– ischemia time of 6 hours is the cutoff: most limbs can be salvaged if revascularization occurs before this; after 8 hours, the amputation rate is between 72% and 90%
– intimal tear with subsequent development of thrombosis can lead to a picture of palpable pulses initially that disappear (delayed loss of pulse)
– children are particularly prone to ischemia and gangrene due to arterial spasm, a rare problem in adults.
Any diminution of pulse, even if the pulse is detectable by Doppler testing, pressure, or palpation,
should be considered abnormal.
– all major arterial injuries should be repaired; venous injuries are controversial
– autogenos vein grafting is preferred
– surgical shortening of the bone may facilitate vascular repair, and leg length can be dealt with later
– ideally, fracture stabilization should precede vascular repair – may require temporary shunting; this needs to be decided upon by the surgeons
– prophylactic fasciotomy is a good thing!
Doing angiography: the question of whether to do angiography or not depends on the perfusion status of the limb.
– If the limb is perfused adequately, and there is no rush to stabilize the bone, then do the angiogram
– If the limb is white and non-perfused, then you may as well assume the injury to the artery is at the level of the fracture and just get on with exposing it.
– If the limb is broken at a number of levels and you are unsure where the injury is, get the angio.
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