Pattern, Management, Results And Complications Of Vascular Injuries Of The Extremities. Report From A Hospital In Jammu

摘要

Vascular injuries of the extremities are a major cause of mortality and morbidity. It is therefore important to diagnose and treat these injuries on an emergency basis. We looked at 34 patients who presented to our department with such injuries and evaluated the results of management. Introduction Major arterial injury can result in disastrous complications ranging from functional disability to death. In the early phases of the Korean war the policay of major arterial ligation resulted in an amputation rate of 60-70%. However with the institution of arterial repair, this rate was considerably reduced.[1] DeBakey et al in 1946 found that arterial injuries resulted in an amputation rate of nearly 75%.[2] Concluding on a depressing note they wrote that ‘no procedure other than ligation is applicable to a majority of vascular injuries’.Although primary repair of acute vascular injuries was performed 200 years ago by Lambert, it became a procedure of choice only in the late 1950s.Pasch et al wrote that a combination of arteriography, fasciotomy, autologous interpositional grafts and completion ateriography can result in salvage rates approaching 100%.[3]Unfortunately the transport rates, theatre facilities and absence of high quality instruments and investigations compounds management of these injuries in the less developed areas of the world. The purpose of this study was to confirm whether these principles of limb salvage in vascular injuries are applicable and reproducible in smaller centers in relatively less developed centers around the world. Material and Methods The study was conducted on 34 patients who presented to the department of orthopaedics, government medical college Jammu.All patients were resuscitated in the emergency department in accordance with the ATLS guidelines. Bleeding was controlled at the outset by applying compression or by clamping the vessels if the local compression was thought to be inadequate. After obtaining history all patients underwent a detailed general physical examination, followed by local examination. Doppler examination of distal pulses was carried out in all the cases.In 33 patients clinical suspicion with Doppler confirmation was enough to warrant a surgical exploration. One patient underwent an arteriography before surgical exploration.All patients underwent surgery within an hour of presentation. In all cases preoperative parenteral antibiotics were combining a third generation cephalosporin and an aminoglycoside were used. In contaminated wounds, metronidazole was added. General, regional or spinal anaesthesia was used depending on the feasibility. The injured vessel was explored and bleeding controlled 2-3 cms from the cut ends facilitating intimal examination. In all cases with associated fractures, fixation was done prior to the commencement of the vascular repair. Proximal and distal clots were removed by a fogarty catheter. Grafts were taken from the sphenous vein when required.Artery repair was done with a continuous fine monofilament 5-0, 6-0 prolene.Open full forearm and leg fasciotomy was done to relieve pressure. The repair was covered with soft tissue.Arterial pulses were monitored by a portable Doppler unit and tissue oxygenation by a pulse oximeter.LMW heparin 2500 daily was given once a day subcutaneously for ten days. This was followed by oral anti platelet drugs for six months. Results The age range of or patients was 7-65 years with an average age of 27.38 years. 30 of the 34 patients were males. 11 cases had suffered the injury in a road traffic accident, 7 due to a firearm, 6 due to a fall, 3 due to a stab, 3 in industrial accidents whileas 4 cases had suffered these injuries iatrogenically. 21 cases had a penetrating trauma.The brachial artery was the most commonly injured artery with 16 patients suffering this injury. 10 patients had a femoral artery involvement. there were 4 axillary, 3 popliteal and 2 posterior tibial injuries.11 cases presented within 6 hours a