Vascular Injury With Fracture or Dislocation
Perfusion | Reduction | ABI/API | CTA | Fixation sequence | Fasciotomy
Immediate Working Categories
Critical Must-Knows
- Vascular injury is diagnosed by limb behaviour, not by X-ray severity alone. A spontaneously reduced knee dislocation can still have popliteal artery injury.
- Hard signs need urgent vascular control. CTA is for patients stable enough for imaging and where imaging will change management.
- ABI/API is a screening tool, not a replacement for clinical judgement. An abnormal or unreliable result prompts vascular imaging or operative assessment.
- Reduction can be limb-saving. A gross dislocation with threatened perfusion should be reduced urgently, with neurovascular status documented before and after.
- The orthopaedic sequence protects the vascular repair. Use rapid external fixation, definitive fixation or a temporary shunt depending ischaemia time and skeletal instability.
- Fasciotomy risk rises after ischaemia and reperfusion. Do not wait for late pulse loss before treating compartment syndrome.
Clinical Pearls
- "The safe first sentence is: assess the patient, control bleeding, document neurovascular status, reduce gross dislocation if limb threatened, then screen with ABI/API or CTA as appropriate.
- "Normal palpable pulses do not end the assessment when mechanism and examination are concerning.
- "Temporary shunting is not definitive repair; it is damage-control perfusion while the patient, skeleton or transfer pathway is made safe.
- "A technically patent artery does not guarantee limb salvage if muscle, nerve, bone and soft tissue are not viable.
Immediate Safety Rule
Do not send an ischaemic limb for routine imaging without a vascular plan. If there are hard signs or a cold pulseless limb after reduction, haemorrhage control and revascularisation take priority.
At a Glance: What Changes Management?
| Question | Finding That Matters | Action |
|---|---|---|
| Is the patient unstable? | Shock, uncontrolled haemorrhage, multiple trauma or threatened airway. | Primary survey, haemorrhage control and damage-control decision-making. |
| Is the limb ischaemic? | Cold, pale, pulseless, painful limb; absent Doppler; motor or sensory deterioration. | Urgent vascular involvement and reperfusion pathway. |
| Is there a gross dislocation? | Knee, ankle, elbow or shoulder deformity with threatened perfusion. | Reduce urgently, document neurovascular status before and after. |
| Are hard vascular signs present? | Active bleeding, expanding haematoma, bruit, thrill or absent pulse. | Vascular team and theatre; imaging only if it will not delay needed control. |
| No hard signs but concern remains? | Soft signs, proximity wound, high-risk fracture pattern or pulse asymmetry. | ABI/API, duplex or CTA depending reliability and local pathway. |
| Is the skeleton unstable? | Fracture-dislocation that will kink, stretch or disrupt repair. | Rapid external fixation, definitive fixation if fast and safe, or temporary shunt. |
Rapid Recall
FLOWInitial Priorities | ABIScreening Logic | SHUNTTemporary Shunt Use |
|---|---|---|
F Find hard signs Bleeding, expanding haematoma, bruit, thrill, absent pulse, ischaemia. | A Above 0.9 Serial examinations if the clinical picture is reliable. | S Severe combined injury Vessel and bone both need urgent attention. |
L Limb reduction Reduce gross dislocation if perfusion is threatened. | B Borderline or abnormal CTA or vascular imaging when stable. | H Haemodynamic damage control Shorten ischaemia while physiology is corrected. |
O Orthopaedic stability Stabilise bone when it protects vascular repair. | I Imaging not for hard signs Do not delay theatre for obvious limb-threatening arterial injury. | U Unstable skeleton Allows skeletal stabilisation before definitive repair. |
W Watch compartments Serial checks after injury, repair and reperfusion. | N Need transfer Restores flow while moving to definitive expertise. | |
T Time critical Use when definitive repair cannot be done immediately. | ||
The limb needs flow before finesse. | ABI/API is a gate, not the whole answer. | A shunt buys perfusion time. |
The limb needs flow before finesse.
ABI/API is a gate, not the whole answer.
A shunt buys perfusion time.
Overview and Epidemiology
Vascular injury associated with a fracture or dislocation is a limb-threatening trauma problem. The orthopaedic surgeon is often the first clinician to recognise the pattern because the vessel injury is hidden behind a dramatic fracture, a reduced dislocation, or an apparently normal pulse.
The common clinical settings are:
- knee dislocation and high-energy tibial plateau fracture with popliteal artery risk
- elbow fracture-dislocation or paediatric supracondylar fracture with brachial artery risk
- shoulder dislocation or proximal humeral fracture, especially in older patients, with axillary artery risk
- pelvic, acetabular, femoral and tibial trauma with major haemorrhage or limb ischaemia
- open fracture, crush injury, blast injury or ballistic trauma with arterial disruption
- iatrogenic injury during fixation, arthroplasty, deformity correction or revision surgery
Core Principle
Treat vascular injury as a sequence problem: resuscitate, control haemorrhage, restore or preserve perfusion, stabilise the skeleton when it protects the repair, and monitor for reperfusion and compartment complications.
Anatomy and Biomechanics
Why fracture-dislocations injure vessels
Vessels are injured by stretch, compression, transection, intimal disruption, thrombosis, spasm or entrapment. A dislocation can tear the artery during the injury, while a fracture spike can lacerate or tent the vessel. Reduction may restore flow, but it can also reveal an intimal injury that later thromboses.
Tethered vessels are vulnerable
- The popliteal artery is relatively tethered around the adductor hiatus and soleus arch, so knee dislocation and plateau fracture patterns can stretch or disrupt it.
- The brachial artery crosses the elbow anteriorly and is vulnerable in supracondylar fracture, elbow dislocation and distal humerus trauma.
- The axillary artery is at risk in shoulder dislocation, proximal humeral fracture and traction injuries around the shoulder girdle.
- The femoral and iliac vessels are at risk in pelvic, acetabular and proximal femoral trauma, especially when haemorrhage is the dominant problem.
Pulse physiology trap
Palpable pulses may persist because of collateral flow, partial injury, vasospasm resolution, or an intimal flap that has not yet thrombosed. A normal pulse is reassuring only when it fits with a normal examination, normal ABI/API and a low-risk mechanism.
Mechanism of Injury
Mechanism helps determine the probability and type of vascular injury.
Mechanism and Vascular Behaviour
| Mechanism | Likely Vessel Problem | Orthopaedic Implication |
|---|---|---|
| Dislocation | Stretch, intimal tear, thrombosis or complete rupture. | Reduce urgently if perfusion is threatened; reassess pulse and Doppler after reduction. |
| High-energy fracture | Laceration by spike, segmental vessel injury, crush or thrombosis. | CTA or direct vascular assessment if abnormal examination or high-risk pattern. |
| Open fracture or ballistic injury | Transection, partial laceration, contamination and compartment risk. | Control bleeding, antibiotics, debridement, fixation and vascular plan. |
| Crush injury | Vascular disruption plus muscle necrosis and reperfusion injury. | Low threshold for fasciotomy and metabolic monitoring. |
| Low-energy shoulder dislocation in older patient | Axillary artery injury from atherosclerotic or fragile vessel stretch. | Check pulse before and after reduction; consider CTA with haematoma or pulse change. |
| Iatrogenic injury | Drill, screw, retractor, saw, osteotome or implant-related injury. | Recognise immediately; control bleeding; call vascular help early. |
Classification Systems
Classify vascular injury in terms that change treatment.
Hard Signs and Soft Signs
| Category | Examples | Action |
|---|---|---|
| Hard signs | Active arterial bleeding, expanding or pulsatile haematoma, bruit, thrill, absent pulse, distal ischaemia. | Urgent vascular control; image only if stable and imaging will not delay needed treatment. |
| Soft signs | History of bleeding, small stable haematoma, pulse asymmetry, neurological deficit, proximity injury. | ABI/API and selective imaging; serial examination. |
| Normal examination | Warm limb, symmetric pulses, normal Doppler, normal ABI/API and reliable clinical setting. | Observation with documented serial checks. |
Clinical Presentation
Obvious presentation
The obvious case is a bleeding or pulseless limb after major fracture or dislocation. Features include:
- active external bleeding or rapidly expanding haematoma
- cold, pale or mottled distal limb
- absent or asymmetric pulses
- absent Doppler signal
- severe pain, paraesthesia or motor weakness
- major fracture-dislocation, open wound or crush mechanism
Subtle presentation
The subtle case is the dangerous one. Examples include:
- knee dislocation that has reduced before arrival
- tibial plateau fracture with symmetric pulses but high-risk mechanism
- shoulder dislocation in an older patient with a small pulse difference
- elbow fracture with a pink hand but abnormal Doppler or neurological deficit
- ballistic wound near a major vessel with no hard signs
- delayed thrombosis after an initially normal examination
Delayed presentation
Delayed vascular injury can present with:
- increasing pain or swelling
- pseudoaneurysm
- arteriovenous fistula
- delayed thrombosis
- compartment syndrome
- claudication or reduced exercise tolerance
- wound breakdown or failed fracture healing due to poor perfusion
Physical Examination
Examination must be repeated and timed. Document findings before reduction, after reduction, after splinting or fixation, after vascular repair, and during postoperative observation.
Look
- limb colour, temperature and capillary refill
- deformity or dislocation
- open wound and active bleeding
- expanding haematoma
- skin tension, blistering or threatened skin
- muscle swelling and compartment tension
- signs of polytrauma or shock
Feel
- radial, ulnar, brachial, dorsalis pedis and posterior tibial pulses as relevant
- compare both limbs
- palpate haematoma gently; do not provoke bleeding
- assess temperature gradient from proximal to distal limb
- assess compartment firmness, but do not rely on firmness alone
Move and neurological examination
- document motor function by named nerves
- document sensory territories
- look for deterioration after reduction or revascularisation
- remember that neurological deficit can be vascular, nerve, compartment or fracture-related
Bedside vascular tests
Bedside Vascular Assessment
| Test | How To Use It | Interpretation |
|---|---|---|
| Handheld Doppler | Check distal arterial signal and compare sides. | Absent or changing signal is concerning even if the limb looks warm. |
| ABI/API | Doppler systolic pressure injured limb divided by uninjured limb or brachial pressure. | Above 0.9 with normal examination supports serial observation; 0.9 or less prompts imaging or vascular assessment. |
| Pulse oximetry waveform | Adjunct in fingers or toes when available. | A waveform can support perfusion assessment but does not replace Doppler and ABI/API. |
| Compartment examination | Pain, passive stretch pain, paraesthesia, analgesia requirement and tense compartments. | Treat clinically clear compartment syndrome urgently. |
Imaging and Investigations
Plain radiographs
Order the radiographs needed to define and reduce the fracture or dislocation. Do not allow routine imaging to delay reduction of a limb-threatening dislocation.
Radiographs help identify:
- dislocation direction and reduction quality
- fracture-dislocation pattern
- tibial plateau, distal femoral, proximal tibial or elbow injuries that carry vascular risk
- open fracture contamination and bone loss
- fixation strategy if external fixation is needed
CT angiography
CTA is the usual first-line vascular imaging test when imaging is needed and the patient is stable enough. It defines:
- vessel occlusion, transection, active extravasation or pseudoaneurysm
- length and level of arterial injury
- relationship to fracture fragments
- distal runoff
- surgical approach and graft planning
CTA Principle
CTA is not a delay tool. It is used when the limb is stable enough for imaging and the result will guide treatment. Hard signs with an obvious operative target can proceed directly to theatre.
Duplex ultrasound
Duplex can be useful for selected stable patients, postoperative surveillance or institutions where rapid expert scanning is available. It is less useful when wounds, dressings, splints, body habitus, pain or time pressure make the study unreliable.
Laboratory tests
Useful tests include:
- full blood count and coagulation profile
- group and crossmatch
- lactate, pH and base deficit in major trauma
- creatine kinase, potassium and renal function when crush, prolonged ischaemia or reperfusion risk exists
- serial haemoglobin when haemorrhage is suspected
Differential Diagnosis
Not every cold or painful limb has the same cause. Differentiate:
Differential Diagnosis of Abnormal Perfusion
| Diagnosis | Clue | Management Implication |
|---|---|---|
| True arterial injury | Hard signs, abnormal ABI/API, CTA lesion, absent Doppler. | Urgent vascular plan. |
| Vasospasm | Often transient, especially in children or after manipulation. | Observe only after senior review and reliable perfusion. |
| Compartment syndrome | Pain on passive stretch, rising analgesia, tense compartments, neurological symptoms. | Fasciotomy; pulses may remain present. |
| Nerve injury | Motor or sensory deficit without perfusion abnormality. | Document and reassess; explore if associated open injury or transection suspected. |
| Shock-related poor perfusion | Bilateral cool limbs, systemic hypotension. | Resuscitate; still examine the injured limb separately. |
| Pre-existing vascular disease | Older patient, calcified vessels, baseline pulse difference. | Compare sides, use Doppler/CTA, avoid false reassurance. |
Management Algorithm
Management is based on physiology, perfusion, fracture stability, time since ischaemia and team availability.
- Primary survey and haemorrhage control.
- Remove constrictive dressings or splints if compromising perfusion.
- Document neurovascular status.
- Reduce gross dislocation if the limb is threatened.
- Reassess and document neurovascular status.
- Identify hard signs.
- If hard signs are present, involve vascular surgery and proceed to control or repair.
- If no hard signs, use ABI/API and CTA pathway when indicated.
- Choose vessel-first, bone-first or temporary shunt sequence.
- Assess fasciotomy need after ischaemia, repair, shunting or reperfusion.
Surgical Technique
Principles:
- reduce dislocations urgently when perfusion is threatened
- splint in a stable position that does not compromise flow
- use external fixation when skeletal instability risks vascular repair or soft tissues
- keep fixation rapid and outside planned vascular or soft-tissue incisions where possible
- reassess Doppler and compartments after fixation
Regional Injury Patterns
Regional Patterns To Actively Check
| Region | Vessel Concern | Practical Checks |
|---|---|---|
| Knee dislocation | Popliteal artery intimal tear, thrombosis or rupture. | Reduce, document pulse/Doppler before and after, ABI/API, CTA when abnormal or uncertain. |
| Schatzker IV-VI tibial plateau | Knee-dislocation equivalent mechanism can injure popliteal vessels. | ABI/API screening even with symmetric pulses is used in many trauma pathways. |
| Elbow dislocation or supracondylar fracture | Brachial artery injury or entrapment. | Check radial/ulnar pulses, hand perfusion, median/AIN function and post-reduction status. |
| Shoulder dislocation in older patient | Axillary artery injury, especially with haematoma or pulse change. | Check pulse before and after reduction; CTA if abnormal or expanding haematoma. |
| Pelvic and acetabular trauma | Major haemorrhage from pelvic vessels more than isolated limb ischaemia. | Binder, resuscitation, pelvic haemorrhage pathway, CTA/angio or packing as indicated. |
| Open tibial fracture | Anterior tibial, posterior tibial or peroneal artery injury with compartment risk. | Doppler, ABI/API, CTA if abnormal; low fasciotomy threshold. |
Fasciotomy and Reperfusion
Compartment syndrome can occur before repair, after reduction, after vascular repair, after shunting, or during resuscitation. It can occur despite restored pulses.
Do not wait for late findings
Late findings include paralysis, pulselessness and pallor. These should not be used as the trigger for fasciotomy. The important early pattern is escalating pain, pain on passive stretch, increasing analgesic requirement, paraesthesia and tense compartments.
Prophylactic fasciotomy
Prophylactic fasciotomy is considered when the risk of missing compartment syndrome is higher than the morbidity of fasciotomy. This is common after prolonged ischaemia, reperfusion, combined fracture and vascular injury, crush injury or unreliable examination.
Documentation
Document:
- time of injury and estimated ischaemia duration
- time of reduction, shunt and repair
- pulse, Doppler and ABI/API findings
- compartment findings and analgesic requirement
- reason for fasciotomy or reason for observation
Complications
Complications To Anticipate
| Complication | Why It Occurs | Prevention or Response |
|---|---|---|
| Missed arterial injury | Normal pulses, spontaneous reduction, incomplete examination. | Repeat examination, ABI/API, CTA when abnormal or uncertain. |
| Thrombosis after repair | Intimal injury, poor runoff, kinking, compression by fracture or swelling. | Protect repair with alignment, monitor Doppler, urgent vascular reassessment if signal changes. |
| Compartment syndrome | Ischaemia, reperfusion, crush, fracture bleeding and resuscitation swelling. | Early fasciotomy when clinical or high risk. |
| Graft infection | Open fracture, contamination, devitalised tissue. | Debridement, soft tissue cover, antibiotics and avoid synthetic graft when possible. |
| Secondary amputation | Muscle necrosis, infection, severe bone/soft tissue loss or failed repair. | Realistic counselling and serial viability assessment. |
| Chronic pain and poor function | Nerve injury, compartment syndrome, stiffness, nonunion and scarring. | Early multidisciplinary rehabilitation and surveillance. |
Postoperative Care
Postoperative care is active surveillance, not routine observation.
Monitoring
- hourly or protocol-based neurovascular checks initially
- Doppler signal documentation
- compartment examination and analgesic requirement
- wound and fasciotomy dressing checks
- graft or repair surveillance according to vascular plan
- renal and metabolic monitoring after crush or reperfusion
Immobilisation and fixation
- external fixator pin sites must not compromise vascular access or planned flaps
- splints should not compress the repair or compartments
- definitive fixation timing depends on physiology, perfusion, soft tissues and infection risk
- vascular graft location affects surgical approach and reoperation planning
Rehabilitation
Rehabilitation depends on nerve, muscle, bone and soft tissue recovery. A perfused limb may still be weak, painful or functionally limited. Early goals are protection of repair, oedema control, joint motion where safe, wound care and realistic patient counselling.
Outcomes and Prognosis
Outcomes depend less on the vessel alone and more on the whole limb.
Important prognostic factors:
- warm ischaemia time
- blunt versus penetrating mechanism
- popliteal or multi-level tibial vessel injury
- associated fracture-dislocation or open fracture
- nerve injury
- muscle viability
- need for fasciotomy
- infection and soft-tissue cover
- patient physiology and rehabilitation capacity
Outcome Sentence
Successful revascularisation is necessary but not sufficient. Limb salvage still depends on viable muscle, stable bone, durable soft tissue, nerve function and absence of infection.
Evidence Base
Penetrating Extremity Vascular Trauma Guideline
- Physical examination and ankle-brachial indices allow expedited triage.
- CTA has become the diagnostic study of choice when imaging is required.
- Tourniquets and intravascular shunts are recognised adjuncts in lower-extremity arterial trauma.
Imaging Vascular Trauma
- CTA was the dominant modern diagnostic modality across the vascular-trauma literature.
- CTA showed acceptable sensitivity and specificity for blunt and penetrating vascular injury in extremity trauma.
Physical Examination and Occult Arterial Injury
- Clinically occult arterial injuries and selected penetrating extremity trauma were safely managed without routine operation when hard signs were absent.
- A small proportion deteriorated and required delayed surgery, supporting the need for surveillance.
Common Pitfalls
Pitfalls That Cause Harm
- Calling the limb safe because a pulse is palpable once.
- Forgetting that a knee dislocation may reduce before presentation.
- Delaying reduction of a threatened limb for routine imaging.
- Sending a patient with hard signs for CTA without vascular agreement.
- Performing prolonged definitive fixation while the foot is ischaemic.
- Repairing the artery without stabilising a skeleton that will disrupt the repair.
- Failing to consider a temporary shunt in a damage-control situation.
- Waiting for pulselessness before diagnosing compartment syndrome.
- Forgetting to document serial neurovascular checks.
- Assuming limb salvage means useful function.
Applied Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Reduced Knee Dislocation With Normal Pulses
"A patient reports a knee deformity that reduced before arrival. The limb is warm and pulses are palpable."
Pulseless Ankle Fracture-Dislocation
"A patient has an ankle fracture-dislocation with a cool foot and absent Doppler signal."
Popliteal Injury With Unstable Distal Femur Fracture
"A patient has a distal femur fracture, absent distal pulses and CTA shows popliteal artery occlusion. The fracture is very unstable."
Reperfusion After Axillary Artery Repair
"An older patient has shoulder dislocation with axillary artery occlusion. Flow is restored after repair, but the arm becomes tense and analgesic requirement rises."
MCQ Practice Points
Hard Signs
Q: What are hard signs of extremity vascular injury? A: Active arterial bleeding, expanding haematoma, bruit, thrill, absent pulse and distal ischaemia are hard signs. They require urgent vascular control rather than routine delayed imaging.
ABI/API
Q: What does an ABI/API above 0.9 mean after extremity trauma? A: If the examination is normal and reliable, it supports serial observation. An ABI/API of 0.9 or less, uncertainty or a discordant high-risk mechanism prompts CTA or vascular assessment.
Knee Dislocation Trap
Q: Why is a spontaneously reduced knee dislocation still dangerous? A: Popliteal artery injury can be occult initially, so the patient still needs vascular screening with documented pulses, Doppler, ABI/API and serial examination.
Temporary Shunt
Q: What is the role of a temporary vascular shunt? A: It restores perfusion during damage control, transfer, skeletal stabilisation or staged repair. It is a bridge to definitive vascular reconstruction, not definitive treatment.
Fasciotomy
Q: Can compartment syndrome occur with pulses present after vascular repair? A: Yes. Reperfusion after vascular repair is a major risk setting, and compartment syndrome remains a clinical diagnosis when signs are clear.
Australian Context
Management depends on local trauma network design. Major combined orthopaedic-vascular injuries should be managed in centres with vascular surgery, trauma surgery, orthopaedic trauma, interventional radiology, intensive care and plastic or reconstructive capability when possible.
In regional settings, the first priorities are haemorrhage control, reduction of limb-threatening dislocations, documentation, early senior consultation and transfer planning. A temporary shunt or external fixator may be part of a damage-control transfer strategy when definitive vascular and orthopaedic reconstruction is not immediately available.
Reference Links
- PubMed: EAST lower-extremity arterial trauma guideline
- PubMed: CTA effectively evaluates extremity vascular trauma
- PubMed: imaging vascular trauma systematic review
- PubMed: physical examination and occult arterial injury follow-up
- PubMed: ABI and ultrasonography systematic review
- PubMed: temporary shunts systematic review
- PubMed: combined orthopaedic and vascular trauma shunting
- PubMed: civilian lower-extremity arterial trauma outcomes
Exam Cheat Sheet
Vascular Injury With Fracture or Dislocation
Clinical summary
First Actions
- •Primary survey and haemorrhage control
- •Document neurovascular status
- •Reduce gross dislocation if limb threatened
- •Repeat examination after reduction
- •Hard signs go to urgent vascular pathway
Screening
- •Pulses alone are not enough
- •Use Doppler and ABI/API
- •Above 0.9 plus normal reliable exam supports serial observation
- •0.9 or less, uncertainty or discordance prompts CTA or vascular review
- •CTA is first-line imaging when stable enough
Sequence
- •Critical ischaemia favours vessel-first
- •Unstable skeleton threatening repair may need rapid external fixation
- •Temporary shunt restores flow during staged care
- •Definitive fixation follows physiology, perfusion and soft tissue readiness
- •Reassess perfusion after every step
Fasciotomy
- •Established compartment syndrome is an emergency
- •High risk after prolonged ischaemia and reperfusion
- •Combined fracture and vascular injury lowers threshold
- •Do not wait for pulselessness
- •Document timing and serial findings