无骨折闭合性四肢主干动脉损伤的早期诊断及治疗

目的研究无骨折闭合性四肢主干动脉损伤的早期诊断和治疗。方法1998年5月一2008年7月,对24例无骨折闭合性四肢主干动脉损伤的患者,在入院后,进行体格检查,结合脉搏血氧饱和度监测仪监测,做出早期诊断,并急诊手术探查,修复损伤动脉。结果23例均一次修复成功,1例术后发生栓塞,术后4h再次探查修复后,动脉获得通畅。术后随访6个月～2年。22例患肢血液循环恢复良好,肢体功能恢复满意。1例经2次手术后,出现中度缺血性肌挛缩,1例合并肘关节半脱位的患者出现轻度肘关节伸直障碍。结论体格检查结合脉搏血氧饱和度监测仪监测,可对无骨折闭合性四肢主干动脉损伤做出早期诊断,及时修复损伤动脉,是挽救受伤肢体,减轻伤残的有效手段。     

Revascularization of the limbs using vein grafts after vascular injuries

We report on 32 patients with vascular injury of a limb undergoing a total of 41 revascularization procedures with interposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated venous injury in four, and an isolated arterial injury in 19 cases. Eighteen per cent of patients with arterial injuries had normal distal pulses on initial examination. Preoperative arteriography was performed in 12 cases, and intraoperative arteriography in four. All venous injuries were diagnosed at operation. In most cases, the contralateral greater saphenous vein was used for grafting. Four patients had postoperative thrombosis after arterial reconstruction resulting in below knee amputation in two cases. Two patients suffered from postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of a superficial femoral vein repair. It is concluded that revascularization of arterial and venous injuries of the extremities with interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in viable limbs.     

Review of intimal arterial injuries. Surgery versus conservative management

This retrospective review was carried out to see if there is any role for selective management for intimal arterial injuries found in the extremities. The study involved retrospective analysis of arterial injuries seen in the extremities during the past four years. A total of 49 vascular injuries were identified which were proved by angiographic finding. There were eight cases which involved intimal injury in the nature of intimal irregularity or a flap seen in the angiogram. Four of these cases were treated surgically. There were four cases treated by conservative follow-up with the patient being placed either on low molecular weight dextran and/or low-dose intravenous heparin if there were no contraindications for the above. All of these patients had a successful outcome with normal angiographic findings of the injured area. The angiograms were done a few weeks following the injuries. The decision to treat conservatively was based on the nature of the injury as well as location of the injury, in one case being the origin of the anterior tibial artery, which is difficult to explore surgically. In conclusion, we believe that in selected instances where there is no distal vascular insufficiency because of the injury or if the patient has a lesion in a surgically difficult area to explore or if there are any other serious life-threatening injuries, the intimal artery injury can be managed conservatively. This also avoids the morbidity and mortality associated with surgical intervention.     

Occult femoral artery injury in relation to fracture of the femoral shaft

Recognized injury of the femoral artery occurs in two per cent of patients with fracture of the femoral shaft. Delay in detection of these arterial injuries has led to unsatisfactory results in a young group of patients. Therefore, 40 patients who had suffered fracture of the femoral shaft 6-20 months (mean 13 months) prior to examination, were haemodynamically assessed using Doppler ankle/arm pressure indices to determine the incidence of occult femoral artery injury. Six patients (15%) exhibited haemodynamically significant abnormalities all in relation to previously injured limbs.     

Results with abdominal vascular trauma in the modern era.

This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.     

Acute penetrating arterial injuries of the forearm. Ligation or repair?

The management of forearm arterial trauma is controversial and follow-up data on such injuries is scant. A survey was made of 249 patients with penetrating forearm trauma to determine the incidence and outcome of arterial injury. Sixty-six patients (26.5%) sustained 69 arterial injuries documented at operation or with angiography. The clinical manifestations of arterial injury were often subtle; 42.4 per cent of the patients had normal pulses and only 7.6 per cent presented with distal ischemia. In 9.1 per cent of the patients there was no clinical evidence of vascular injury. The most frequent types of arterial injury were transection (72.5%) and partial laceration (14.5%). Arterial repair was performed in 84.8 per cent of the cases, and resection with end-to-end anastomosis was usually possible. Volar compartment fasciotomies were necessary in 18.2 per cent of the cases. The early postoperative complications seen were wound-related, and these were six times more frequent in the group undergoing arterial ligation (36% vs 6%). In 49 patients evaluated an average of 6 months after repair, the patency rate determined by clinical examination was 85.7 per cent. Because of a high incidence of associated nerve (56.1%) and tendon (54.5%) injuries, the functional status of the injured extremity was less satisfactory, with only 49.2 per cent of the patients having normal hand function. Since the forearm vessels can be repaired with minimal morbidity and acceptable results, arterial ligation is recommended only when repair is not readily accomplished, or when treatment of a more pressing associated injury demands priority.     

Civilian arterial trauma of the upper extremity: An 11 year experience in 267 patients

Two hundred ninety-eight arterial injuries in 269 upper extremities were reviewed. Penetrating agents accounted for 250 injuries (93 percent) and blunt trauma for 19 (7 percent). Fifty-nine axillary, 126 brachial, 65 radial, and 48 ulnar arteries were damaged. Twenty-six extremities had more than one artery injured. The initial vascular examination revealed no abnormalities or was equivocal in 16 percent of all patients and in 32 percent of those with axillary artery injuries. Adjacent upper extremity structures were injured in 195 limbs (73 percent).Resection and primary anastomosis (54 percent) or vein interposition grafting (26 percent) were the most frequent methods of repair. Two deaths (0.7 percent) occurred and four amputations (1.5 percent) were required. Distal pulses were present at discharge in 93 percent of the evaluable extremities. Despite excellent success with arterial reconstruction, functional results were limited by associated nerve injuries. One hundred fifty patients (49 percent) had nerve deficits at discharge, and 71 (27 percent) had serious functional limitations.     

Subclavian vascular injuries

This study comprises 228 patients with penetrating injuries of the subclavian vessels. The vein alone was involved in 44 per cent, the artery alone in 39 per cent, and both vessels in 17 per cent. The majority of the victims (61 per cent) did not reach the hospital alive, and in those who were operated on the mortality was 15.5 per cent (overall mortality 66 per cent). The overall mortality of venous injuries was significantly higher than the arterial ones (P less than 0.01), probably because of the dangerous complication of air embolism. Physical examination is reliable in the diagnosis of these injuries and there is no need for an emergency angiogram. The clavicular incision was the preferred approach. Repair was performed in 94 per cent of those with arterial injury. Vein injuries were treated by suture in 60 per cent and ligation in 40 per cent. A selective conservative approach is advised.     

Priorities in diagnosis and treatment of blunt chest injuries

The evaluation of thoracic injuries is only one aspect of the total assessment of a severely injured patient. In a series of 675 hospitalized patients, blunt chest injury was associated with craniocerebral injury in 55 per cent, with abdominal injuries in 20 per cent and with fractures of the extremities in 38 per cent. Both diagnostic and therapeutic procedures go hand in hand. Immediately life-threatening situations (hypovolaemia, respiratory insufficiency, tension pneumothorax and cardiac tamponade) should be diagnosed by clinical signs and treated before radiographs are taken. The chest radiograph is the basic tool for diagnosis of thoracic injuries, although it will not reveal a possible impairment of lung function. Special attention should be paid, and further evaluation is necessary, in suspected rupture of the diaphragm (present in 4 per cent), rupture of the aorta (2 per cent), bronchial rupture (0.5 per cent) and cardiac contusion (16 per cent). Most blunt thoracic injuries can be treated adequately by intercostal tube drainage. Operative intervention has been found necessary in 8 per cent of cases. Indications for thoracotomy are clearly defined.     

Electrical injury of wrist: classification and treatment - clinical analysis of 90 cases

Between January 1980 and December 1989, a prospective study was carried out on 114 upper limbs in 90 patients, which were electrically burned with the wrist as the current entrance site. Based upon extensive clinical investigations of arterial injury and its adverse effect on hand circulation, a grading system is suggested for electrically injured wrists based on the severity of injury. The total amputation rate was 39.4 per cent in this group, which was composed of miscellaneous cases with various injuries. However, in subgroups of Type I to Type IV, the amputation rates were 0, 0, 80 and 100 per cent, respectively. A new method to repair the circumferential wound of an electrically burned wrist as well as to bypass the blood flow to the obstructed hand, using a pedicled greater omentum transfer and vascular anastomosis between gastroepiploic artery and the palmar artery, was successfully used in a Type III case.     

Traumatic vascular injuries: Methods and results of repair

An analysis of thirty-six civilian traumatic arterial injuries was performed to determine the frequency, site, and mechanism of injury. The mechanism of injury was evenly divided between penetrating (nineteen) and blunt injuries (seventeen). Blunt trauma from motor vehicle accidents and penetrating injuries from gunshot wounds accounted for approximately 85 per cent of the injuries. Four of fifteen repairs in lower extremity arterial injuries resulted in amputation. Prolonged ischemia and massive soft tissue injury were the major causes of amputation. Eleven upper extremity arterial injuries were repaired with return of distal pulses in ten patients whereas one patient required subclavian artery ligation after rupture of a saphenous vein graft repair. Approaches for exposure, means of repair, and results are discussed.     

Dislocation of the knee

The complications of knee dislocations may be disastrous and must be anticipated. In most series, a 25 to 30 per cent incidence of arterial damage is reported. If the artery is not repaired, the incidence of amputation can be up to 72.5 per cent. The popliteal artery should be evaluated and vascular repair performed as needed. This must be completed within a 6 to 8-hour period after injury for optimal results. Peroneal nerve injuries are common, and permanent neurologic damage may result. The neurovascular injury should be well documented both at the time of injury and in the preinjury state. After all problems affecting limb survival are solved, open repair of all ligamentous injuries is recommended to provide ligamentous stability and congruity of the joint. Prior to performing the procedure, a surgeon must have a thorough knowledge of the anatomy of the knee. Rehabilitation techniques and early postoperative motion are important for guiding the injured patient through the immediate and late postoperative period.     

Accidental falls using ladders leaning against a wall. A study of 266 cases in relation to the cause of the accident, sequelae and prevention

Falling accidents rank high on the list of industrial accidents in the building industry, accounting for 5.6 per cent (2) of allnotifiable cases. Studies were conducted into 266 falling accidents from lean-to-wall ladders, with age, trade, time of accident, cause of accident, and consequences being separately analysed. More than 50 per cent of all falling accidents occurred to workers while they were climbing ladders. Slight injuries accounted for 60.5 per cent, moderate injuries for 32.7 per cent, and severe injuries for 6.8 per cent. The falling depths of 79 per cent were between 0.3 m and 1.99 m. Lower extremities were primarily affected by distortion or dislocation, while upper extremities were more often injured by fractures. Non-compliance with safety rules was the most common single cause.     

Vascular injuries to the extremities in a suburban trauma center

The purpose of this study was to examine the experience with extremity vascular injuries of a level II suburban trauma center. A retrospective chart review was undertaken to include all patients admitted in a 6-year period with vascular injuries to the extremities. The vessels injured were identified along with the mechanism of injury. The method of repair was recorded. All associated neurologic injuries were investigated. Follow-up records, when available, were reviewed. Between January 1, 1996, and November 30, 2002, 48 patients were admitted with 56 vascular injuries to the extremities. Blunt trauma was the mechanism in 24 patients while penetrating trauma was the mechanism in the other 24 patients. The limb salvage rate was 95 per cent. Of the 28 injuries to upper extremity vessels, 24 were associated with neurologic injuries. In contrast, only 3 neurologic injuries were found in patients with lower extremity vascular injuries. In contrast to most urban centers, the distribution of vascular injuries to the extremities in a suburban setting was equally divided between blunt and penetrating injuries. The majority of functional impairment was related to neurologic injury rather than tissue ischemia from vascular injury.     

The role of contrast arteriography in suspected arterial injuries of the extremities

The records of 215 patients presenting with 218 penetrating or blunt injuries to the extremities from 1977 through 1983 have been reviewed. All patients presenting with pulsatile hemorrhage, expanding hematoma, or absent distal pulses were explored immediately. Patients with injuries in close proximity to a major artery but without classical signs of arterial injury were explored routinely from 1977 through 1980. Thereafter, similar patients were evaluated initially with contrast arteriography and explored only if arteriographic abnormalities suggested arterial injury. Routine exploration of proximity injuries has been compared with selective exploration based on contrast arteriography. Sixty-one patients (group 1) underwent routine exploration for proximity injuries. Vascular injuries were detected in ten (16%) patients, while 51 (84%) of the explorations were negative. Eighty-four patients (group 2) with proximity injuries were studied arteriographically. Ten patients (11.9%) were explored on the basis of abnormal arteriograms, and eight arterial injuries were confirmed. Two (2.4%) of the 84 patients in this group had negative explorations. The use of contrast arteriography enabled the authors to reduce their negative exploration rate from 84 to 2.4 per cent in the management of proximity injuries.     

Blunt trauma of the diaphragm: a 15-county, private hospital experience.

During a 6-year period, 52 patients with nonpenetrating trauma to the diaphragm were treated in eight acute care hospitals, serving a 15-county area of Michigan. Charts were reviewed to identify patterns of injury, treatment, and outcome. Preoperative diagnosis was made in 50 per cent of cases based on chest x-ray findings; the remainder were diagnosed intraoperatively. Clinical examination revealed respiratory distress, decreased breath sounds, or elevated hemidiaphragm in 81 per cent of patients. Forty-two per cent of patients sustained significant head injuries. Fractures were present in 75 per cent of patients. Major chest injury was found in 92 per cent. Intra-abdominal organs were herniated in 67 per cent of cases with the stomach being most common (54%). The spleen was the most commonly injured abdominal organ (60%). The left diaphragm was injured in 75 per cent of cases; 2 per cent were bilateral. The most common postoperative complication was pneumonia. Mortality in this series was 13 per cent, with no case being related to the diaphragmatic injury. The authors conclude that blunt injuries to the diaphragm in the multiply-injured patient present a clinical diagnostic challenge requiring a high index of suspicion. Optimal care requires a multi-disciplinary critical care team to manage the high incidence of associated central nervous system, orthopedic, and chest injuries and associated high mortality rates.     

无伴行动脉损伤的肢体静脉干损伤的修复

目的探讨无伴行动脉损伤的肢体静脉干损伤的机制,以及诊断、救治和修复方法. 方法 1993年1月～2002年6月共收治12例患者,均为男性,年龄18～35岁.受伤至手术时间30 min～2 h.均为锐器刺伤.在积极抗休克的同时进行血管修补7例,端端吻合5例.合并头颅胸腹部损伤患者同时给予相应手术处理. 结果除1例患者因严重的脑外伤死亡外,余11例患者伤口均Ⅰ期愈合.随访1～5年,平均2年4个月,彩色多普勒检查见血流通畅,无血栓形成.其中8例肢体功能和血循环恢复良好;3例合并伴行神经损伤者血循环恢复良好,但肢体功能恢复欠佳,遗留感觉及运动障碍. 结论无伴行动脉损伤的肢体静脉干损伤是一种严重的损伤,采取应急止血、积极抗休克、及早修复损伤血管和合理处理合并伤等是挽救患者生命的重要措施.     

Management of Gulf War casualties.

During the Gulf War 84 patients underwent surgery in the Jubail Armed Forces Hospital, Saudi Arabia. The median time to evacuate casualties to hospital was 8 h 40 min. Fragments caused 88 per cent of injuries; 11 per cent were caused by bullets. Multiple lesions were encountered in 70 per cent of patients. The extremities (76 per cent) were the most frequently injured site, the lower limbs more so than the upper. Soft tissue injuries prevailed (59 per cent).     

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.     

A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.