import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Vascular Assessment Vascular assessment is essential before and after any orthopaedic intervention. Examiners expect you to systematically assess peripheral pulses, recognize signs of compartment syndrome, and understand the urgency of vascular compromise. "Pulseless and pink" does NOT exclude ischemia. ## Quick Reference One-Pager ## Peripheral Pulse Examination **Brachial Artery:** - Location: Medial to biceps tendon in antecubital fossa - Palpate: With fingers in medial bicipital groove - Used for: Blood pressure measurement **Radial Artery:** - Location: Lateral wrist, just medial to radial styloid - Palpate: Two fingers, press against radius - Most commonly assessed upper limb pulse **Ulnar Artery:** - Location: Medial wrist, lateral to FCU tendon - Palpate: May be harder to feel than radial - Important to assess before radial artery cannulation **Femoral Artery:** - Location: Below inguinal ligament, midway between ASIS and pubic symphysis - Palpate: Use 2-3 fingers, firm pressure - May be only palpable pulse in shock **Popliteal Artery:** - Location: Posterior knee, between heads of gastrocnemius - Technique: Knee slightly flexed, fingers wrap around knee - Hardest pulse to palpate (deep) **Dorsalis Pedis Artery:** - Location: Dorsum of foot, lateral to EHL tendon - Palpate: At level of 1st/2nd metatarsal base - Congenitally absent in 10% (check PT instead) **Posterior Tibial Artery:** - Location: Behind and below medial malleolus - Palpate: In groove between malleolus and Achilles - Reliable landmark, less anatomic variation ## Capillary Refill **Technique:** - Press nail bed for 5 seconds - Release and count seconds to return of color - Compare sides **Normal:** - Less than 2 seconds (some say less than 3) **Prolonged (greater than 2-3 seconds):** - Arterial insufficiency - Peripheral vasoconstriction (cold, shock) - Venous congestion **Caution:** - Affected by temperature - Less reliable in cold environment - Compare with opposite side ## Signs of Vascular Compromise **Acute Arterial Occlusion (6 Ps):** - **Pain**: Severe, out of proportion - **Pallor**: Pale/white limb - **Pulselessness**: Absent distal pulses - **Perishing cold**: Cold to touch - **Paresthesia**: Numbness/tingling - **Paralysis**: Late sign, ischemic muscle **Chronic Arterial Disease:** - Intermittent claudication - Rest pain (severe) - Trophic changes (hair loss, shiny skin) - Ulceration (punched out, painful) - Dependent rubor, elevation pallor **Acute Venous Occlusion (DVT):** - Swelling (unilateral leg) - Pain (calf) - Warmth - Distended veins - Homan's sign (unreliable) **Chronic Venous Disease:** - Varicose veins - Edema (pitting) - Skin changes (hemosiderin) - Lipodermatosclerosis - Venous ulcers (medial malleolus) **Limb-Threatening Ischemia:** Signs requiring URGENT intervention: 1. **Pulseless** limb (complete occlusion) 2. **Paralysis** (muscle ischemia) 3. **Poikilothermia** (cold, color change) 4. **Paresthesia** progressing to **anesthesia** **Time is muscle!** - 6 hours to irreversible damage ## Compartment Syndrome **Definition:** Increased pressure within a closed fascial compartment compromising tissue perfusion. **Causes:** - Fractures (tibial shaft, forearm) - Crush injury - Tight casts/dressings - Reperfusion injury - Burns - Bleeding disorders **Classic Presentation:** - Pain out of proportion to injury - Pain on passive stretch of muscles in compartment - Tense, swollen compartment - Paresthesia (nerve ischemia) - Paralysis (late - muscle death) - Pulselessness (very late - doesn't exclude diagnosis) **Compartment Syndrome - Key Points:** 1. **Pain on passive stretch** is the most sensitive early sign 2. **Presence of pulses does NOT exclude compartment syndrome** 3. **Clinical diagnosis** - don't wait for pressure measurement if obvious 4. **Treatment**: Emergency fasciotomy 5. **Pressure threshold**: Greater than 30mmHg or within 30mmHg of diastolic **In unconscious/intubated patients:** Rely on pressure measurement **Four Compartments:** 1. **Anterior Compartment:** - Contents: Tibialis anterior, EHL, EDL, deep peroneal nerve - Test: Passive plantarflexion of ankle/toes - Signs: Foot drop, first web space numbness 2. **Lateral Compartment:** - Contents: Peroneus longus and brevis, superficial peroneal nerve - Test: Passive inversion - Signs: Weak eversion, lateral dorsum numbness 3. **Deep Posterior Compartment:** - Contents: FHL, FDL, tibialis posterior, tibial nerve/vessels - Test: Passive dorsiflexion of toes - Signs: Weak toe flexion, sole numbness 4. **Superficial Posterior Compartment:** - Contents: Gastrocnemius, soleus, sural nerve - Test: Passive dorsiflexion of ankle - Signs: Weak plantarflexion ## Trauma Vascular Assessment **Before Any Intervention:** 1. Document pulses (present/absent) 2. Document capillary refill 3. Document motor function 4. Document sensory function 5. Compare with other side 6. Document time of assessment **After Intervention:** - Repeat and document all findings - Compare with pre-intervention - Note any changes **Hard Signs of Vascular Injury:** - Pulseless limb - Active hemorrhage - Expanding hematoma - Bruit or thrill - Distal ischemia (6 Ps) **Soft Signs:** - History of hemorrhage - Small hematoma - Reduced but palpable pulse - Neurological deficit **Supracondylar Fracture (Pediatric):** - Brachial artery at risk - Check radial pulse - Volkmann's ischemic contracture if missed **Knee Dislocation:** - Popliteal artery at risk (40% injury rate) - MUST have angiography even if pulse present - Intimal tear may present delayed **Tibial Fracture:** - Compartment syndrome common - Serial examinations essential - Low threshold for fasciotomy **Femoral Shaft Fracture:** - Blood loss (1-2L into thigh) - Femoral artery can be injured - Compartment syndrome of thigh possible ## Ankle-Brachial Index (ABI) **Technique:** - Measure systolic BP at ankle (dorsalis pedis or posterior tibial) - Measure systolic BP at brachial artery - Calculate: ABI = Ankle BP ÷ Brachial BP **Interpretation:** | ABI | Interpretation | |-----|----------------| | Greater than 1.0 | Normal | | 0.9-1.0 | Acceptable | | 0.6-0.9 | Claudication likely | | 0.4-0.6 | Rest pain likely | | Less than 0.4 | Severe, critical limb ischemia | | Greater than 1.3 | Calcified vessels (diabetic) | **Use:** - Pre-operative assessment - Peripheral arterial disease assessment - Monitor perfusion after intervention ## Summary Presentation ## Examination Sequence 1. **Inspection**: Color, swelling, wounds, deformity 2. **Pulses**: All palpable pulses, compare sides 3. **Capillary refill**: Nail beds, compare sides 4. **Temperature**: Gradient, compare sides 5. **Compartments**: Palpate for tension 6. **Passive stretch**: Each compartment 7. **Sensory**: Nerve territories 8. **Motor**: Key movements 9. **Document**: Time, findings, comparison 10. **Re-examine**: Serial if any concern ## Examiner Tips