Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVIII: Vascular Injuries

Postoperative Care

United States Department of Defense

After arterial repair, the injured limb should be kept at or slightly above the level of the heart. If the extremity has been flexed, gradual extension over a period of several days is encouraged to avoid development of a contracture. Equinus deformity of the ankle is prevented by assuring that the ankle is splinted in a neutral position. Active muscle exercises are begun in the early postoperative period. As soon as other injuries permit, ambulation is encouraged and progressively increased.

When arterial continuity has been restored in situations where there is questionable viability of muscle tissue, the patient must be observed closely for (1) a decrease in urinary output, which is evidence of acute renal insufficiency; (2) increasing temperature and pulse rate as evidence of wound infection; and (3) increasing pain, confusion, fever, and tachycardia. These latter signs of toxicity may be evidence of clostridial myositis. Myoglobinuria may result from muscle necrosis. Development of any of the above are indications for debridement of necrotic muscle or for early amputation of a clearly nonviable extremity. If the vascular repair fails, but none of these complications develops, amputation of the nonviable extremity can be deferred until a clear line of demarcation is established.

If fasciotomies were not performed at the time of arterial repair, the patient must be carefully observed for development of a compartment syndrome Fasciotomy should be seriously considered at the time of arterial repair when there has been a concomitant major venous injury, when there has been a delay of greater than six hours between arterial injury and repair, when there has been an associated crush injury or muscle maceration, and when significant edema is already present at the time of operation. Therapeutic fasciotomies should be performed at the first clinical evidence of an increase in compartment pressures as manifested by loss of previously present pulses, or the development of paresthesias or anesthesia in the distribution of the major nerves supplying the affected part. In the upper extremity, additional clinical signs suggesting the need for fasciotomy include pain on passive motion of the fingers and thumb, and spasm of the wrist and finger flexors leading to a persistent flexion attitude of these structures. In the lower extremity, the first nerve to suffer is the deep peroneal, as manifested by pain on passive motion of the ankle and great toe and decreased sensation in the dorsal web space between the great toe and the second toe.

If compartment pressures are measured, a pressure between 30-40 mm Hg should increase ones vigilance and should lead to fasciotomy if signs and symptoms develop. A compartment pressure greater than 40 mm Hg represents a recognized indication for fasciotomy. In the lower leg, adequate decompression of all four compartments can be obtained through two incisions. One posteromediallyplaced incision is used to open the superficial and deep posterior compartments. A second incision placed anterolaterally is used to open the anterior and lateral compartments. The vertical skin incisions should measure 10-12 cm in length and should be left open for delayed primary closure or skin grafting, if necessary. The fascia can be opened all the way to the ankle using either a fasciotome or scissors.

Fasciotomy of the forearm and hand requires four incisions. Two are placed vertically on the dorsum of the hand between the second and third and the fourth and fifth metacarpals, respectively. A third incision is placed vertically on the dorsum of the forearm. The final incision is used to decompress the flexor compartment of the forearm and the palm of the hand. This incision is a lazy-S which starts on the proximal ulnar forearm, curves across to the radial flexor forearm, returns to the ulnar forearm, then extends to the mid-palm just ulnar to the thenar crease.

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Operational Medicine 2001

Health Care in Military Settings

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