Combined Vascular & Skeletal Trauma

Table of Contents

VASCULA
R TRAUMA

1 Objectives
2 Overview
3 Diagnosis
4 Management
5 The decision to amputate
6 Management Algorithm
6.1 1. Resuscitation
6.2 2. Risk factors for amputation
6.3 3. Amputation technique
6.4 4. Hards signs of vascular injury
6.5 5. Investigation
6.6 6. Fasciotomy
6.7 7a. Damage control
6.8 7b. Definitive repair
6.9 8. Vascular shunts
6.10 9. Skeletal stabilization
6.11 10. Exclusion of clinically significant vascular injury
6.12 11. Wound management
6.13 12. Secondary amputation
6.14 13. Limb salvage
7 References
8 Authors & Contributors

Objectives

1. Understand the clinical manifestations of vascular injury and the

diagnostic approaches to confirm or exclude vascular injury in
complex extremity trauma.
2. Know the appropriate prioritization of management of vascular
injury, skeletal injury, and soft tissue and nerve and tendon injury in
complex extremity trauma
3. Be familiar with the criteria for early amputation in complex
extremity trauma.

Overview

Complex extremity trauma involving both arterial and skeletal injuries

remains challenging. This combination of injuries is rare, comprising only
0.2% of all military and civilian trauma, and only 0.5%-1.7% of all extremity
fractures and dislocations. Vascular and trauma surgeons are more likely
than orthopedic surgeons to encounter these injuries, as 10%-70% of all
extremity arterial injuries are associated with skeletal trauma. In past years,
the great majority of complex extremity injuries in the civilian sector have
been caused by blunt trauma, although in some recent series penetrating
trauma has caused a majority of these injuries. Combat injuries of this type
from military series usually are due to high velocity penetrating trauma.
Combined arterial and skeletal extremity trauma imparts a substantially
higher risk of limb loss and limb morbidity than do isolated skeletal and
arterial injuries. Debakey and Simeone documented this in WWII battle
casualties, in which all injured arteries were ligated, reporting amputation in
60% of all combined injuries and 42% in isolated arterial injuries. Although
McNamara and coworkers(65) reported a substantial improvement in limb
salvage from isolated arterial injuries in the Vietnam War, combined injuries
still had a 10-fold greater rate of limb loss(23% vs 2.5%). These authors
also documented a higher incidence of failed vascular repair among combined
extremity injuries (33%) than among isolated extremity arterial
injuries(5%). Romanoff and coworkers reported more than a 3-fold increase
in limb loss in combined combat extremity trauma compared to isolated
arterial injuries (36% vs 11%) in the hostilities in Israel. This trend has
continued into recent years in the civilian sector, even in the most
experienced trauma centers, where amputation rates approaching 70% still
are reported from combined arterial and skeletal extremity trauma, while less
than 5% of limbs currently are lost following isolated arterial or skeletal
trauma. Limb loss most commonly is attributed to delay in diagnosis and
revascularization in most published series of this unique trauma. Major nerve
damage, extensive soft tissue injury which disrupts collaterals and prevents
adequate vessel coverage, infection, and compartment syndrome are other
reasons for such a high rate of loss of these severely compromised limbs.

Diagnosis

Prompt diagnosis is essential if rapid treatment and optimal limb salvage is to

be achieved in these complex extremity injuries. This requires that a high
index of suspicion of arterial trauma be applied to every injured extremity by
noting whether any hard signs are present (i.e. active hemorrhage, large,
expanding or pulsatile hamatoma, bruit or thrill over wound, absent distal
pulses, and signs of distal ischemiathe 5 Ps: pain, pallor, paralysis,
paresthesias, poikilothermy, or coolness). The presence of hard signs in any
blunt or complex extremity trauma requires immediate arteriography due to
the relatively low incidence of surgically significant arterial injury in this
setting. This is best done by the surgeon as a percutaneous hand-injected
study in the trauma center, or on the operating table, to minimize time delay
while achieving excellent accuracy.

Popliteal artery injury

Popliteal artery injury

Popliteal artery injuries following leg fractures with hard

signs of vascular injury (reduced or absent distal
pulses). Both angiograms were done as one-shot
percutaneous angios and patients were then operated
on immediately.

The absence of hard signs excludes major arterial injury with sufficient
accuracy to allow further diagnostic workup to be avoided. Since most
complex extremity trauma does not manifest hard signs, avoiding the
considerable expense of arteriography in this population has substantial
economic advantages.

Superficial femoral
artery injury - intimal
flap

Resolution at 6
weeks

Blunt supracondylar femur fracture with

asympomatic superficial femoral artery
nonocclusive intimal flap identified on ER
angiography. Non-operatively observed.

Popliteal artery
injury nonocclusive

Resolution at 1
week

Undisplaced tibial plateau fracture

from gunshot wound with no hard
signs. Angiogram shows nonocclusive intimal injury of the

popliteal artery. The injury was

observed and repeat angiogram one
week later documents complete
resolution.

6 weeks later, after ORIF, repeat

angiogram documents complete
resolution of arterial injury.

This principle holds true even for the especially high-risk injury of posterior
knee dislocation, in which setting routine arteriography has been advocated
in all cases, due to a substantial risk of popliteal artery disruption and its
associated high rate of limb loss. However, those published studies that
compare the clinical manifestations of patients with posterior knee dislocation
with outcome show no surgically significant arterial injuries in that majority
of patients who have no hard signs (Table 1), confirmed by follow-ups of up
to 2 years. Again, most cases present without hard signs, allowing major
resource savings at no harm to the patient by using only physical findings to
exclude arterial injury. Arteriography is indicated only in that minority of
patients with knee dislocation presenting with hard signs, to exclude the
need for surgery in those 30% of patients who do not have an arterial injury.
Immediate surgery without imaging may be undertaken if the clinical picture
clearly indicates vascular injury(i.e. absent pulse, cold ischemic foot).

Table 1: Relation of Physical Findings of Vascular Injury to

Outcome Following Knee Dislocation
Author

No.
KD

Hard Signs Present

No.
(%) a

Surgery
(%)

Hard Signs Absent

No.
(%) a

Surgery(%)

Kaufman et
al

19

4 (21)

4 (100)

15 (79)

Treiman et
al

115

29 (25)

22 (75)

86 (75)

Dennis et al

38

2 (13)

2 (100)

36 (87)

Kendall et al

37

6 (16)

6 (100)

31 (84)

Miranda et
al

32

8 (25)

6 (75)

24 (75)

Martinez et
al

23

11 (48)

2 (18)

12 (52)

Hollis et al

39

11 (28)

7 (64)

28 (72)

Stannard et
al

134

10 (8)

9 (90)

124 (93)

Total

437

81 (18)

58 (72)

356
(82)

There is no clear role for noninvasive testing in the initial evaluation of

complex extremity injuries (Doppler pressures or signals, duplex U/S), due to
a paucity of studies of their use in this category of trauma, and uncertainty

over its accuracy in the presence of severe tissue disruption and large bulky
dressings. Further study is necessary to clarify this. Again, the physical exam
quite clearly answers all questions of management in this setting, as absent
pulses mandates ruling out vascular injury, and present pulses in the absence
of other hard signs reliably excludes vascular injury as well as any imaging
modality. Noninvasives add nothing and may lead the examiner astray, as
Doppler flow signals may be transmitted by collaterals around a completely
occluded or transected vessel, while a pulse can not. Thus, Doppler flow
signals DO NOT exclude a vascular injury. The presence or absence of a pulse
is all that is necessary to decide on the next step in diagnosis.

Management

Appropriate prioritization of the management of the vascular and skeletal

injuries is a major determinant of limb salvage. Initial fracture stabilization
and fixation has been advocated in past years, due to concerns that an
established vascular repair will be disrupted by subsequent orthopedic
manipulation, as long as there is no overt ischemia. However, published
evidence has refuted such concerns, showing minimal disruption of initial
vascular repairs, and no adverse impact of prompt revascularization on
outcome. Also, substantial tissue damage still can occur in the absence of
clinical signs of ischemia, as our understanding of compartment syndrome
has made clear. Further, clinical studies have shown a substantially higher
rate of limb salvage among combined vascular and skeletal extremity injuries
in which revascularization is performed first, compared with those in which it
is delayed until the skeleton is addressed.

ER Arteriogram

Popliteal artery - End to end

anastomosis

Completion
arteriogram

Undisplaced, stable blunt tibial plateau fracture with no distal pulses. ER

angiogram identified the popliteal artery injury. Immediate exploration and
repair with end to end anastomosis, followed by internal fixation. Completion
angiogram documents two vessel flow to foot. Prophylactic fasciotomy was
performed.

In fact, definitive vascular repair should be delayed in cases of unstable or

severely comminuted fractures or dislocations, segmental bone loss, or
severe soft tissue destruction and contamination, due to the risk of undue
tension or slack on the repaired vessel when the limb is fixed at its proper
length, and to the possibility of disruption from skeletal manipulation. But
this should not ever delay immediate restoration of perfusion to the
extremity, which can be accomplished rapidly by temporary intraluminal
shunting until skeletal stabilization and soft tissue debridement has been
completed. Alternatively, immediate definitive vascular repair should be the
means of initial revascularization in the setting of uncomplicated and stable
skeletal injuries in which minimal subsequent manipulation and length
discrepancy is anticipated.

Arteriogram

Popliteal artery injury

Shunt in place

Comminuted supracondylar femur crush fracture with no pulses. On-table

angio in the operating room documented popliteal artery injury, leading
to immediate vascular exploration. Transected popliteal artery was
isolated, controlled, and shunted to restore distal flow while ex-fix placed
to stabilize joint. Definitive arterial repair was then performed.

External fixation of the skeleton is preferred when rapid stabilization is

necessary, in open, comminuted and unstable fractures, or in the presence of
severe soft tissue disruption and contamination. Internal fixation has been
used successfully in this setting, and is preferred if the patient s condition
permits.
The consensus of authorities now favors limb revascularization as the first
priority in all combined extremity trauma. How the revascularization is
accomplished(i.e. definitive repair or temporary shunting) is a matter of
judgement based on the nature of the skeletal and soft tissue injuries and
the condition of the patient. Only with a cooperative multidisciplinary effort,
with close communication between the trauma, orthopedic and plastic
surgeons, can the outcome of these injuries be optimized.

Elbow fracture-dislocation

Shunt in brachial artery

Saphenous vein repair

Completion arteriogram
Blunt elbow fracture-dislocation with brachial artery transection and
large soft tissue degloving. Transected brachial artery was shunted and
a cross-elbow ex-fix placed to stabilize the joint. Then a reversed
saphenous vein graft arterial repair was performed. The completion
angio documents two vessel flow to hand.

In addition to prompt diagnosis with on-table arteriography, liberal use of a

number of surgical adjuncts has improved limb salvage following combined
arterial and skeletal extremity trauma. Intra-operative completion
arteriography is important to document patency of the repair, as any
technical errors could easily result in limb loss in these severely compromised
limbs. Four compartment fasciotomy should be applied liberally and
prophylactically in this setting due to the high risk of compartment syndrome
following reperfusion. Extra-anatomic bypass, and pedicled or free-tissue flap
coverage should be considered in the setting of severe contamination and
soft tissue injury or loss to protect the vascular repair. Careful attention to all
of these considerations, as well as to avoiding unnecessary surgery for
nonocclusive arterial lesions, and meticulous postoperative surveillance, has
led to dramatic improvements in limb salvage, with amputation rates even in
this challenging setting falling below 10% in a small number of recent
studies.

The decision to amputate

Among the most difficult challenges in the management of complex

extremity trauma is the decision as to whether and when amputation is
indicated. Recent advances in the ability to salvage limbs have led to
prolonged and aggressive reconstruction efforts following injuries which
would have undergone amputation in the past. Such heroic efforts actually
may harm patients in terms of prolonging hospitalization and time lost from
work, as well as increasing sepsis, operative procedures, and even mortality.
These outcomes are especially undesirable if amputation or severe limb
dysfunction ultimately occur anyway.
Although it is often difficult to predict soon after injury which extremities will
require amputation, there are injuries of such destruction and severity that a
decision for immediate, or primary, amputation can be made easily. These
are injuries in which it is obvious that attempts at revascularization are futile
due to the extent of soft tissue and skeletal trauma, major nerves are
transected, or other life-threatening injuries are present which prevent any
attention to the limbs. Gustilo III-C injuries (comminuted open tibial-fibular
fractures with arterial injury) are an example of limb trauma generally
mandating immediate amputation.
However, most complex extremity injuries are not that clear cut. In these
cases, immediate revascularization should be performed, along with
important surgical adjuncts such as shunts, fasciotomy, or extra-anatomic
bypass, the skeleton should be stabilized promptly by either traction or
external fixation, and then the extremity should be observed over the next
24-48 hours to determine what level of function and tissue viability returns.
Nerve transection never should be assumed, but only determined by direct
visualization, as vascular insufficiency or muscle damage alone may cause
profound deficits that can be confused with nerve damage. If
revascularization fails, tissue loss is severe or worsens, systemic sepsis or
crush syndrome develops, or profound neurologic or functional deficits
persist, amputation then should be performed. If improvement occurs, limb
salvage may proceed, but should be assessed just as critically at each
successive stage to minimize unnecessarily prolonged, costly and futile
efforts.

Mangled Upper Extremity

Mangled upper extremity
treated by immediate
amputation.

Crush to lower leg

Comminuted tibia & fibula
fractures from crush injury
in a 64 year old diabetic
male with no distal pulses
and acute ischemic
changes. Underwent
immediate below-knee
amputation.

A number of scoring systems have been developed to objectify this difficult

decision that is so often clouded by subjective and wishful thinking, often at
the patients expense. Although none have been found to be prospectively
useful in predicting amputation or the degree of functional impairment, they
do focus attention on those factors which most closely correlate with
outcome, and which must be a part of the treatment decision.
High-Risk Factors for Ultimate Limb Loss or Severe Dysfunction

Gustilo III - C skeletal injuries

Transected tibial or sciatic nerve

Transection of 2 of 3 upper extremity nerves

Prolonged ischemia (> 6-12 hours)

Shock and life-threatening associated injuries

Below-knee arterial injury

Extensive soft tissue loss

Crush injury

Multiple fractures

Elderly with medical comorbidity

Severe contamination

Patient preference

Another major consideration in this decision is whether the injury is in the

upper or lower extremity, as the former is less likely to require amputation,
being more tolerant of deficits in protective sensation, motor function,
weight-bearing concerns, and length discrepancy, and prostheses tend to be
less satisfactory.
This decision must be a matter of clinical judgement based on each individual
case, and it must always involve a consensus of the entire health care team,
including the trauma, orthopedic, vascular and plastic surgeons,
rehabilitation specialist, psychologist, nursing, and most importantly the
patient and family. The sophistication of limb prostheses, prompt return to
work, short hospitalizations and lower costs and morbidity following early
amputation are often preferable to salvage efforts which may take months or
years and still fail. The ultimate goal is to return the patient to a comfortable,
self-sufficient and productive life as quickly as possible.

Management Algorithm

1. Resuscitation
Resuscitation and management of all life-threatening injuries must take
priority over any extremity problems. Only active extremity hemorrhage
must be controlled at this time by direct pressure, tourniquet, or direct
clamping of visible vessels (in that order of preference) as a life saving
measure. Blind clamping in wounds is discouraged and potentially harmful to
limb salvage.
Once attention is directed to the extremity, neurovascular injury must be
assumed in all injured extremities until definitively excluded as the first
diagnostic priority. Vascular injury must be found and treated within 6 hours
to maximize the chance of limb salvage, as it is the major determinant of
limb salvage.

2. Risk factors for amputation

Gustilo III-C injuries comminuted, open tib-fib fractures with

vascular disruption.

Sciatic or tibial nerve, or two of the three major upper extremity

nerves, anatomically transected

Prolonged ischemia (>4-6 hours)/muscle necrosis

Crush or destructive soft tissue injury

Significant wound contamination

Multiple/severely comminuted fractures/segmental bone loss

Old age/severe co-morbidity

Lower vs. upper extremity

Apparent futility of revascularization/failed revascularization

These factors have been applied over the course of the last two decades in
several scoring systems to predict primary amputation. Although the scoring
systems have validated these factors to be associated with a worse prognosis
for limb salvage, none have adequate prospective reliability to permit a
definitive decision for amputation to be made solely based on a score alone.

3. Amputation technique
If early amputation is deemed necessary, a guillotine-type amputation
should be performed at an appropriate level above the destructive wound.
Marginally viable soft tissue should be preserved and the open wound
copiously irrigated and dbrided of contaminating debris. The amputation
stump should be dressed with a bulky absorbent dressing and protective
splint if amputation is below the knee and/or elbow. Early return to the
operating room for further wound debridement and definitive management
should be anticipated.

If the need for amputation is not clear on initial presentation, limb salvage
should be attempted and the extremity observed carefully for the next 24-48
hours for soft tissue viability, skeletal stability, and sensorimotor function.

4. Hards signs of vascular injury

Active hemorrhage

Large, expanding or pulsatile hematoma

Bruit or thrill over the wound(s)

Absent palpable pulses distally

Distal ischemic manifestations (pain, pallor, paralysis, paresthesias,

poikilothermy, or coolness)

5. Investigation
The presence of any one or more hard signs mandates immediate arterial
imaging to confirm or exclude vascular injury. Most hard signs in this setting
(as much as 87%) are NOT due to vascular injury, but rather to soft tissue
and bone bleeding, traction of intact arteries to lose pulses, or compartment
syndrome. When imaging is not possible, immediate surgical exploration of
the vessel at risk must be done. If these measures exclude surgically
significant vascular injury (i.e. no occlusion, extravasation, transection) then
the treatment of soft tissue and skeletal injuries may proceed. *How this
reperfusion is achieved depends on the patients hemodynamic status,
physiologic parameters, skeletal stability, wound characteristics, and resource
availability.

6. Fasciotomy
A 2-incision, 4 compartment fasciotomy of the distal extremity should be
performed liberally in complex extremity trauma at the time of initial
revascularization due to the high risk of compartment syndrome. If it is
elected not to do this immediately, observation must include the frequent
direct measurement of compartment pressures due to the poor sensitivity of
the clinical examination for the presence of compartment syndrome.

7a. Damage control

A definitive vascular repair should be avoided, and there should be
consideration for placement of a temporary intraluminal shunt in the
proximal and distal ends of the injured vessel after distal thrombectomy and
regional or systemic heparinization (if not contraindicated) in the following
settings:

Hemodynamic instability, coagulopathy, acidosis, hypothermia of the

patient

Unstable skeleton

Major wound contamination/infection or soft tissue deficits precluding

wound coverage

Requirement for any definitive repair more complex than lateral

suture or end to end anastomosis (i.e. extra-anatomic bypass,
interposition graft)

Austere environment with no resources for definitive management

Other life threatening injuries requiring urgent management

If tourniquet control or ligation of injured extremity vessels are the only

means of controlling life-threatening hemorrhage, and reperfusion is not
possible due to the nature of the wound or the environment, then immediate
evacuation is necessary to achieve revascularization within 6 hours if limb
salvage is to be attempted.

7b. Definitive repair

Definitive repair should be performed provided:

Hemodynamic and physiologic stability of patient

Stable skeleton

Clean wound with adequate viable soft tissue

Availability of necessary time and resources

No other injuries requiring more urgent management

8. Vascular shunts
Many commercial plastic intraluminal shunts are available. However plastic IV
tubing, or connecting tubing that accompanies many closed suction drains, is
sufficient if irrigated with heparinized saline before use. The ends of the
tubing are placed in the proximal and distal segments of the injured artery,
secured by a silk suture tied around the vessel over the shunt and then also
tied directly on the shunt itself to prevent dislodgement. Alternatively, shunt
clamps are available to clamp the vessel over the shunt. Flow through the
shunt should be monitored regularly by palpating distal arterial pulsation
and/or using a Doppler device to detect flow signals through the shunt or
distal vessel. If flow ceases, the shunt and distal vessel must be
thrombectomized with a Fogarty catheter and reinserted. If not
contraindicated, systemic heparinization may facilitate shunt flow.

9. Skeletal stabilization
Only skeletal stabilization by splint or external fixation should be done after
reperfusion in those settings found in 7a above. Definitive internal fixation of
skeletal extremity injuries should be delayed until conditions in 7b above are
reached, and after definitive vascular repair is performed.

10. Exclusion of clinically significant vascular injury

The absence of any hard sign in an injured extremity excludes a surgically
significant vascular injury as reliably as any imaging modality. If all hard
signs are absent, no vascular imaging or exploration is necessary, and
treatment of skeletal and soft tissue injuries may proceed immediately.

11. Wound management

Wounds should be inspected frequently and any dead/necrotic tissue should
be dbrided and dressings changed accordingly.

12. Secondary amputation

Amputation after initial attempts at limb salvage should be considered if risk
factors for limb loss persist. However, the patient s family, as well as
involved surgical specialists, should be informed and involved in this decision
whenever possible. Efforts to avoid excessive morbidity, cost, procedures,
and hospital stay for limbs that will ultimately be amputated or without
function should be avoided. Any adverse impact of the extremity on the
patients health, i.e. sepsis, rhabdomyolysis, hyperkalemia, ARDS, or other
life-threatening problems mandate immediate secondary amputation.

13. Limb salvage

Continue limb salvage efforts and monitor patient closely for changes that
may warrant secondary amputation.

References

1. Howe HR, Poole GV, Hansen KJ, et al: Salvage of lower extremities
following combined orthopedic and vascular trauma: A predictive salvage
index. Am Surg 53:205,1987.
2. McNamara JJ, Brief DK, Stremple JF et al: Management of fractures with
associated arterial injury in combat casualties. J Trauma 13:17,1973.
3. Applebaum R. Yellin AE, Weaver FA et al: Role of routine arteriography in
blunt lower extremity trauma. Am J Surg 160:221,1990.
4. Norman J, Gahtan V, Franz M et al: Occult vascular injuries following
gunshot wounds resulting in long bone fractures of the extremities. Am Surg
61:146,1995.
5. Miranda FE, Dennis JW, Veldenz HC et al: Confirmation of the safety and
accuracy of physical examination in the evaluation of knee dislocation for
popliteal artery injury: A prospective study. J Trauma 49:375,2000.
6. Feliciano DV, Mattox KL, Graham JM et al: Five-year experience with PTFE

grafts in vascular wounds. J Trauma 25:71,1985.

7. Feliciano DV, Accola KD, Burch JM et al: Extraanatomic bypass for
peripheral arterial injuries. Am J Surg 158:506,1989.
8. Khalil IM, Livingston DH: Intravascular shunts in complex lower limb
trauma. J Vasc Surg 4:582,1986.
9.Mubarak SJ, Hargens AR: Acute compartment syndromes. Surg Clinic North
Am 63:539,1983.
10. Feliciano DV, Cruse PA, Spjut-Patrinely V et al: Fasciotomy after trauma
to the extremities. Am J Surg 156:533,1988.
11. Attebery LR, Dennis JW, Russo-Alesi F et al: Changing patterns of arterial
injuries associated with fractures and dislocations. J Am Coll Surg
183:377,1996.
12. Bishara RA, Pasch AR, Lim LT et al: Improved results in the treatment of
civilian vascular injuries associated with fractures and dislocations. J Vasc
Surg 3:707,1986.
13. Johansen K, Daines M, Howey T et al: Objective criteria accurately
predict amputation following lower extremity trauma. J Trauma 30:568,1990.
14. Palazzo JC, Ristow AB, Cury JM et al: Traumatic vascular lesions
associated with fractures and dislocations. J Cardiovasc Surg 27:688,1986.
15. Romanoff H, Goldberger S: Combined severe vascular and skeletal
trauma: management and results. J Cardiovasc Surg 20:493,1979.
16. Kaufman SL, Martin LG: Arterial injuries associated with complete
dislocation of the knee. Radiology 184:153,1992.
17. Treiman GS, Yellin AE, Weaver FA et al: Examination of the patient with a
knee dislocation: the case for selective arteriography. Arch Surg
127:1056,1992
18. Dennis JW, Jagger C, Butcher JL et al: Reassessing the role of
arteriograms in the management of posterior knee dislocations. J Trauma
35:692,1993.
19. Kendall RW, Taylor DC, Salvian AJ et al: The role of arteriography in
assessing vascular injuries associated with dislocations of the knee. J Trauma
35:875,1993.
20. Martinez D, Sweatman K, Thompson EC: Popliteal artery injury
associated with knee dislocations. Am Surg 67:165,2001.
21. Durham RM, Mistry BM, Mazuski JE et al: Outcome and utility of scoring
systems in the management of the mangled extremity. Am J Surg
172:569,1996.
22. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of
reconstruction or amputation of leg-threatening injuries. N Engl J Med

2002;347:1924-31.
23. Stannard JP, Sheils TM, Lopez-Ben RR, et al: Vascular injuries in knee
dislocations: the role of physical examination in determining the need for
arteriography. J Bone Joint Surg 2004;86A:910-915.
24. Hollis JD, Daley BJ. 'Knee Dislocations: is arteriography always
necessary? 10-year institutional review.' Abstract EAST January 2004. J
Trauma 2004;56:227

Authors & Contributors

Eric R. Frykberg, MD. FACS

Professor of Surgery, University of Florida, Jacksonville, Florida

trauma.org 10:5, May 2005