by John H Scurr
The majority of personal injury cases involve soft tissue injuries or fractures to the long bones. Some of the more serious injuries include head injuries, injuries to the spinal column, chest, and abdominal injuries.
Acute vascular injuries may or may not be recognised at the time of the initial assessment. This applies to both arterial and venous injuries.
In this article I will discuss the presentation, investigation and management of acute arterial and venous injuries.
I will also discuss a common complication associated with many serious injuries and that includes the development of venous thrombo-embolic disease. Venous thrombo-embolic disease includes deep vein thrombosis, usually affecting the legs but not always. It can affect the pelvic veins and it can affect the arm veins. The most serious complication is of course the fatal pulmonary embolism. In many instances, warning emboli will occur, and with appropriate treatment the situation can be reversed.
With regard to vascular injuries, the arterial injuries are usually the most serious. They can be caused by direct trauma - penetrating injuries, or indirect trauma – for example dislocation of joints may be as sociated with acute arterial problems.
When a seriously ill patient is assessed, the assessment usually involves the initial rapid assessment including whether the patient is breathing, whether they have an adequate circulation, but also whether or not they have a circulation to their arms and legs.
The commonest presentation is an acute pulseless cold limb which may be pale on appearance.
Provided the arterial injury is recognised and appropriate steps taken to correct it, there may be no long term damage.
Any significant delay in recognising the injury will result in ischaemic changes commonly giving rise to the compartment syndrome. A compartment syndrome occurs usually in the main compartments of the lower leg but can occur in the forearms where, due to ischaemia i.e. lack of blood supply, the muscles will swell, the compartment gets compressed and the blood supply cut off, resulting in irreversible neuro logical and muscular damage.
It is important to recognise vascular injuries as soon as possible and take steps to reconstruct them. A dislocation of the knee can be associated with complete disruption of the popliteal artery, or severe damage to the popliteal artery such that acute obstruction occurs.
Provided this is recognised within two to four hours immediate restorative surgery can be undertaken and the circulation to the limb restored.
If there is a significant delay of four to six hours then preventative release of the compartment should be undertaken to prevent irreversible muscle damage.
The key to all these injuries is recognition.
When there is a suspicion of an injury i.e. the colour of the limb is pale, absent pulses, then steps should be taken to carry out a vascular assessment.
Initial examination using Duplex ultrasound imaging may be appropriate but inevitably it invariably leads to an intra-arterial injection known as an angiogram.
Once the angiogram has been undertaken, then vascular reconstruction can be carried out.
There is no real value in carrying out vascular reconstruction on its own. An orthopaedic surgeon needs to stabilise the limb.
In cases where there has been dislocation of the knee, steps need to be taken to make sure there is no recurrent dislocation at the same time that the vascular injury is repaired.
Long bone injuries are often associated with penetrating injuries of the artery. Again, stabilisation of the fracture is necessary at the same time. There should be no delay in restoring the circulation to the limb.
Any significant delay in restoring the circulation or any failure to recognise the compartment syndrome leads to a very high incidence of amputation.
Amputation can be prevented by recognising these injuries at an early stage and by taking steps to correct them.
From a personal injury or indeed from a clinical negligence perspective, proper assessment of these patients are essential.
Any patient that has lost a limb as a result of a personal injury accident will usually have a limb that has been preserved.
Information from the good limb can often indicate whether the patient was at risk of losing the limb at some point in the future or whether the limb loss is entirely due to the accident.
From a clinical perspective, the best opportunity to save a limb occurs at the time of, or shortly after, the accident.
In personal injury cases we are often presented with cases where the outcome has already been determined and it is simply a question of determining compensation.
Once you bear in mind that sometimes the management of these patients may fall far short of what is expected and the limb loss, although initially caused by the accident, can be attributed to the management of the patient in the post-accident phase. Over the years I have been involved in many thousands of cases involving problems with arterial supply to the legs and been able to provide an opinion on long-term potential problems but also more importantly whether the problems would have been avoided but for the treat ment received.
Any patient with serious injuries will be relatively immobile and immobility is one of the most important factors in the development of a deep vein thrombosis.
A deep vein thrombosis occurs when the circulation slows. It is often accompanied by direct damage to the vein wall and may be accompanied by an alteration in the blood’s ability to clot.
Any cases involving significant bleeding will provoke a clotting response. A combination of the clotting response, damage to veins and immobility predis poses the development of a deep vein thrombosis.
In general, following acute injuries, surgeons are reluctant to provide DVT prophylaxis until they know there are no bleeding complications.
Although a delay in preventing DVT thromboprophylaxis may result in a DVT, it usually prevents that DVT extending, giving rise to a more serious condition, a pulmonary embolism.
Once a patient is stabilised and the risk of bleeding excluded, then DVT prophylaxis should be provided. DVT prophylaxis is indicated in patients over the age of 40, patients with serious injuries or patients with prolonged immobility. A failure to provide DVT prophylaxis may represent substandard medical care.
The issues are often not quite so clear and sometimes there is justification for not giving DVT prophylaxis. Each case therefore needs to be decided on its merits.
When a patient who has undergone a limb injury then presents with increasing pain, particularly in the lower leg often associated with swelling, a simple investigation called a Duplex Ultrasound scan can determine whether there is a deep vein thrombosis.
We need to do a full leg ultrasound scan. Simply im aging the femoral vessels may miss calf-vein thrombi.
At the time of presentation, the calf-vein thrombi may not be relatively significant but there is a potential for them to extend into the main veins and then embolise to the lungs.
Where a patient has only had the thigh veins scanned, they need to be re-scanned after a period of a few days. Where the full leg ultrasound has been done with no evidence of deep vein thrombosis then provided DVT prophylaxis is applied there is probably no need to repeat that scan.
Sadly, many patients will present with an acute shortness of breath. In more extreme examples they may present with sudden cardiac arrest and irreversible changes leading to death.
Any patient who has chest pain following a road traffic accident should have a pulmonary embolism excluded.
A CT pulmonary angiogram can be carried out. This involves a simple injection and a CT scan.
It is a relatively easy way of determining whether there is evidence of a pulmonary embolism.
If a pulmonary embolism is diagnosed and the patient receives immediate treatment, usually in the form of intravenous heparin, then the survival rate is greater than 90%.
If a patient survives for 24 hours following the diagnosis of acute pulmonary embolism then I would normally expect them to survive.
If a patient does not have the diagnosis of pulmonary embolism made, no treatment administered, then 90% of those patients will die from the pulmonary embolism.
Unfortunately a small pulmonary embolism may cause shortness of breath, it may include coughing up a small amount of blood. This sign may be missed and if it is missed the next sign can be the fatal clot.
Again with all cases of venous disease, one should be aware of this potential problem. Prophylaxis is important and should be applied if practical.
Early diagnosis and treatment of clots is also very important.
Damage to the veins at the time of the accident can include very serious bleeding complications. The management of tears in veins is often more complex than the management of arterial injuries.
Simply tying off a vein may be lifesaving but it can often result in very severe distal obstruction and long term problems.
Again, we are often able to assess these cases posttrauma but ideally, recognition at the time of the incident and steps taken to correct it are ideal.
The introduction of venous stenting to prevent bleeding and to maintain patency has changed the outcome in many of these patients.
Acute damage to the veins is well recognised and we can usually treat it. Occasionally we cannot and then we have to deal with the consequences.
The consequences of acute venous damage are very similar to the consequences of a post-venous thrombosis.
In post-venous thrombosis the valves are damaged, the veins may be narrowed and symptoms may include venous reflux where the blood tends to pool in the lower limbs, resulting in swelling, skin discolouration and eventually ulceration. Or, where there is evidence of narrowing, this can result in venous claudication i.e. when a patient walks they get a bursting sensation in the limbs.
All these relatively serious complications of arterial and venous injuries need to be assessed. Ideally, early assessment and intervention will produce the best outcome.
A failure to assess them and carry out appropriate reconstruction may result in a significant claim against the treating doctor.
Sadly, in many cases of personal injury where veins and arteries have been damaged, the assessment is simply one of recognising the damage and predicting the future.
Mr John H Scurr
Consultant General and Vascular Surgeon
Senior Lecturer
MBBS (Hons), BSc (Hons 1st Class) FRCS
Tel: 020 7259 0692 & 00 353 1 293 7863
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Established in Dublin in 2000 and expanded to London, to provide expert medical opinion in cases involving medical negligence and personal injury.
