Missile-induced vascular trauma

During seven and a half years of serious hostilities amidst the civilian population of Northern Ireland, a wide variety of vascular injuries inflicted by low and high velocity missiles and bomb explosions were observed. One hundred and thirteen patients, 96.5 per cent males of average age 26.8 years, sustained 191 vascular injuries and were treated at the Royal Victoria Hospital. Treatment commenced within one hour in 87 per cent of patients. Reduced limb ischaemia time, early bleeding control and vascular repair with restoration of flow within 6 hours of injury in 94.4 per cent of patients contributed to an excellent result in 85.5 per cent of survivors. Despite rapid admission, the mortality rate within 3 days of injury was 12.4 per cent, these patients sustaining trauma to major vessel trunks and vital organs. Associated nerve injuries (25 per cent) and skeletal injuries (30 per cent) were treated appropriately. A special group of 38 patients were ‘knee-capping’ victims and contributed to the majority of popliteal vessel trauma. A total of 14.9 per cent of primary arterial and 3 per cent of primary venous reconstructions failed due to thrombotic occlusion, but early postoperative revision was successful in every case. The overall amputation rate for lower limb injuries was 6.9 per cent; of these 5 cases, 4 had popliteal vessel injuries, in 2 of which infection (acute clostridial and chronic osteomyelitis) was partly responsible. Significant wound infection was otherwise absent. The pathophysiological aspects pertinent to the range of weaponry and methods of assault are presented. The operative and postoperative management and results are discussed in the light of documented military and civilian experience.