Fractures with major vascular injuries from gunshot wounds

Implications of surgical sequence

Timothy P. McHenry, John B. Holcomb, Noriaki Aoki, Ronald Lindsey

Research output: Contribution to journalArticle

59 Citations (Scopus)

Abstract

Background: The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study. Methods: A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed. Results: There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 ± 8.6 days compared with 10.8 ± 8.1 days (p = 0.03). Conclusion: For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.

Original languageEnglish (US)
Pages (from-to)717-721
Number of pages5
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume53
Issue number4
StatePublished - Oct 1 2002
Externally publishedYes

Fingerprint

Gunshot Wounds
Vascular System Injuries
Fracture Fixation
Blood Vessels
Wounds and Injuries
Extremities
Hospitalization
Orthopedics
Brachial Artery
Thigh
Amputation
Upper Extremity
Fasciotomy
Bone and Bones
Incidence

Keywords

  • Fasciotomy
  • Fracture
  • Gunshot wound
  • Limb salvage
  • Vascular injury

ASJC Scopus subject areas

  • Surgery

Cite this

Fractures with major vascular injuries from gunshot wounds : Implications of surgical sequence. / McHenry, Timothy P.; Holcomb, John B.; Aoki, Noriaki; Lindsey, Ronald.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 53, No. 4, 01.10.2002, p. 717-721.

Research output: Contribution to journalArticle

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abstract = "Background: The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study. Methods: A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed. Results: There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80{\%}) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36{\%}) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 ± 8.6 days compared with 10.8 ± 8.1 days (p = 0.03). Conclusion: For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.",
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