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ABSTRACTHigh velocity pelvic injury with limb vascular injury posesdifficulties as immediate surgery for limb reperfusion isindicated. However immediate vascular interventiondeviates from conventional principles of damage controlfollowing major injuries. We present two cases of this rarecombination of injuries. In both cases, early limbrevascularization is possible despite presented with multipleinjuries and pelvic fracture.

Key Words: Limb vascular injury; pelvic injury; revascularization;damage control orthopaedic

INTRODUCTIONThe management of high velocity polytrauma patients posesa major challenge. Damage control surgery for multipleinjured patients has led to increase their survival for the pastfew decades. Vascular injury is challenging in the context ofdamage control because of the conflict between time-consuming vascular reconstruction and urgent need toalleviate the procedure before a patient sustains anirreversible physiological insult. Currently, there are no clearstandard guidelines and algorithms for hemorrhage control inunstable complex pelvic fracture associated with limbvascular injury.

Patients' consent regarding publishing this case report wasobtained.

CASE REPORTCase 1A 27-year old lady motorcyclist was involved in a head-oncollision with a car and sustained multiple injuries. She was

initially presented in with stable hemodynamic andhemoglobin of 7.7gm /dL. She sustained right superior andinferior pubic rami fracture and bi-columnar acetabulumfracture (Fig 1-A), comminuted mid-shaft with a neck ofright femur fracture, fracture distal end left radius, and rightknee dislocation (Fig 1-B). The wound debridement andexternal fixator of the right femur and screw fixation of theneck of right femur were performed in another hospital. Thepelvic and acetabulum fracture were stabilized with pelvicexternal fixators. During post operation, she was intubatedand sedated in ICU. However, 7 hours of post operationnoted distal circulation right lower limb not palpable, CTangiogram of right lower limb revealed there was a segmentof filling defect of 5 cm over right popliteal artery with gooddistal run-off and collaterals. (Figure 1-C)

Immediate stabilization of femur fractures and reversesaphenous vein graft for revascularization of the limb withprophylaxis fasciotomy were done within 15 hours. The kneedislocation was managed by posterior capsule repair andexternal fixation stabilization. The post-operative bloodcreatine phosphokinase was 7442 U/L and was increasing intrend during the first 3 days post operation, and later starteddecreasing in trend and normalized 7 days later. Urine outputand renal function were good throughout post-operativeperiod. She was in ICU for 12 days following vascularreconstruction, due to lung collapse and secondary infectionwith nosocomial infections. She required prolongedventilation and low dose noradrenaline. Pelvic and acetabulumdefinitive fixation were done as a delayed procedure 23 dayslater through Letournel approach (Fig 1-D).

After six months of post injury she could walk withoutcrutches. All fractures healed without complication.However, she had persistent medial collateral kneeinstability and right foot drop secondary to peroneal nervepalsy.

Immediate Revascularization of A Traumatic Limb VascularInjury associated with Major Pelvic Injuries

Hanifah J, MBBCh (Ain Shams), Paiman M, MMed Orth (USM), Nawfar AS, MMed Orth (USM), Tengku-Muzaffar TMS, MMed Orth (USM), Wan-Azman WS*, MS Plastic (USM),

Faisham WI, MMed Orth (USM), Sahran Yahya, MMed Orth (USM)

Department of Orthopaedic Surgery, Universiti Sains Malaysia, Kubang Kerian, Malaysia*Plastic Reconstructive Unit, Universiti Sains Malaysia, Kubang Kerian, Malaysia

Date of submission: July 2015Date of acceptance: October 2015

Corresponding Author: Faisham WI, Department of Orthopaedic, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian,Kota Bharu, KelantanEmail: faisham@usm.my

http://dx.doi.org/10.5704/MOJ.1511.014

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Fig. 1a: 3D Computed tomography (CT imaging) revealed rightbicolumnar acetabulum fracture, fracture left superiorand inferior pubic rami, fracture right neck of femur.

Fig. 1b: Initial radiograph right knee showing right kneedislocation.

Fig. 1c: 3D reconstruction Computed Tomography (CT Imaging)revealed thrombosed of right popliteal artery ondislocated knee.

Fig. 1d:Pelvic radiograph following open reduction and ringinternal fixation showing acceptable alignment, screwfixation neck of femur in situ.

Fig. 2a:A Photograph of open pelvic fracture wound. Fig. 2b:3D Computed Tomography (CT imaging) showing leftsuperior and inferior pubic rami fracture, and openingof left sacroiliac joint.

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Case 2A 23-year old young man motorcyclist was involved in acollision with a car and presented with profuse bleeding overthe perineum. There was an open laceration wound over themedial aspect of left proximal thigh extending to the perianalregion measuring about 10 x 2 cm with continuous bloodoozing. (Fig 2-A). Computed tomography (CT) scansdemonstrated severe pelvic injuries, including a left superiorand inferior pubic rami fracture with left sacroiliac jointdisruption (Fig 2-B). The hypovolemia was transient andwas managed with fluid resuscitation and 3 pints of bloodtransfusion. There was proximal tibial plateau fracture in thecontralateral limb with popliteal artery thrombosis of 4 cmwith good collaterals and distal run-off. (Fig 2-C)

Emergency debridement of the perineal wound and pelvicpacking through modified Stoppa approach were done. Thebleeding was secured by clipping multiple branches ofinternal iliac artery and veins particularly the obturatoranastomoses. The pelvis was then stabilized with a longplate. (Fig 2-D).

The right popliteal vessel exploration and revascularizationusing saphenous vein graft were done 8 hours after injury. Hewas managed in ICU for 48 hours and there was no evidenceof reperfusion injury. The creatine phosphokinase was 8588

U/L during first 24 hours and normalized within 3 days. Noevidence of reperfusion injury and renal and lung functionswere normal throughout the acute event. The total durationof hospital stay was 16 days.

DISCUSSIONFor severely multiple injured patients who are in an‘unstable' or ‘in a critical' clinical condition, damage controlorthopaedic is the current treatment of choice. Its purpose isto avoid worsening the patient's condition by the "secondhit" of a major orthopaedic procedure and delay definitiverepair until a time when the overall condition is optimized1.Both cases fall into a borderline group whereby thehypovolemia was transient and there was no major organinjury that proceeded to deterioration following earlysurgery. Priorities to control bleeding in open pelvic injuryand vessels reconstruction to salvage the limb was the aimsfor both cases. Vascular injury is challenging in the contextof damage control because of inherent conflict between timeconsuming vascular reconstruction and the urgent need toabbreviate the procedure before the patient sustains anirreversible physiological insult. The perfect vascularreconstruction also will complicate massive blood loss,coagulopathy and hypothermia that will lead to irreversibleshock particularly in the present of pelvic injuries.

Hemodynamic stability and speed of surgery, earlyrevascularization has been the gold standard for managementof vascular injuries2. However, both cases were presentedwith pelvic injury that needed early damage controlmanagement. Special attention should be given to thesystemic effect of reperfusion especially long ischemic timeas highlighted in the first case. Prolonged and persistentmyoglobulinemia and renal failure in the presence of multi-organ injuries can cause a negative impact on survival. Both

Fig. 2c: 3D reconstruction Computed Tomography (CT Imaging)revealed blood collection over left periacetabular regionand thrombosed of right popliteal artery with gooddistal run-off.

Fig. 2d:Pelvic radiograph following open reduction and ring andsacroilliac joint internal fixation.

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REFERENCES

1. Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg 2003; 85-B: 478-84.2. Fox N, Rajani RR, Bokhari F, Chiu WC. Evaluation and management of penetrating lower extremity arterial trauma: An Eastern

Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73(5): 315-203. Pohlmann T, Bosch U, Gensslen A, Tscherne H. The Hannover experience in management of pelvic fracture. Clin Ortho Rel

Research 1994: 305: 69-804. Hauschild O, Strohm PC, Culeman U, Pohleman T, Suedkamp NP, Koestler W, et al. Mortality in patients with pelvic fracture:

result from the German pelvic injury register. The J Trauma Inj Infect Crit Care 2008; 64: 449-4555. Jagdish Krishnan, M Paiman, AS Nawfar, MI Yusof, W Zulmi, WS Azman, et al. The outcome of salvage surgery for vascular

injuries in the extremitis. Special consideration for delayed revscularisation Malays Orthop J 2014 ; Vol 8 No 1:11-17.

patients had good collateral circulation with a short segmentof thrombosis. The delayed vascular reconstruction waspossible without higher risk of reperfusion injury.

Open pelvic injury may result in high-energy trauma, whichplaces patients at risk for multiple life-threatening injuries.Mortality rate is higher in the presence of hemodynamicinstability especially when continuous bleeding withouttamponade occurs in open pelvic fracture. Early openpacking and vascular control has been advocated to improvethe survival in this difficult situation3. The Hannover groupexperiences comparing early total care and damage controlorthopaedic showed that significant decrease mortality ratewith early total care surgery with open packing andstabilization in complex unstable pelvic fracture4. However,complex pelvic injury with vascular injury associated withhigh mortalities despite aggressive and immediatetreatment5.

The presence of limb vascular injury associated withcomplex pelvic fracture in both patients causes the dilemma,of deciding which one should be operated first. The presenceof limb vascular injury can result in life-threatening injury ifthe bleeding is not controlled. However, once controlled, itmay be given lower priority for vascular repair in order toaddress other life-threatening conditions. In both cases, limbvascular injuries were repaired after more than golden periodof 6 hours. Previously, studies proposed by many authors,

the warm ischaemic time for limb vascular injury is 6 hoursto maximize limb salvage. However, some literature showsthat delayed revascularization also produces acceptable limbsalvage outcomes5.

Both cases responded to initial resuscitation with stablehemodynamic. Clinically, both cases were not in extremesthat prompted the damage control orthopaedic approach toimprove survival. However, in the first case limbrevascularization was done early but she had complicationwith lung collapse and sepsis that required prolongedventilation and ICU stay. This further delayed definitivefixation of the pelvic fractures. In the second case, thepriority was to control the bleeding first because of thepresence of an open wound, and loss of tamponade effect.Hemostatic control and definitive fracture stabilization of thepelvic fractures were performed first in order to minimizebleeding. Later, vascular repair and definitive fixation oflimb fractures were performed when all blood parameterswere stable.

In conclusion, limb revascularisation of patients withvascular injury and complex pelvic fractures is possible withacceptable morbidity. Both of these cases are very rarecircumstances and will guide us for future management.Decision for surgical priority with special consideration ofdamage control is mandatory to achieve survival.

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