Vascular Assessment

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

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

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)

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

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

Technique:

• Measure systolic BP at ankle (dorsalis pedis or posterior tibial)
• Measure systolic BP at brachial artery
• Calculate: ABI = Ankle BP ÷ Brachial BP

Interpretation:

Use:

• Pre-operative assessment
• Peripheral arterial disease assessment
• Monitor perfusion after intervention

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