The incidence of arterial injuries in extremity fractures is approximately 1% to 2%.1 Any delay in treatment increases the amputation rate. In patients with combined vascular and orthopedic injuries but without a mangled extremity, there is still controversy regarding whether to give priority to the fracture fixation or to the vascular repair.2-4 While there are no universally accepted protocols, there are widely accepted principles of treatment such as using a multidisciplinary team to manage treatment, restoring limb perfusion in less than 6 to 8 hours, and achieving stable and rapid fracture fixation with only minimal additional soft-tissue trauma. Occasionally, a speedy orthopedic fixation may precede definitive vascular repair.
This article presents a case of an open tibial shaft fracture associated with a torn anterior tibial artery in which the fracture was treated with an unreamed tibial nail before the artery was repaired.
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Figure 1: Angiography demonstrating an absent segment of the distal anterior tibial artery at the level of the midshaft tibial fracture (Gustilo type IIIA).
A 20-year-old soldier was wounded in combat and suffered from both penetrating gunshots and blunt leg injuries. The patient arrived at our institution 3 hours after being wounded.
On examination, the patient was fully alert and conscious. Tachypnea of 30 breaths/minute was noted. His blood pressure was 80/50 mm Hg, and his pulse rate was 130 beats/minute. An abdominal examination revealed the abdomen was tense and the pelvis was stable. An open midshaft fracture (Gustilo type IIIA) of the left tibia was splinted, and the patients heels were swollen.
Cross-table cervical spine, chest, and pelvic radiographs were normal. Ultrasound disclosed free intra-abdominal fluid leading to urgent laparotomy and eventual splenectomy.
Further treatment was focused on the lower limb injuries. The leg was pale with no palpable pedal pulses and a weak posterior tibial Doppler signal. Formal angiography revealed a torn anterior tibial artery (Figure 1), and the patient was returned to the operating room to complete the vascular repair. The time from the injury was 5 hours.
The patient was in the supine position. A support was used under the thigh to elevate the knee, and a C-arm fluoroscopy was available. Through a 4-cm long infrapatellar incision, an unreamed tibial nail was introduced. Fracture alignment for nail insertion was achieved by manual traction. The nail was secured proximally by 2 interlocking screws inserted through the jig (Figure 2).
The procedure took 20 minutes and provided good alignment with adequate length for a vascular end to end interposition venous bypass. The distal interlocking screws were inserted in a freehand manner at the end of the vascular reconstruction. Debridement, fasciotomy, and primary skin grafts ended the procedure.
The patient also had bilateral calcaneal fractures. Treatment of these fractures by open reduction and plating was delayed for 10 days until the swelling subsided.
Six months postoperatively, examination revealed an open bypass with a strong palpable dorsalis pedis pulse and a normal ankle brachial index. The distal screws were removed to achieve dynamization.
Three years postoperatively, the patient had moved and was contacted by telephone. He reported no leg pain, full range of motion of knee and ankle, and no further procedure related to the tibia fracture. Follow-up radiographs that were sent to us demonstrated union of the fracture (Figure 3).
Figure 2: Schematic illustration showing the unreamed tibial nail in the tibial shaft fracture secured proximally by 2 interlocking screws.
There is great controversy regarding the type and timing of fracture stabilization in long bone fractures associated with vascular injuries.1-9 Brinker et al7 noted the decision to repair a single infrapopliteal vessel is at the discretion of the attending vascular surgeon because clear criteria are lacking. Eisner and Ammann1 supported reconstruction only in cases in which >2 of the distal leg arteries are injured or the extremity is ischemic.
However, we believe that in stable patients who are managed by a multidisciplinary and competent team, all efforts should be made to maintain maximal vascular continuity. This approach is based on the fact that arteriosclerosis involving the tibioperoneal trunk and the tibial vessels is one of the most difficult lesions to treat and often leads to limb loss, tissue loss, or other peripheral vascular morbidity such as intermittent claudication.
Foreseeing such hazards should dictate an aggressive approach in distal revascularization when possible because there is no guarantee that any patent artery will not be involved in peripheral occlusive arterial disease in the future. Merlini9 argued that because the popliteal artery is a terminal system without collaterals, if two of the infrapatellar vessels are affected, the risk of amputation rises to 65%.
The basic rationale is that having patent arteries will decrease the odds of future ischemia. Regarding the treatment sequence and type of fracture fixation, our institutional policy, which has yielded good results, is to use a temporary vascular shunt with subsequent bone stabilization before definitive vascular repair. The main advantages in deferring the vascular repair are to prevent jeopardizing it by unstable bone fragments, extra tension, manipulation, and redundance.5
After the fracture has been adequately reduced, a vascular graft of correct length is fashioned and the anastomoses are placed without tension.3 Using this staged procedure, the final graft is not manipulated during the fracture reduction or any other orthopedic manipulation.
The use of a temporary shunt must be individualized. According to Gates,5 the routine use of a vascular shunt allows for unhurried debridement and proper reconstruction of the vascular injury after bony stabilization, thus making the procedure longer. In contrast, Howard and Makin8 believe the use of shunts have little effect on the duration of limb ischemia. At the same time using a temporary vascular shunt in the relatively small arteries of the calf is time consuming and the preferred full anticoagulation often is contraindicated by soft tissue and skeletal trauma, which can leave the surgeon with a false feeling of security but lead to shunt thrombosis.
We believe there are clear advantages to using unreamed tibial nailing for tibial shaft fractures with associated tibial vascular injuries. Preconditions are that the wound is not dirty and only a short period of time has elapsed from the injury. Generally, intramedullary nailing techniques are well-known and are used as a standard in treating lower limb diaphyseal fractures. The technique described is rapid and does not require additional devitalization of the involved soft tissues. Quick and satisfactory bone alignment and fixation is achieved before the vascular repair. The distal interlocking screws are inserted at the end of the operation to allow the final vascular repair to be performed without delay.
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Figure 3: AP (A) and lateral (B) radiographs taken 3 years postoperatively show uneventful union.
There is a risk of deep infection but this may be minimized by careful debridement, mechanical lavage, and antibiotic therapy. The alternative is to use an external fixator, which permits rapid fixation without additional soft tissue injury but carries significant disadvantages such as pin tract infection, pin loosening, and the need for daily care. In addition, soft tissue transfer is more difficult with the fixator in place.
In the tibia, an increased rate of malunion and delayed union have been reported compared with other forms of treatment.4,10 In a meta-analysis of the treatment alternatives of open tibial fractures, Bhandari et al11 found a reduced incidence of reoperations, superficial infections, and malunions with the use of unreamed nails compared to external fixation. Shannon et al12 compared the results of fixation by external fixation or unreamed nails for open tibia fractures in 30 patients who were divided into 2 similar groups; less complications and shorter time to union were recorded in the unreamed tibial nailing group.
Although our experience is limited to the reported case, there are serious arguments to consider using unreamed tibial nailing in treating tibial shaft fractures even when associated with vascular injuries.
- Eisner LG, Ammann JF. Vascular injuries: diagnosis and technical procedure [in German]. Helv Chir Acta. 1994; 60(6):1053-1059.
- Braten M, Helland P, Myhre HO, Molster A, Terjesen T. Eleven femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation. Acta Orthop Scand. 1996; 67(2):161-164.
- Feliciano DV. Evaluation and treatment of vascular injuries. In: Browner BD, Levine AL, Jupiter JB, Trafton PG, eds. Skeletal Trauma. 2nd ed. Philadelphia, PA: WB Saunders; 1998:349-361.
- Iannacone WM, Taffet R, Delong WG Jr, Born CT, Dalsey RM, Deutsch LS. Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation. J Trauma. 1994; 37(3):446-451.
- Gates JD. The management of combined skeletal and arterial injuries of the lower extremity. Am J Orthop. 1995; 24(9):674-680.
- Schlickewei W, Kuner EH, Mullaji AB, Gotze B. Upper and lower limb fractures with concomitant arterial injury. J Bone Joint Surg Br. 1992; 74(2):181-188.
- Brinker MR, Caines MA, Kerstein MD, Elliott MN. Tibial shaft fractures with an associated infrapopliteal arterial injury: a survey of vascular surgeons opinions on the need of vascular repair. J Orthop Trauma. 2000; 14(3):194-198.
- Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg Br. 1990; 72(1):116-120.
- Merlini M. Treatment of vascular lesions associated with open fractures [in French]. Helv Chir Acta. 1992; 59(1):119-128.
- Turren CH, DiStasio AJ. Treatment of grade IIIB and grade IIIC open tibial fractures. Orthop Clin North Am. 1994; 25(4):561-571.
- Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001; 83(1):62-68.
- Shannon FJ, Mullett H, ORourke K. Unreamed intramedullary nail versus external fixation in grade III open tibial fractures J Trauma. 2002; 52(4):650-654.
Drs Cohen and Rath are from the Department of Orthopedic Surgery and Dr Szendro is from the Department of Vascular Surgery, Soroka Medical Center, Ben Gurion University, Beer-Sheva, and Dr Sheinis is from the Department of Orthopedic Surgery, Beilinson Medical Center, Petach-Tikwa, Israel.
Drs Cohen, Sheinis, Rath, and Szendro have no relevant financial relationships to disclose.
Correspondence should be addressed to: Eugen Cohen, MD, Orthopedic Surgery, Soroka Medical Center, Ben Gurion University, Reger Blvd, Beer Sheva, Israel 84101.