Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

 

Injuries to extremities are often accompanied by vascular complications. The rates of vascular injuries vary both in war and peace time (0.2-4 % of all injured victims) [1, 2, 3, 4]. During the last years one can observe significant increase in number of injuries accompanied by magistral arterial injuries. According to the data, the rates of such injuries increased 2-3 times for the past decade [5]. Magistral arterial injuries are characterized with variability of locations and extension depending on application site and force of an injuring factor. They relate to severe injuries because of high frequency of local and general complications (15.4-48.4 %) [6].

In closed and opened vascular injuries the changes in injured arteries differ from each other significantly. Opened vascular injuries are accompanied by bleeding, hemorrhage-associated increasing anemia and usually diagnosed at prehospital stage [1]. In closed vascular injuries the clinical signs are less common; therefore, diagnostic difficulties are possible. Closed injury causes injuries to magistral vessels (6.8-50 %) [7, 8].

In case of the least suspicion of magistral arterial injury it is necessary to perform angiography or ultrasonic examination [1, 9, 10]. However angiography (despite its high information capacity) is still performed in big clinics, and it is not available everywhere. Ultrasound techniques with blood flow color mapping became widely spread. Duplex scanning (DS) of vessels is a routine, available, informative and safe technique in most clinics at the present time. DS is especially irreplaceable in closed vascular injury diagnostics in both acute and remote periods [9, 10].

In closed injuries with influence of significant forces the arterial wall ruptures are possible, with their direction from intima towards adventitia (more solid layer). Injuries can affect all layers or be limited only with intima detachment. In cases of full arterial wall rupture and disruption of the branches, acute blood loss develops and hematoma appears (pulsating and non-pulsating). Commonly, diagnostics of arterial ruptures in bleeding, hematoma or acute ischemia is realized without difficulties. However some arterial injuries are accompanied with non-apparent clinical manifestations and can be not identified timely in severe injuries to extremities. Shock develops after articular and nerve injuries, and bone fractures. Shock worsens severity of state in patients and disguises acute ischemia in extremities [1, 9]. Severe injury can be accompanied by arterial spasm in view of extremity ischemia. In different situations it is important to identify a cause of ischemia for timely adequate aid.

The research objective is the analysis of possible difficulties in diagnostics of arterial injuries in closed trauma on the example of several clinical cases.

Clinical case #1

Insignificant intima ruptures cause local detachment and clot formation. Parietal thrombus can be not identified in case of insignificant disorder of arterial patency. It is associated with long term absence of clinical manifestations. We observed the case of the abdominal aorta traumatic injury.

The patient, age of 69, with road traffic injury, was admitted to the traumatology department with diagnosis: closed, non-complicated, stable fracture of ThX2, L1 and L2 vertebral bodies; fractured transverse process of ThX2 to the left; closed fracture of transverse processes in L1 and L2; heart contusion. Bed rest continued for two weeks. There were no clinical manifestations of vascular injuries and signs of ischemia in extremities. After the patient got to her feet, the immediate sharp pain in lower abdomen and the lower extremities appeared, as well as sudden coldness and paleness in both legs. The suspicion was related to dissecting aneurism in the aortic abdominal part. Aortic DS was immediately carried out.

During ultrasound examination an aortic extension was not found. The aorta diameter was 1.6 cm along the entire length. The hypoechogenic homogenous masses narrowing artery opening were visualized in the aorta opening below the region of origin of the renal arteries. In the color mapping mode one could observe harsh disconnection in blood flow. Aortic patency was satisfactory in the region above the clot. The blood flow was characterized with magistral type in the aorta, the upper mesenterial artery, celiac artery and the renal arteries. Blood flow was absent in the iliac arteries, but the arterial opening was free of thrombotic masses (Fig. 1, 2).

Figure 1 The abdominal aorta. Thrombotic occlusive mass in the aorta opening. Distal origin of the superior mesenteric artery (SMA)

Figure 2 Aorta cross-section. Occlusive mass in the aorta opening. Preserved perfusion in the superior mesenteric artery (SMA) and in the inferior vena cava (IVC)

                   

The emergent surgical intervention included thrombectomy from abdominal part of the aorta. Blood flow restored completely in the aorta and the extremities (Fig. 3).

Figure 3

The abdominal aorta, bifurcation region. The patency is established completely

Therefore, after spinal fracture the same aortic and intima injuries appeared. As result, the parietal thrombus developed. During the bed rest the non-occlusive aortic clot did not have significant influence on patency and did not cause ischemia. Therefore, a vascular complication was not found in proper time. After permitting the vertical position and increasing intraabdominal pressure the thrombus detachment from the aortic wall and its penetration into bifurcation regions with aortic opening occlusion and acute ischemia in both extremities appeared. DS allowed identifying character of aortic injury and the volume of surgical intervention.

Clinical case #2

Commonly, acute occlusive arterial thrombosis is characterized with apparent clinical manifestations and low rate of non-detection. However severe patient’s state is a possible cause of mistake or late diagnostics.

The patient with polytrauma, closed femoral fracture and closed comminuted fractures of both bones of the left leg was transferred from other city on the second day after the trauma. Aside from significant edema, the leg was cold and pale. Emergent DS was performed for estimating characteristics of vascular injuries. The significant changes were observed in tissues around the vascular bundle in the popliteal region. Hypoechogenic formation without clear borders was visualized. The popliteal artery was patent. The color mapping mode showed sharp color disconnection before posterior tibial artery mouth. The hypoechoic homogenous thrombotic masses were identified in the proximal posterior tibial artery; blood flow was absent (Fig. 4). The conclusion was made about popliteal artery injury with formation of an extensive hematoma in the popliteal region and thrombosis in the posterior tibial artery at the level of its mouth.

Figure 4

Occlusive thrombotic mass in the mouth of posterior tibial artery

The posterior tibial artery lumen narrowed sharply in the middle and distal one-third of the leg. Low amplitude flow of collateral type was identified in the lumen, i.e. arterial patency presented under the level of thrombosis. Segmentary arterial spasm was identified.

During emergency surgical intervention a big tension hematoma was found. It developed as result of bordering injury to the popliteal artery and it compressed the posterior tibial artery at the level of the upper one-third. Thrombectomy was performed, as well as suturing the popliteal artery, hematoma removal and arterial compression correction. The extremity blood flow was restored.

In this case the popliteal artery injury was not diagnosed in the level I hospital. The apparent edema in the injured extremity and severe general state of the patient resulted in underestimation of vascular injury severity. It is possible that the degree of ischemia was increasing during 24 hours as result of persistent bleeding and increasing hematoma size; tibial artery compression was likely not an immediate event. Absence of adequate timely assistance could result in irreversible changes and extremity loss. DS evaluated the level, characteristics and the volume of the arterial injury.

Clinical case #3

Subadventitious aneurysm develops as result of intima and tunica media rupture. Disordered integrity in all coats of arterial vessels results in significant bleeding to surrounding tissues and development of pulsating hematoma. Later it resulted in traumatic aneurism.

The figure 5 demonstrates a sonogram demonstrating a comminuted fracture of the femoral bone. The patient was operated because of the fracture. Planned DS was carried out for exclusion of venous thrombotic complications. The examination found a femoral arterial aneurysm (pulsating hematoma), which developed as result of a boundary injury to the femoral artery with a bone fragment. A non-significant injury to the arterial wall was found during surgical intervention for the fracture. Subsequently, a false aneurism with rapid turbulent stream in the aneurism opening developed.

Figure 5

Pseudoaneurism (pulsating hematoma) of the superficial femoral artery (SFA)

There are no clinical manifestations in case of little size of such aneurisms. The danger is development of sudden massive hemorrhage. Surgical assistance was realized timely after identification of the vascular complication with DS technique.

Clinical case #4

Significant arterial spasm is a specific complication of severe non-penetrating arterial injury. It caused by reflectory response to pain syndrome. The degree of manifestation is different. Often it is accompanied by limb ischemia. In such cases, DS allows to exclude presence of anatomic arterial injury requiring emergent surgical intervention and to confirm spasm, i.e. irreversible changes.

The patient K., age of 37, was admitted to the clinic several hours after the road traffic accident. The diagnosis was: polytrauma; closed complicated fracture of 1^st, 2^nd, 3d, 9^th and 10^th ribs to the left; bilateral minimal hydrothorax; minimal hydrothorax to the left; left lung contusion; respiratory distress syndrome of degree 1-2; closed lateral fracture of sacrum to the left; intrapelvic retroperitoneal hematoma; closed intraarticular comminuted fracture of both legs in proximal one-third; mild cerebral contusion; cardiac contusion; traumatic shock of degree 2.

After the realized emergent surgery the patient was transferred to the ICU. During the follow-up the suspicion of possible vascular complications appeared. The extremities were cold by touch. Arterial pulsation was not palpated in the malleolar region and in the back of the foot.

The examination identified changes in the veins and the arteries in both extremities (Fig. 6, 7). The superficial femoral arteries demonstrated significant bilateral narrowing (up to 2.5-3.5 mm). The arterial wall was thick (1.4-1.6 mm) with persistent differentiation into layers. The popliteal and leg arteries showed homogenous narrowing. However the magistral type blood flow persisted (with low rate and high resistance index). The movable small clots were identified in the superficial femoral veins on both sides.

Figure 6 The superficial femoral artery (SFA) of the left lower extremity, the diameter of 3.4 mm. In the superficial femoral artery the small segmentary unsmooth clot is visualized

Figure 7 The superficial femoral artery of the right lower extremity (diameter of 2.3 mm). The narrow mobile clot is visualized in the opening of the superficial femoral vein (SFV) below the ostial valve cusps

     

The arterial changes were caused by apparent arterial spasm in both lower extremities at the background of traumatic shock, i.e. they had functional characteristics confirmed by the dynamic examination one week later (Fig. 8, 9). The repetitive bilateral DS showed increasing diameters for all limb arteries and decreasing arterial wall thickness. The arterial lumen increased more than two times. The lineal and volumetric blood flow values normalized. Venous thrombosis demonstrated significant progression on both sides.

Figure 8 The diameter of the superficial femoral artery (SFA) of the left lower extremity is 7.5 mm. Progressing venous thrombosis of the superficial femoral vein (SFV), fixation of the moving element of the clot

Figure 9 The diameter of the superficial femoral artery (SFA) of the right lower extremity is 6.1 mm. Extensive ascendant occlusive thrombosis of the superficial femoral vein (SFV)

    

The signs of evident arterial spasm in such big arteries were very rare in the patients with severe trauma.

Mainly, in acute trauma period, spasm state is associated with leg arteries in view of diffuse luminal narrowing, decreasing lineal systolic rate during persistent blood flow of magistral type. One should remember about a possibility of such vascular response to prevent incorrect interpretation of identified ultrasonic changes.

 

CONCLUSION      

Diagnostic difficulties relating to injured arteries can develop in severe general state of the patient, when clinical signs of ischemia are absent. Local intima injuries with non-occlusive clot formation are not diagnosed because of clinical manifestations. There is a danger of late identification of arterial injury with gradual development of compression and late development of pseudoaneurism. Almost 20 year experience with duplex scanning for diagnosing vascular complications in patients with polytrauma slows recommending this technique as an obligatory procedure for closed injuries to extremities.