial artery segment deep to the largest puncture wound found (Fig. 41-16).
Thrombosis of brachial artery deep to the largest puncture wound from the dog bite.
Saphenous vein interposition graft performed. Distal pulses and Doppler flow assessed and found to be normal. Wound closed primarily. Thin sponge and tape dressing applied.
Serial right pulse examinations, neurologic examinations, and assessment of muscle compartments in addition to inspection of upper arm wound axillary wound site for presence of hematoma.
Fully recovered without neurologic deficit and normal upper extremity blood flow.
A 42-year-old male, restrained driver of sport utility vehicle crashes head-on into tree. Aspirated in the field and arrives 40 minutes after injury. He has been intubated in the field.
BP 120/80, HR 110, Resp 18, temperature 37°C, GCS 8T, no wrist pulses in right arm, wrist Doppler pressure 70 mm Hg, FAST, x-rays, and CT imaging reveal severe head injury, chest injuries, Grade II splenic laceration, complex pelvis fractures with hematoma, and right humerus fracture. To angiogram for embolization hypogastric arteries, right arm arteriogram obtained (Fig. 41-17).
Thrombosis of brachial artery at fracture site with profunda brachial artery collateral flow to distal brachial artery. Wrist pressure 70 mm Hg.
Brachial artery injury with collateral flow generated wrist pressure of 70 mm Hg is not immediate limb threat. There are multiple potentially life-threatening injuries that preclude immediate extremity vascular repair.
Stabilized with critical care management of his multiple injuries including placement of intracranial pressure monitor. Right arm splinted and followed closely for adequacy of collateral flow. Compartment pressures in forearm measured daily and remained normal. Temporized for 72 hours, overall status improved. To operating room for saphenous vein interposition brachial artery and fixation humerus.
Slow recovery with mild central neurologic deficit. Normal motor and sensory exam in right arm, full function and normal upper extremity blood flow.
A 20-year-old man suffers close-range shotgun wound to the left arm while bird hunting with his father and brother. He presents 1 hour after injury with severe pain and a pressure dressing and splint on this left arm.
BP 130/80, HR 120, Resp 20, temperature 37°C. Isolated shotgun wound in left arm with extensive tissue loss. The arm is insensate, paralyzed, and pulseless below the level of the elbow. He has extensive bone and tissue loss (Fig. 41-18).
Shotgun wound to left arm. No sensation or motor function and wrist pulses and Doppler signals absent.
Obvious severe loss of major vascular and neurologic structures and extensive musculoskeletal tissue in left forearm. This patient needs to go directly to the operating room with orthopedic surgery, vascular surgery, and plastic and reconstructive surgery colleagues to perform an assessment and determine whether limb salvage or amputation needs to be performed.
Examination under anesthesia in the operating room by the trauma surgeon and specialty colleagues confirms extensive tissue loss including loss of long segments of the median, ulnar, and radial nerves. The prognosis for limb salvage is extremely grave and there is no chance for functional recovery even if extensive vascular artery and vein grafting and free tissue transfer are performed. This is not a salvageable limb and immediate amputation just above the elbow is performed. The trauma surgeon talks with family to explain the situation. A complete series of pictures of the extremity injury is taken and copies placed in the chart.
Patient recovers rapidly and is fitted with robotic arm prosthesis. He returns to college the next semester.
A 23-year-old male struck in left groin by shrapnel from exploding gas canister aboard a Navy ship; transected femoral artery and vein were ligated aboard ship. Now, 13 hours later he arrives by helicopter transport.
BP 120/80, HR 100, Resp 20, temperature 37°C. Isolated left groin injury packed with moist gauze. Left leg is cool, anesthetic, paralyzed, and pulseless. Calf compartments are tense.
The patient is not well beyond the “golden period” of 6–8 hours and already has signs of compartment syndrome. The risk of limb loss is very high. The only hope for limb salvage is the prompt restoration of blood flow and calf compartment fasciotomy.
Patient is given 5,000 U heparin bolus. A four-compartment fasciotomy of the calf is performed first. Generous incisions are made and the muscle appears ischemic (Fig. 41-19).
Fasciotomy incisions: (A) lateral incision releasing anterior and lateral compartments and (B) medial incision for release of posterior compartments.
Exploration of the femoral region reveals that the superficial femoral artery and the common femoral vein have been ligated. Clamps placed above and below ligation sites, ligatures removed, Fogarty catheter thrombectomy performed, heparin saline flushed, and 12 French shunt inserted in superficial femoral artery. Copious amounts of thrombus flushed out of distal veins by tightly wrapping the leg with an Esmark bandage from the foot to the upper thigh. Proximal femoral vein back flushed copiously to clear small amount of thrombus. Small chest tube cut to fashion suitable size shunt and placed in the common femoral vein.
Long segment of vein harvested from uninjured right leg. Interposition graft performed in the superficial femoral artery. Panel graft fashioned by opening long segment of saphenous vein longitudinally and sewing it in a spiral around a 36 French chest tube. This graft is interposed in the common femoral vein (Fig. 41-20).
Left groin repair site. Common femoral artery, profunda femoral artery, vein interposition in superficial femoral artery, and spiral vein graft in the common femoral vein.
Femoral wound closed and fasciotomy wounds loosely wrapped. Central line placed to follow volume status and maintain high urine output because of risk of acute renal failure from myoglobinuria. Leg placed in continuous passive motion device. Full anticoagulation with heparin begun 12 hours following operation.
Early to mild myoglobinuria without significant increase in creatinine. Rapid swelling muscles of calf but all remained viable. Rapid return of motor and sensory function in first week. However, postischemic neuropathic pain continued for 4 weeks. Fasciotomy wounds covered with split-thickness skin grafts at 7 days. Muscles remained viable and, by 6 weeks, neurologic function returned to 90% of normal with mild residual sensory deficit. Postoperative screening using duplex scan of veins of lower extremity weekly—no thrombus formation. Patient remained on warfarin for 3 months.
A 27-year-old male construction worker grinding steel fitting felt stinging sensation in left mid thigh and rapid onset of pain and swelling. Small tear in jeans and puncture wound on mid-left anterior–medial thigh.
BP 130/80, HR 90, Resp 20, temperature 37°C. Firm swelling in area of puncture wound and obliquely from mid upper thigh to lower anterior–medial thigh. Normal pulses throughout left leg and ankle–brachial index normal and equal to right leg. CT angiogram of left leg obtained (Fig. 41-21).
CT angiogram. (A) Cross-section and (B) VTR views revealing lacerated left superficial femoral artery with acute pseudoaneurysm within the sartorius muscle.
Partial injury of superficial femoral artery with acute pseudoaneurysm requires immediate exploration and repair. Depending on status of the vessel wall, local repair, vein patch angioplasty, or interposition graft will be required.
Left and right legs prepped and draped. Incision made along course of artery of sufficient length for proximal and distal control. Longitudinal 15 mm laceration with remainder of artery wall normal and no vein injury found. Vein patch angioplasty performed. Hematoma evacuated and wound closed with closed suction drain (Figs. 41-22 to 41-24).
Left leg preparation and draping. Landmarks marked on leg to outline site injury, course of artery, sartorius muscle, and margin femur leg. Incision made over course of sartorius muscle.
Longitudinal 15 mm laceration from shrapnel wound to left superficial femoral artery.
Saphenous vein patch repair with preservation of normal luminal diameter of superficial femoral artery.
Discharged home on day 4 following operation. Returned to work at 1 month.
A 30-year-old male police officer shot close range with shotgun at scene of domestic violence call. Through-and-through wound in upper right calf. Minimal blood loss at scene and pressure dressing in place with bleeding controlled.
BP 110/60, HR 100, Resp 16, temperature 37°C. Isolated through and through right calf wound. Extensive tissue damage (see below). Pulses and Doppler signals absent at ankle. Plantar sensation intact but diminished. Dorsiflexion of foot intact, plantar flexion present but diminished. Catheter arteriogram obtained (Fig. 41-25).
Arteriogram revealing occlusion of proximal posterior tibial and peroneal arteries and at mid-anterior tibial artery. Associated fracture of tibia and extensive loss in midportion of fibula.
Although severe vascular and musculoskeletal injury, nerve damage is limited with partial motor and sensory deficit. Saphenous vein bypass to distal tibial vessel and orthopedic stabilization with external fixation has favorable prognosis for limb salvage and recovery of function.
Patient is given 5,000 U heparin bolus in trauma bay. Both legs prepped and draped. Injury has decompressed the anterior and lateral compartments. Medical compartments decompressed through same long medial incision on calf to expose distal posterior tibial artery. Saphenous vein bypass to distal posterior tibial artery performed. Extensive debridement wounds and external fixation performed by orthopedic surgery colleague. Partial closure of wounds with application of Wound Vac™ dressings. Split-thickness skin graft applied at 5 days after initial operation. Compartment fasciotomy of the calf is performed first (Figs. 41-26 and 41-27).
(A) Medial calf entrance wound and (B) lateral exit wound in shotgun injury.
Intraoperative completion angiogram at distal anastomosis of reverse saphenous vein popliteal to posterior tibial bypass.
At 3 weeks, discharged home with external fixation tibia, continued physical therapy. Ultimately recovered with mild weakness in plantar flexion of foot and mild sensory deficit in heel and plantar aspect of foot. Promoted to sergeant and given desk job.
A 35-year-old male bag handler at the airport distracted, drives tractor into a flatbed baggage trailer. Open right knee and proximal tibial fracture with active bleeding. Tourniquet and pressure dressing applied.
BP 100/50, HR 120, Resp 25, temperature 37°C, GCS 15. Complain of severe right leg pain. Tourniquet in place. Dressing taken down. No sensation or movement of foot and calf and no pedal pulses or Doppler tones present at ankle. Lines placed, intubated, and taken directly to the operating room. X-rays reveal extensive disruption of femoral condyles, patella, tibial plateau, and proximal tibia (Fig. 41-28).
Open fractures with bone fragments missing distal femur, tibial plateau, proximal tibia, and severe soft tissue injuries.
Extensive soft tissue and skeletal trauma and associated vascular injury with need for tourniquet need immediate operative management. Portable x-rays and intraoperative angiogram can be performed as needed. Orthopedic surgery colleague needs to be involved as soon as possible to manage injuries, assess chances of limb salvage, and decide if immediate amputation needed. Trauma surgeon needs to discuss preoperatively with patient and family, if at all possible, the threat of limb loss and the possible need for immediate amputation. The status of the peroneal and tibial nerves will be one of the most important determinants of the possibility of limb salvage.
Prep and drape of both legs, proximal control of popliteal vessels above the knee obtained, and tourniquet removed. Exploration of knee and upper calf reveals transaction and maceration of popliteal artery, vein, tibial nerve, and peroneal nerve. Extensive open fractures with bone fragments completely avulsed femoral condyles, tibial plateau, and proximal tibia. The decision is made to perform guillotine amputation above the knee and delay closure for 48 hours to assess extent of further muscle necrosis (Fig. 41-29).
Exploration reveals complete transaction and maceration popliteal vessels and tibial and peroneal nerves and extensive open fractures. Patient required an above knee amputation.
Recovered and was fitted with dynamic above-knee prosthesis. Returned to work with some limitations 4 months later.