Chirurgia (2013) 108: 700-705

No. 5, September - October

Copyright© Celsius

Diagnosis and Treatment of Limb Fractures Associated with Acute Peripheral

Ischemia
G.I. Popescu1, O. Lupescu1, M. Nagea2, C. Patru2
1
“Carol Davila” University of Medicine and Pharmacy, Orthopaedics and Trauma Department, Clinical Emergency Hospital,
Bucharest, Romania
2
Orthopaedics and Trauma Department, Clinical Emergency Hospital, Bucharest, Romania

Rezumat Abstract
Acute Peripheral Ischemia (API) is the most severe acute
Diagnosticul æi tratamentul în fracturile de membre asociate
complication after both open and closed fractures, as
cu ischemie perifericã acutã
ischemia compromises not only the vitality of the affected
Ischemia perifericã acutã (API) este cea mai severã complicaåie limb, but also the patient’s life, because metabolic anaerobic
acutã a fracturilor închise æi deschise, având în vedere faptul cã changes following ischemia have serious local and general
ischemia afecteazã nu numai vitalitatea membrului afectat, ci consequences. These explain why early diagnosis of API is
chiar viaåa pacientului, întrucât alterãrile datorate metabolis- very important for the prognosis of the traumatized limb.
mului anaerob consecutive ischemiei au consecinåe redutabile The authors analyse cases when API was not diagnosed
locale æi generale. Aceasta explicã de ce diagnosticul precoce immediately after trauma, but some time after the first
al ischemiei periferice acute este foarte important pentru examination, due to either low systolic BP or to late onset
prognosticul unui membru traumatizat. Autorii analizeazã of API. The patients were analysed concerning the type of
cazurile când aceasta nu a fost diagnosticatã imediat post- the fracture, the reason for delayed diagnosis of API, the
traumatic, ci dupã un oarecare interval de timp, fie datoritã moment of API diagnosis and the arterial injury. In all those
valorilor iniåiale scãzute ale TA sistolice, fie datoritã instalãrii cases, surgery was performed immediately after API
tardive a ischemiei. Pacienåii au fost evaluaåi din punct de diagnosis, in order to identify and treat the complex injuries
vedere al tipului de fracturã, motivelor diagnosticului tardiv, (bone and vascular).
momentului efectuãrii acestuia æi tipului de leziune arterialã.
În aceste cazuri, intervenåia chirurgicalã a fost efectuatã cu Key words: limbs, fractures, acute peripheral ischemia,
maximã urgenåã, pentru a identifica æi trata leziunile complexe thrombosis
(osoase æi vasculare).

Cuvinte cheie: membre, fracturi, ischemie perifericã arterialã,

trombozã
Introduction
Modern traumatology is characterized by higher energy trauma
agents, like high-speed vehicles (generating more severe road
traffic accidents), high velocity missiles, complex technical
Corresponding author: Olivera Lupescu, MD, PhD procedures using inflammable materials, generating severe
“Carol Davila” University of Medicine and work accidents. When interacting with the victims, all of
Pharmacy, Bucharest, Romania
Orthopedics and Trauma Department these produce severe injuries, because the energy of the trauma
Clinical Emergency Hospital Bucharest agent is almost entirely transferred to the affected tissue
E-mail: [email protected] (except a very small amount, lost due to friction), producing
 701

different amounts of cellular and tissular disruptions. When Table 1.

acting on a part of one limb, traumatic forces are transferred to
its structures, often producing a fracture, but high energy A. Skeletal\ soft – tissue injury
agents generate complex injuries: bone, muscular, vascular and Low energy
nervous injury. (stab, simple fracture, low velocity gunshot wound) 1
The proximity of the bones to the blood vessels of the Medium energy
limbs often generates vascular complications, which are so (open or multiple fractures, dislocation) 2
complex that a unique classification is difficult to be High energy
established, as many criteria are to be discussed: the type of the (close range shotgun, high velocity gunshot, crush) 3
vessels affected (arteries, veins, or both), the size of the vessels Very high energy
(large, medium or small), the main effect of the injury (above end gross contamination, soft- tissue avulsion) 4
(ischemia or hemorrhage) the amount of the vascular wall and B. Limb ischemia
diameter affected, the local consequences (functional and Absent ischemia 0
structural damages of the tissues produced by the vascular Pulse reduced or absent but perfusion normal 1
injury), systemic impact of the vascular damage (by itself and Pulseless, paresthesias, diminished capillary refill 2
by local metabolic changes). Cool, paralyzed, insensate, numb 3
Considered to be the most severe of all the vascular C. Shock
complications of trauma, arterial injuries have both local Systolic blood pressure always over 90 mm Hg 0
and general consequences due to Acute Peripheral Ischemia Hypotensive transiently 1
(API), which can be defined as the syndrome consisting of Persistent hypotension 2
metabolic disturbances, followed by structural changes of the D. Age (years)
affected tissues, with clinical correspondence, due to the <30 0
imbalance between the local need of blood and the amount 30-50 1
of oxygenated blood supply, diminished after arterial >50 2
injuries. (1)
It is known that acute ischemia affects all tissues, depending
on their sensitivity to hypoxia (which is the main consequence fracture needs immediate surgical debridement avoids the
of ischemia), so the moment when the hypoxic injury of situation of not-diagnosing API, since the vessels are examined
different tissues becomes clinically detectable, depends on the intraoperatively. When the fracture is closed, it is very
metabolism of each tissue, and especially on the oxygen- important for the trauma surgeon to perform a thorough
dependence of that metabolism (i.e., the more oxygen is clinical examination of the injured limb, especially after certain
involved in the metabolism of a certain tissue, the earlier that types of fracture, when he must “expect” arterial damage.
tissue becomes necrotic following acute ischemia). (2) As the correct treatment of arterial injuries, concerning
The importance of acute ischemia is not only local, but it the moment and the type of intervention, is vital not only for
soon becomes systemic, as necrotic tissues, especially the the limb, but also for the patient’s life, early diagnosis of API
muscles, generates anaerobic metabolic products which is absolutely necessary, and this is performed primarily by
produce liver and kidney failure. (3) That is why modern clinical examination, which shows disappearance (or decrease,
scoring systems of limb trauma refer not only to the fracture, compared to the contralateral limb) of the peripheral pulse.
but also to the vascular status following trauma, and one good After that, Doppler and arteriographic examinations show the
example is the well- known MESS Score, which evaluates the location accurately and give information about the type of
prognosis of an ischemic limb, concerning both local and injury. (6,7)
systemic factors: the age of the patient, signs of API, signs of Since peripheral pulse is the major indicator for the
shock and the energy of the traumatic agent. (4) arterial status of the limb, it is also the most important factor
The Mangled Extremity Severity Score (MESS) may be used in clinical diagnosis of API. It is palpable only if systolic
used to decide whether to perform amputation in patients blood pressure exceeds 60 mmHg, when peripheral pulse will
with injuries involving a limb. (Table 1) be palpable at the other limbs except the ischemic one. If
Score doubles for ischemia > 6 hours. systolic blood pressure is less than 60 mm Hg, peripheral pulse
A total MEES score of 7 or greater is predictive of will not be palpable at any of the limbs, so API diagnosis is
amputation. impossible until hemodynamic stabilization.
It is to be underlined that the modern tendency of scoring The purpose of the study is not to describe the treatment
the injuries is highly valuable not only for multiple trauma, of closed fractures associated with arterial injuries, but to
but for limb trauma, as well, as it reflects the severity of the present two major problems concerning diagnosis of API
injury. (5) Literature shows that API can complicate most complicating closed fractures, when API is not detected at the
skeleton traumas, that it can occur simultaneously with the first clinical examination: the situations when systolic blood
skeleton injury, or after a certain period of time, called “ free pressure is under 60 mm Hg (acute post-traumatic hypo-
interval”, after open fractures (type III C in Gustillo-Andersen tension) and peripheral pulse is not palpable as well as those
classification), and closed fractures. The fact that the open when there is a ”free interval” between trauma and API onset.
702

Material and Method

Fifty-four patients were operated on in the Orthopedics and

Trauma Clinic of Emergency Hospital Bucharest between
1.01.2001 and 1.01.2011 for API (complicating closed fractures)
which could not be diagnosed by primary examination, but
sometime after the first examination. None of the patients had
any arterial pathology before trauma (revealed by the patients,
by their families or according with to the clinical findings).
The patients were studied concerning the type of the
fracture, the reason for delayed diagnosis of API, the
moment of API diagnosis and the arterial injury.
Using the AO classification, the types of the fractures Figure 1.
were: twenty femoral shaft fractures, sixteen fractures of distal
femur, ten tibial fractures, and eight humeral fractures.
In all fifty-four cases, API was not detected at the first
examination, but after some time, for two main reasons, so
the patients were divided into the following two groups:
Group A – thirty-six cases, mean age 42.6 years (twenty-six
to sixty-six years), with systolic blood pressure less than 60
mmHg at first examination. The patients in this group did not
have palpable pulse at any of the peripheral arteries when they
were first examined. After hemodynamic stabilization,
peripheral pulse became palpable except on the distal part of
the affected limb, and the mean time between first examina-
tion and the moment when API was diagnosed was sixteen
minutes. (Fig. 1)
Group B - eighteen cases, mean age 32 years (fourteen to Figure 2.
fifty-six years), with bilateral peripheral pulse palpable on the
first examination at upper and lower limbs; after a certain
period of time – mean value fourteen hours (twelve to eighteen minutes) in twenty-four cases, when acute hypotension
hours) - API was clinically diagnosed at one of the limbs, as produced by trauma was corrected by oxygen, intravenous fluid
peripheral pulse was no longer detectable, and the signs of and drug administration, without requiring any surgical
ischemia also appeared. (Fig. 2) procedure. The time was longer than fifteen minutes (not
In all these cases, when API was diagnosed, arteriography exceeding thirty-three minutes) in twelve cases when hypoten-
was performed, and afterwards surgical treatment confirmed the sion was produced by associated injuries, which needed surgical
arterial injury, described it precisely and repaired the treatment: eight ruptured spleens, which needed splenectomy,
associated injuries. Surgery consisted of the following standard three liver injuries, which needed hepatorhaphy, one
procedures: bone stabilization, venous drainage restoration for mesenteric disinsertion, with haemoperitoneum, which
humeral and femoral veins, major arterial axis restoration, required resection and haemostasis. (Table 2)
associated injuries of muscles, nerves, tendons treatment, and The arterial injuries in group A suggested by arteriography
decompressive fasciotomy, for reperfusion syndrome and precisely described intraoperatively, were (Table 3).
prophylaxis. Group B - eighteen cases, mean age thirty-two years
The patients from the two groups were studied for the (fourteen to fifty-six years), with bilateral peripheral pulse
type of the fracture, the moment of API diagnosis, and the palpable on the first examination at upper and lower limbs;
arterial injury producing API. after a certain period of time – mean value fourteen hours
(twelve to eighteen hours) - API was clinically diagnosed at
Results
The fractures in group A were: Table 2.
- twelve femoral shaft fractures,
- ten distal femoral fractures, Number The time between the first examination and
of cases the moment when API was first diagnosed
- eight tibia fractures,
- six humeral fractures. 24 less than 15 minutes, but above 10 minutes
The time between the first examination and the moment 12 longer than 15 minutes, but not exceeding 33
when API was first diagnosed was of an average value of sixteen minutes
minutes. This time was less than fifteen minutes (above ten Total 36 Mean time 16 minutes
 703

Table 3. Table 4.

arterial section seventeen complete-twelve Number The time between the first examination
cases cases of cases and the moment when API was first diagnosed
incomplete-five 18 less than 18 hours, but above 12 hours
cases Total 36 Mean time 14 hours
injury of internal and
medium layer, with
intact external layer eight cases represented by both clinical and etiopathogenic conditions of
thrombosis three cases API.
compression and spasm eight cases
incomplete section with A. Absent pulse in one limb after patient hemodynamic
subsequent thrombosis five cases stabilization

1. Diagnosis of API is a clinical one – the absence of

one of the limbs, as peripheral pulse was no longer detectable, peripheral pulse is the major sign, detected by the physician,
and signs of ischemia also appeared: pallor, pain and decreased who has to evaluate the vascular status of the injured limb.
cutaneous temperature in all the eighteen cases, and There are certain situations when API cannot be diagnosed
paresthaesia in two cases. The signs that alerted the patients, immediately after trauma, even if the arterial injury exists. Two
who required repeated ortho-pedically examination (which of these situations are discussed in this study: the first refers to
detected the absence of peripheral pulse) were: the sensation post-traumatic hemodynamic changes, which disturb clinical
of “ cold fingers” of the fractured limb - eighteen cases, pain – evaluation of the vascular status. This evaluation concerns the
six cases, paresthaesia - twelve cases. Since API was diagnosed arterial and venous circulation - the arterial evaluation includes
in early stages, none of the neurological signs of irreversible subjective elements, described by the patient, and objective
ischemia (paralysis or anesthesia) appeared. (Table 4) elements - peripheral pulse, cutaneous temperature and colour,
The fractures in group B were: capillary pulse, active movements. (9) If the subjective
- eight femoral shaft fractures, elements cannot be described by the patient due to his status,
- six distal femoral fractures, two tibia fractures, peripheral pulse is the only reliable element. As acute ischemia
- two humeral fractures. is defined as an imbalance between the local needs and practi-
The arterial injury in group B (detected intra-operatory) was cal supply of oxygen determined by an arterial acute injury,
arterial thrombosis in all eighteen cases. In two cases minimal peripheral pulse of the injured limb must be compared with the
lateral injuries of the artery (a longitudinal 2 mm injury in one pulse of other limbs, in order to be sure that the pulse absence
case and a round lateral injury with 3 mm in diameter) with is not the consequence of a chronic disease, like arteritis.
subsequent thrombosis were detected; in these cases, the 2. If the peripheral pulse cannot be detected in any of
hematoma surrounding the artery had a medium size and acted the limbs due to acute post-traumatic hypotension, it is
as a compressive haemostatic mechanism. impossible to diagnose API in one of the limbs until hemo-
dynamic stabilization, which leads to the presence of the
Discussion peripheral pulse in all the limbs except the ischemic one.
That means that when the patient’s blood pressure is
Arterial injuries complicating fractures are situations quite critically low, and the peripheral pulse is absent in all the
often described in literature and seen in trauma services, since limbs, clinical examination of the injured limb must be
agents with high traumatic force transfer their energy to all the repeated until the patient is stable and the pulse appears, in
tissues in the involved region. As Acute Peripheral Ischemia is order to ensure that arterial damage has not occurred near
a situation that needs immediate treatment, otherwise not the fracture. If the pulse is symmetrical at the upper and
only the affected part of the limb will be compromised, but lower limbs, it means that there is no disturbance of the
sometimes the patient’s life too, the early diagnosis of this peripheral arterial flow in that moment.
condition is vital for the patient. (8) It is, first of all, very 3. If the pulse is absent in one limb that limb is ischemic
important to understand the traumatic mechanism and to and we have to find out whether the ischemia is due to recent
evaluate properly all the features of the initial accident. This trauma or it precedes trauma. If that limb has a fracture and
will allow the surgeon to look for all the potential injuries the clinical examination suggests that the arterial injury level
starting from the initial aspects. (9,10) is at the site of the fracture, the probability of direct fracture-
We suggest an algorithm which is aimed to establish the arterial damage correlation is very high and it must be
steps that the medical examiner has to follow for a proper considered at once. An arteriographic examination is
medico-legal evaluation of API cases. (11) Because the medico- recommended and if, hazardously, this is not possible,
legal evaluation is done usually late after patient admission in immediate surgery must be performed. (12,13,14) The
the orthopedics clinic, the medico-legal case review is based possibility of ischemia existing before trauma is very low, and
on the patient clinical files. The subject of this algorithm is this can be suggested by an obvious difference at the inspec-
704

tion of the ischemic limb, characteristic for chronic injuries

(atrophy of the muscles, skin, hairiness, nails, or even signs of
gangrene). This situation is quite rare, but it must be considered
and if the patient cannot provide any useful information for a
differential diagnosis, arteriographic examination may
complete the clinical findings. Nevertheless, whenever the
suspicion of acute injury exists, even on an arteritic back-
ground, surgical evaluation will clear up the diagnosis. (15)

B. The situation represented by the cases when there

is a certain period usually called “free interval”
between the trauma and the API onset (a few hours)

In our study, the arterial injury in the cases with a late onset
of API was arterial thrombosis. Literature presents post-
traumatic arterial thrombosis as a very serious complication, as
Figure 3. API-toes cyanosis
it occurs late after trauma, the artery looking intact, but the
mechanism is a microscopic one: the initial trauma is only a
contusion which does not disrupt the arterial wall, but
produces thrombosis or disruption of the vasa vasorum -
generating ischemia of the arterial wall. The most sensitive
structure to ischemia (of the entire arterial wall) is the internal
layer (the intimae). Subsequently to the initial trauma, the
intimal layer is injured both directly (mechanical) and
indirectly, through ischemia of the wall. The injury of the
intimae damages the connections between the endothelial
cells, so the endothelium loses its continuity from place to
place, exposing the subendothelial collagen fibres to the blood
flow, which generates conditions for blood cell adherence,
leading to thrombosis. (16,17,18) (Fig. 3, 4)

Conclusions
After trauma, ischemia is frequently diagnosed after “alarm
signs” (the sensation of “cold fingers” of the fractured limb, Figure 4. Intramuscular thrombosis
pain, paresthaesia) are reported by the patient to the physician,
who performs a new examination, suspecting an ischemia. The
earlier the ischemia is diagnosed, the better the prognosis of References
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