Injuries of the Limbs in Polytrauma: Upper and Lower Limbs

  • Anna Maria Ierardi
  • Filippo Pesapane
  • Natalie Lucchina
  • Andrea Coppola
  • Filippo Piacentino
  • Andrea Sacrini
  • Salvatore Alessio Angileri
  • Gianpaolo Carrafiello
Chapter

Abstract

Extremity injuries are the second most common traumatic injuries after head injuries and account until 80% of all cases of vascular trauma. Peripheral injuries are usually not immediately lethal, whether due to penetrating or blunt injuries; nevertheless, a prompt identification of the injuries is crucial for a correct management.

There has been a growing role for both diagnostic and interventional radiology (IR) in all types of trauma affecting different areas of the body, with imaging becoming an integral part of the multidisciplinary approach to modern trauma care.

Nowadays, successful revascularization with limb salvage is almost routine, and ischemic limb loss has become the rare exception.

Despite success in arterial repair, desirable outcomes with regard to extremity function and disability more often depend on successful identification and treatment of the frequent coexisting injuries to the bone, nerves, and soft tissue.

The aim of this chapter is to focalize on injuries of the limbs in polytraumatic patient and to the decision processes associated with the workup and the endovascular interventions (EVIs) of these injuries.

Keywords

Polytrauma Upper limb Lower limb Vascular injuries Radiology Interventional radiology Endovascular repair 

References

  1. 1.
    Dua A, Desai SS, Holcomb JB, Burgess AR, Freischlag JA. Clinical review of vascular trauma. Berlin: Springer; 2014.CrossRefGoogle Scholar
  2. 2.
    Kaewlai R, Avery LL, Asrani AV, et al. Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics. 2008;28(6):1771–84.CrossRefPubMedGoogle Scholar
  3. 3.
    Pasch AR, Bishara RA, Lim LT, et al. Optimal limb salvage in penetrating civilian vascular trauma. J Vasc Surg. 1986;3(2):189–95.CrossRefPubMedGoogle Scholar
  4. 4.
    Murthy R, Hastings GS, Richard HM, Levitin A. Angiography and endovascular intervention for vascular trauma to the extremities. Semin Intervent Radiol. 2003;20(2):081–8.CrossRefGoogle Scholar
  5. 5.
    Monazzam S, Goodell PB, Salcedo ES, Nelson SH, Wolinsky PR. When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities. J Trauma Acute Care Surg. 2017;82(1):133–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Frykberg ER, Vines FS, Alexander RH. The natural history of clinically occult arterial injuries: a prospective evaluation. J Trauma. 1989;29(5):577–83.CrossRefPubMedGoogle Scholar
  7. 7.
    Uyeda JW, Anderson SW, Sakai O, Soto JA. CT angiography in trauma. Radiol Clin N Am. 2010;48(2):423–38. ix–xCrossRefPubMedGoogle Scholar
  8. 8.
    Wallin D, Yaghoubian A, Rosing D, et al. Computed tomographic angiography as the primary diagnostic modality in penetrating lower extremity vascular injuries: a level I trauma experience. Ann Vasc Surg. 2011;25(5):620–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Fox N, Rajani RR, Bokhari F, et al. 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 Suppl 4):S315–20.CrossRefPubMedGoogle Scholar
  10. 10.
    Foster BR, Anderson SW, Uyeda JW, Brooks JG, Soto JA. Integration of 64-detector lower extremity CT angiography into whole-body trauma imaging: feasibility and early experience. Radiology. 2011;261(3):787–95.CrossRefPubMedGoogle Scholar
  11. 11.
    Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surg Clin North Am. 1995;75(2):207–23.CrossRefPubMedGoogle Scholar
  12. 12.
    Pezeshki Rad M, Mohammadifard M, Ravari H, et al. Comparing color Doppler ultrasonography and angiography to assess traumatic arterial injuries of the extremities. Iran J Radiol. 2015;12(1):e14258.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. 1991;31(4):515–9. discussion 519–522CrossRefPubMedGoogle Scholar
  14. 14.
    Feliciano DV, Moore FA, Moore EE, et al. Evaluation and management of peripheral vascular injury. Part 1. Western Trauma Association/critical decisions in trauma. J Trauma. 2011;70(6):1551–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373(9673):1455–61.CrossRefGoogle Scholar
  16. 16.
    Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics. 2005;25(Suppl 1):S133–42.CrossRefPubMedGoogle Scholar
  17. 17.
    Iacobellis F, Ierardi AM, Mazzei MA, et al. Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications. Br J Radiol. 2016;89(1061):20150952.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Shah N, Anderson SW, Vu M, et al. Extremity CT angiography: application to trauma using 64-MDCT. Emerg Radiol. 2009;16(6):425–32.CrossRefPubMedGoogle Scholar
  19. 19.
    O’Moore PV, Denham JS, Steinberg FL. The complications of angiography: a prospective study. Radiology. 1988;169:317.Google Scholar
  20. 20.
    Egglin TK, O'Moore PV, Feinstein AR, Waltman AC. Complications of peripheral arteriography: a new system to identify patients at increased risk. J Vasc Surg. 1995;22(6):787–94.CrossRefPubMedGoogle Scholar
  21. 21.
    Adibi A, Krishnam MS, Dissanayake S, et al. Computed tomography angiography of lower extremities in the emergency room for evaluation of patients with gunshot wounds. Eur Radiol. 2014;24(7):1586–93.CrossRefPubMedGoogle Scholar
  22. 22.
    Hiatt MD, Fleischmann D, Hellinger JC, Rubin GD. Angiographic imaging of the lower extremities with multidetector CT. Radiol Clin N Am. 2005;43(6):1119–27. ixCrossRefPubMedGoogle Scholar
  23. 23.
    Willmann JK, Wildermuth S. Multidetector-row CT angiography of upper- and lower-extremity peripheral arteries. Eur Radiol. 2005;15(Suppl 4):D3–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Anderson SW, Lucey BC, Varghese JC, Soto JA. Sixty-four multi-detector row computed tomography in multitrauma patient imaging: early experience. Curr Probl Diagn Radiol. 2006;35(5):188–98.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma. 2005;59(1):217–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Bynoe RP, Miles WS, Bell RM, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg. 1991;14(3):346–52.CrossRefPubMedGoogle Scholar
  27. 27.
    Patterson BO, Holt PJ, Cleanthis M, et al. Imaging vascular trauma. Br J Surg. 2012;99(4):494–505.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: a comparison using the National Trauma Data Bank. Vasc Endovasc Surg. 2011;45(7):592–7.CrossRefGoogle Scholar
  29. 29.
    Hyre CE, Cikrit DF, Lalka SG, Sawchuk AP, Dalsing MC. Aggressive management of vascular injuries of the thoracic outlet. J Vasc Surg. 1998;27(5):880–4. discussion 884–885CrossRefPubMedGoogle Scholar
  30. 30.
    Abouljoud MS, Obeid FN, Horst HM, et al. Arterial injuries of the thoracic outlet: a ten-year experience. Am Surg. 1993;59(9):590–5.PubMedGoogle Scholar
  31. 31.
    Castelli P, Caronno R, Piffaretti G, et al. Endovascular repair of traumatic injuries of the subclavian and axillary arteries. Injury. 2005;36(6):778–82.CrossRefPubMedGoogle Scholar
  32. 32.
    Joo JY, Ahn JY, Chung YS, et al. Therapeutic endovascular treatments for traumatic carotid artery injuries. J Trauma. 2005;58(6):1159–66.CrossRefPubMedGoogle Scholar
  33. 33.
    Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg. 2003;38(3):451–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Klocker J, Falkensammer J, Pellegrini L, et al. Repair of arterial injury after blunt trauma in the upper extremity - immediate and long-term outcome. Eur J Vasc Endovasc Surg. 2010;39(2):160–4.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Joshi V, Harding GE, Bottoni DA, Lovell MB, Forbes TL. Determination of functional outcome following upper extremity arterial trauma. Vasc Endovasc Surg. 2007;41(2):111–4.CrossRefGoogle Scholar
  36. 36.
    Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010; (26):1–31.Google Scholar
  37. 37.
    Stalp M, Koch C, Ruchholtz S, et al. Standardized outcome evaluation after blunt multiple injuries by scoring systems: a clinical follow-up investigation 2 years after injury. J Trauma. 2002;52(6):1160–8.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kovacs F, Pollock JG, DeNunzio M. Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases. Vasc Endovasc Surg. 2012;46(3):269–72.CrossRefGoogle Scholar
  39. 39.
    Wagner WH, Yellin AE, Weaver FA, Stain SC, Siegel AE. Acute treatment of penetrating popliteal artery trauma: the importance of soft tissue injury. Ann Vasc Surg. 1994;8(6):557–65.CrossRefGoogle Scholar
  40. 40.
    Goltz JP, Basturk P, Hoppe H, Triller J, Kickuth R. Emergency and elective implantation of covered stent systems in iatrogenic arterial injuries. Rofo. 2011;183(7):618–30.CrossRefPubMedGoogle Scholar
  41. 41.
    Shah DM, Corson JD, Karmody AM, Fortune JB, Leather RP. Optimal management of tibial arterial trauma. J Trauma. 1988;28(2):228–34.CrossRefPubMedGoogle Scholar
  42. 42.
    Zhong S, Zhang X, Chen Z, et al. Endovascular repair of blunt popliteal arterial injuries. Korean J Radiol. 2016;17(5):789–96.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Lopera JE, Suri R, Cura M, Kroma G, El-Merhi F. Crural artery traumatic injuries: treatment with embolization. Cardiovasc Intervent Radiol. 2008;31(3):550–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Becker GJ, Benenati JF, Zemel G, et al. Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Interv Radiol. 1991;2(2):225–9.CrossRefPubMedGoogle Scholar
  45. 45.
    DuBose JJ, Rajani R, Gilani R, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785–92.CrossRefPubMedGoogle Scholar
  46. 46.
    Scott AR, Gilani R, Tapia NM, et al. Endovascular management of traumatic peripheral arterial injuries. J Surg Res. 2015;199(2):557–63.CrossRefPubMedGoogle Scholar
  47. 47.
    Lopera JE. Embolization in trauma: principles and techniques. Semin Intervent Radiol. 2010;27(1):14–28.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    G Cornalba FM, AM Ierardi, G Carrafiello. Equipment and logistic organization for endovascular procedures (OR vs. hybrid room)” in Endovascular techniques in the managment of aortic and peripheral arterial disease. Minerva Medica. 2015. https://www.minervamedica.it/it/preview.php?pdf=L10031.
  49. 49.
    Resnick SB, Resnick SH, Weintraub JL, Kothary N. Heparin in interventional radiology: a therapy in evolution. Semin Intervent Radiol. 2005;22(2):95–107.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Ierardi AM, Piacentino F, Fontana F, et al. The role of endovascular treatment of pelvic fracture bleeding in emergency settings. Eur Radiol. 2015;25(7):1854–64.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Doody O, Given MF, Lyon SM. Extremities--indications and techniques for treatment of extremity vascular injuries. Injury. 2008;39(11):1295–303.CrossRefPubMedGoogle Scholar
  52. 52.
    Gould JE, Vedantham S. The role of interventional radiology in trauma. Semin Intervent Radiol. 2006;23(3):270–8.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Ierardi AM, Xhepa G, Duka E, et al. Ethylene-vinyl alcohol polymer trans-arterial embolization in emergency peripheral active bleeding: initial experience. Int Angiol. 2015;34(6 Suppl 1):28–35.PubMedGoogle Scholar
  54. 54.
    Carrafiello G, Lagana D, Mangini M, et al. Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience. J Vasc Interv Radiol. 2011;22(1):34–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Johnson CA. Endovascular management of peripheral vascular trauma. Semin Intervent Radiol. 2010;27(1):38–43.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg. 2007;46(6):1222–6.CrossRefPubMedGoogle Scholar
  57. 57.
    Thorneycroft IH, Goldzieher JW. Venous thromboembolism. A review. J Reprod Med. 2003;48(11 Suppl):911–20.PubMedGoogle Scholar
  58. 58.
    Aryafar H, Kinney TB. Optional inferior vena cava filters in the trauma patient. Semin Intervent Radiol. 2010;27(1):68–80.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Johnson ON 3rd, Gillespie DL, Aidinian G, et al. The use of retrievable inferior vena cava filters in severely injured military trauma patients. J Vasc Surg. 2009;49(2):410–6. discussion 416CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Anna Maria Ierardi
    • 1
  • Filippo Pesapane
    • 1
  • Natalie Lucchina
    • 2
  • Andrea Coppola
    • 2
  • Filippo Piacentino
    • 2
  • Andrea Sacrini
    • 1
  • Salvatore Alessio Angileri
    • 1
  • Gianpaolo Carrafiello
    • 1
  1. 1.Diagnostic and Interventional Radiology Department, San Paolo HospitalUniversity of MilanMilanItaly
  2. 2.Unit of RadiologyInsubria UniversityVareseItaly

Personalised recommendations