ORIGINAL ARTICLE
A Lower Extremity Musculoskeletal and Vascular Trauma
Protocol in a Children’s Hospital May Improve Treatment
Response Times and Appropriate Microvascular Coverage
Itai Gans, MD,*† Keith D. Baldwin, MD, MSPT, MPH,*† L. Scott Levin, MD, FACS,†
Michael L. Nance, MD, FACS,* Benjamin Chang, MD,*† Stephen J. Kovach III, MD,†
Joseph M. Serletti, MD, FACS,† and John M. Flynn, MD*†
Objectives: Pediatric lower extremity (LE) vascular injuries
present many issues: microvascular surgeons are usually unavailable
to stand-alone pediatric institutions, and the rate of morbidity
including limb loss can be high if revascularization is delayed
beyond the critical period of 8 hours. We assessed if time to
revascularization was impacted by institution of a lower extremity
vascular trauma protocol (LEVP).
Design: Level II retrospective prognostic.
Setting: Level I pediatric trauma center.
Patients/Participants: Pediatric patients presenting with ische-
mic lower extremities requiring urgent management (2000–2013).
Intervention: LEVP—a team of specialized microvascular sur-
geons, who have developed and manage a call schedule for our
pediatric trauma center to offer care 24 h21$d21, 7 d21$wk21, and
365 d21$y21 to our children’s hospital.
Main Outcome Measurements: Treatment team expertise, time
to revascularization, and use of time-delaying preoperative radio-
graphic vascular studies performed before and after initiation of LEVP.
Results: We identified 22 patients with ischemic LEs (16 patients
treated before/6 patients treated after LEVP initiation). Mean time
from admission to definitive vascular care was 6.4 hours preprotocol
(20% . 8 hours)/4.6 hours postprotocol (0% . 8 hours). Before
protocol initiation, 38% of LE vascular injuries were treated by LE
microvascular repair-capable surgeons, and 37.5% had a preoperative
radiographic vascular study compared with 100% and 0%, respec-
tively, postprotocol initiation. Before protocol initiation, 37.5% had
a preoperative radiographic vascular study compared with 0% after
protocol initiation.
Accepted for publication September 23, 2014.
From the *Children’s Hospital of Philadelphia; and †Hospital of the University
of Pennsylvania, Philadelphia, PA.
Presented in part at the Annual Meeting of the American Academy of
Orthopedic Surgeons, New Orleans, LA, March 2014, and as an e-poster
at the Annual Meeting of POSNA, Hollywood, CA, May 2014.
The authors report no conflict of interest.
This study is IRB approved.
Reprints: John M. Flynn, MD, Children’s Hospital of Philadelphia, Division
of Orthopedics, 34th and Civic Center Boulevard, Philadelphia, PA
19104 (e-mail: flynnj@email.chop.edu).
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 29, Number 5, May 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Conclusions: Since LEVP initiation, we have required no pre-
operative radiographic vascular studies, there has not been a revas-
cularization delay of .8 hours, and with appropriate staff surgeon
coverage, the flow of care has improved with the new ability to
address and care for these challenging injuries. To potentially
improve the timeliness of vascular care and better match the skills
of the practitioner to the injury, pediatric centers should consider
implementation of an LEVP within their institutions.
Key Words: lower extremity, vascular, pediatrics, trauma
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2015;29:239–244)
INTRODUCTION
Lower extremity (LE) vascular injuries present unique
challenges for pediatric trauma centers. These injuries occur
relatively infrequently; however, the rate of morbidity (includ-
ing limb loss) can be high. If revascularization is delayed and
limb ischemia exceeds 6–8 hours, irreversible damage to the
muscles and necrosis may occur, dramatically increasing ampu-
tation rates even if delayed revascularization is achieved.1–3
Amputation rates as high as 50%–78% have been reported in
the literature after these urgent LE injuries in adult patients4,5
with little data currently available for the pediatric population.
Vascular surgeons are not routinely available on staff at
pediatric hospitals as they typically are at adult trauma centers
(where these surgeons may also perform elective vascular
surgery). Pediatric vascular surgery as a specialty has not been
developed, and in the majority of stand-alone children’s hos-
pitals, the specialty does not exist. Additionally, the specialized
care of pediatric LE vascular injuries may require the care of
surgeons with microvascular training. In the United States,
there is a paucity of surgeons with microvascular surgical
training, a statistic that is even more dramatic in pediatric
hospitals.6 To offer timely care to children with combined
LE musculoskeletal and microvascular injuries, we developed
a lower extremity vascular trauma protocol (LEVP) (Fig. 1).
The LEVP engages microvascular surgeons capable of per-
forming small vessel anastomosis and arterial repair and/or
grafting to provide uninterrupted coverage for traumatic LE
ischemic vascular injuries at our children’s hospital.
www.jorthotrauma.com | 239
 Gans et al
FIGURE 1. LE trauma—combined mus-
culoskeletal and vascular injury protocol.
The objective of this study was to assess the impact of
this protocol at a Level I pediatric trauma center with
particular focus on patient management before and after
initiation of LEVP.
PATIENTS AND METHODS
We queried the trauma database at our Level I pediatric
trauma center for cases of LE musculoskeletal trauma over
a 13-year period (January 2000–January 2013) and identified
615 patients for further evaluation. We then reviewed these
cases and identified 22 patients presenting with an ischemic
LE requiring urgent management. An LE was considered
ischemic if the patient presented with poor perfusion, pulse-
lessness, pallor, and/or a cold LE. Patients who had under-
gone LE vascular surgery at an outside hospital before
presentation were excluded.
Demographic information, mechanism of injury, diag-
nosis, and treatment details were obtained through retrospec-
tive chart review. We next compared treatment team, time to
definitive vascular treatment, and number of radiographic
vascular studies performed before and after the initiation of
our LE vascular care protocol. A 2-tailed Student t test was
used to compare the data before and after initiation of the
LEVP.
The LE vascular care protocol engages microvascular
surgeons capable of small vessel anastomosis and arterial
repair/grafting to care for traumatic LE ischemic vascular
injuries at our children’s hospital. Our stand-alone children’s
hospital is a large, level I trauma, tertiary care center with 535
240 | www.jorthotrauma.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 29, Number 5, May 2015
inpatient pediatric beds serving .1 million combined inpa-
tient and outpatient patient visits per year with no microvas-
cular surgeons on staff. As such, we contacted a team of
surgeons trained in microvascular surgery at an adjacent adult
trauma center, who agreed to develop and manage a call
schedule for our pediatric trauma center to offer care
24 h21$d21, 7 d21$wk21, and 365 d21$y to our children’s
hospital. This call schedule was established for the care of
pediatric blunt or penetrating vascular injuries requiring
microvascular surgical care, and the team consists of surgeons
who have trained in either orthopedic or plastic surgery with
specialty training in microvascular repair surgery. They have
generally arranged the schedule to be available to our child-
ren’s hospital in a fashion that minimizes the extra call burden
on their current schedules. These surgeons are on-call directly
to the emergency and trauma attending physicians who assess
whether the patient might require specialized microvascular
care based on a physical examination. They directly contact
our microvascular team to avoid spurious calls regarding non-
emergent cases (ie, intravenous infiltration or suspected deep
vein thrombosis). Because the microvascular surgeons volun-
teer to care for our patients with no additional incentive other
than obligation of civic duty, we ensure that the specialized
microvascular team is only contacted with appropriate cases
that require their expertise.
RESULTS
There were 8 females and 14 males with a mean age of
11 years (2–17 years) meeting the inclusion criteria. Sixteen
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
 J Orthop Trauma  Volume 29, Number 5, May 2015 Pediatric Lower Extremity Vascular Trauma Protocol

patients were treated before the initiation of the LEVP, and 6

TABLE 2. Observed Vascular Injuries and Associated
patients were treated after the protocol initiation. Vascular
Orthopedic Injuries
management included closed fracture reduction in 2 cases,
open fracture reduction in 2 cases, untethering of the neuro- No. of Associated No. of
Vascular Injuries Patients Orthopedic Patients
vascular bundle in 1 case, arterial end-to-end anastomosis in 3 Observed (n) Injuries (n)
cases, and artery repair with vein graft in 11 cases. Distal
Deep femoral artery 1 Proximal tibia 8
artery ligation and control to stop arterial bleeding was per- transection fracture
formed in 3 cases deemed to have sufficient distal collateral Superficial femoral 5 Distal femur 5
circulation based on pulse oximetry, capillary refill, and skin artery transection fracture
turgor (Table 1). Only cases requiring the attention of a micro- Popliteal artery 8 Fibula fracture 3
vascular surgeon were included in further analysis. transection
The deep femoral artery was transected in 1 case, Posterior tibialis 2 Open disruption of 2
superficial femoral artery in 5 cases, popliteal artery in 8 artery transection joint capsule
cases, posterior tibialis in 2 cases, and dorsalis pedis in 3 Dorsalis pedis artery 3 Compartment 2
transection syndrome
cases. There was 1 case with tethering of the popliteal
Popliteal 1 Posterior knee 1
neurovascular bundle and 2 cases with compression of the neurovascular dislocation
popliteal artery, which resolved with fracture reduction. bundle tethering
Associated orthopedic injuries included proximal tibia frac- Popliteal artery 2 Lower extremity 1
tures in 8 cases, distal femur fractures in 5 cases, fibula compression degloving
fractures in 3 cases, open disruptions of the joint capsule in 2
cases, compartment syndrome in 2 cases, posterior knee
dislocation in 1 case, and extensive LE degloving requiring
free flap reconstruction in 1 case (Table 2). The mean dura- DISCUSSION
tion of hospitalization was 9.7 days (2–21 days). Pediatric LE vascular injuries are a rare but potentially
A representation of all 22 patients with important devastating event. Amputation rates as high as 50%–78% have
patient demographic, physical examination findings, and been reported in the literature after the occurrence of these
patient level information is presented in Tables 3 and 4. urgent LE injuries.4,5 In 1949, Miller and Welch1 showed in
The mean time from admission to definitive operative experiments on canine limbs that the critical period for arterial
vascular care was 6.4 hours before the initiation of the LEVP repair is 6–8 hours after recognized limb ischemia. Delayed
compared with 4.6 hours postprotocol initiation (P = 0.733). treatment resulted in increased muscle damage, necrosis, gan-
Before the LEVP initiation, 20% of the cases had revascular- grene, and rates of required amputation. These findings have
ization procedures performed at .8 hours after presentation been further validated in recent retrospective analyses on
compared with 0% postprotocol initiation (P = 0.237). human subjects, indicating that revascularization of a traumati-
Before LEVP initiation, 37.5% of the patients had cally induced ischemic LE in ,8 hours significantly decreases
a preoperative diagnostic radiographic vascular study (angio- rates of limb dysfunction and amputation.2,3,7,8
gram or arteriogram) compared with 0% after protocol Since the initiation of our LEVP, there has been no
initiation (P = 0.079). Additionally, before LEVP initiation, delay in definitive vascular treatment of .8 hours. Although
38% of LE vascular injuries were treated by LE the observed difference in our current series did not achieve
microvascular-capable surgeons capable of small vessel anas- statistical significance, this study was not powered to detect
tomosis and arterial repair. Of patients treated before the moderate differences in time to vascular treatment because of
LVEP initiation, 50% were treated by children’s hospital the rarity of pediatric LE ischemic trauma. Nonetheless,
staff, 44% by physicians consulted from an adjacent adult although this difference was not statistically significant, it
hospital, and 6% were transferred to the adult hospital for did represent a .25% decrease in the time to definitive care.
vascular care. After protocol initiation, 100% of LE vascular This decrease is likely clinically significant because urgent
injuries were treated by LE microvascular repair-capable revascularization of the ischemic limb minimizes rates of
adult reconstructive plastic surgeons who have made them- morbidity and LE amputation.1,2,9 Additionally, a statistically
selves available to the pediatric trauma attending surgeons for significant difference was found after the initiation of our
emergent traumatic LE vascular injuries (P = 0.009). LEVP in the microvascular repair training level of treating
surgeons because those surgeons without specialty training in
microvascular repair were no longer required to treat or assess
TABLE 1. Vascular Management Strategies Used
these specialty cases. In this case, matching the appropriate
physician with the appropriate training to treat the appropriate
Vascular Management No. of Patients (n)
injury may improve outcomes and decrease rates of morbidity
Artery repair with vein graft 11 and mortality.
Fracture reduction (only) 4 The majority of clinical data describing optimal treat-
Distal artery ligation and control of 3 ment for combined traumatic LE musculoskeletal and vascu-
bleeding lar injuries are derived from experience in an adult patient
Arterial end-to-end anastomosis 3 population. Adult institutions typically have attending vascu-
Neurovascular bundle untethering 1 lar surgeons on staff and available to care for LE vascular

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. www.jorthotrauma.com | 241

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Gans et al J Orthop Trauma  Volume 29, Number 5, May 2015

TABLE 3. Summary Table of Each Individual Patient Included in This Study Including Injury Details, Mechanism of Injury, Physical
Examination Findings, Vascular Injuries, and Other Comorbidities
Patient Age at Presentation (y) Sex Laterality Use of New LEVP Protocol Mechanism of Injury
1 2.3 F Right No GSW
2 7.8 F Left No Pedestrian versus MV
3 15 M Right No Pedestrian versus MV
4 9.3 M Right No Penetrating glass laceration
5 4.8 M Right No Lawn mower blade injury
6 16.9 M Right No Penetrating knife laceration
7 17.1 M Left No GSW
8 4.4 F Left No GSW
9 8.3 M Right No GSW
10 9.3 M Left No Penetrating injury
11 2.4 F Left No Penetrating glass laceration
12 12.2 F Right No Pedestrian versus MV
13 13.4 M Right No Sports-induced injury (football)
14 8.1 F Left No Pedestrian versus MV
15 15.7 M Right No Pedestrian versus MV
16 13.1 M Right No Pedestrian versus MV
17 14.6 M Right Yes GSW
18 15.4 M Right Yes Penetrating tree branch wound
19 8.4 F Right Yes Penetrating glass wound
20 17.1 M Right Yes Sports-induced injury (soccer)
21 14.9 F Left Yes GSW
22 10.9 M Left Yes Pedestrian versus MV
Significant Physical Examination Findings
DP PT Bony Open Shock 2/2 Blood
Patient Pulse Pulse Deformity Fracture Loss Vascular Injuries Other Comorbidities
1 0 0 No No Yes PA transection Open disruption of joint capsule
2 0 0 No Yes No SFA transection Degloving injury, femur
fracture
3 0 1 No No No PA transection Posterior knee dislocation
4 1 2 No No No DP transection Lacerated tendons
5 0 0 No Yes No PA transection Lacerated tendons
6 0 0 No No Yes DFA transection —
7 0 0 No No Yes SFA transection —
8 0 0 No No Yes SFA transection Femur fracture
9 0 0 No Yes No PA transection Open disruption of joint
capsule, tibia fracture
10 0 0 No No No SFA transection —
11 1 2 No No No DP transection Lacerated tendons
12 0 0 Yes No No PA transection Tibia fracture, impending CS
13 1 2 Yes No No SFA transection Femur fracture
14 0 0 Yes Yes No PT transection Tibia fracture, lacerated tendons
15 0 0 Yes No No PA compression Femur fracture, tibia fracture
16 0 0 Yes No No PA compression Tibia fracture, fibular fracture
17 0 0 Yes Yes No PA transection Fibula fracture
18 2 2 No Yes No DP transection Tibia fracture, lacerated tendons
19 0 0 No No Yes PA transection Lacerated tendons
20 0 0 Yes No No PT transection Tibia fracture, fibula fracture,
CS
21 0 0 Yes Yes No PA transection Tibia fracture
22 0 1 Yes Yes No Tethering of popliteal NV Femur fracture
bundle
0, Nonpalpable nondoplerable; 1, doplerable; 2, palpable; CS, compartment syndrome; DFA, deep femoral artery; DP, dorsalis pedis; F, female; GSW, gun shot wound; M, male;
MV, motor vehicle; NV, neurovascular; PA, popliteal artery; PT, tibialis posterior; SFA, superficial femoral artery.

242 | www.jorthotrauma.com Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 J Orthop Trauma  Volume 29, Number 5, May 2015 Pediatric Lower Extremity Vascular Trauma Protocol

TABLE 4. Summary Table of Each Individual Patient Included in This Study Including Diagnostic Modalities Used, Surgical
Procedure, and Outcome
Diagnostic Limb Salvage Outcome (Limb
Use of New Studies Surgical Procedures Saved Versus
LEVP Arteriogram or Computed Amputated at Time of Latest
Patient Protocol Radiographs Tomography Angiogram OREF, ORIF, CRPP, CREF Follow-Up)
1 No X — Arterial repair with vein graft Limb saved
2 No X X Arterial repair with vein graft, Limb saved
OREF
3 No X X Arterial repair with vein graft Limb saved
4 No X — Distal artery ligation and control of Limb saved
bleeding
5 No X — Arterial end-to-end anastomosis Limb saved
6 No X — Arterial end-to-end anastomosis Limb saved
7 No X — Arterial end-to-end anastomosis Limb saved
8 No X X Arterial repair with vein graft Limb saved
9 No X X Arterial repair with vein graft Limb saved
10 No X X Arterial repair with vein graft Limb saved
11 No X — Distal artery ligation and control of Limb saved
bleeding
12 No X X Arterial repair with vein graft, Limb saved
OREF
13 No X — CRPP Limb saved
14 No X — OREF Limb saved
15 No X — OREF Limb saved
16 No X — CREF Limb Saved
17 Yes X — Arterial repair with vein graft Limb saved
18 Yes X — Distal artery ligation and control of Limb saved
bleeding
19 Yes X — Arterial repair with vein graft Limb saved
20 Yes X — Arterial repair with vein graft, Limb saved
OREF
21 Yes X — Arterial repair with vein graft, Limb saved
OREF
22 Yes X — Untethering of neurovascular Limb saved
bundle, ORIF
CREF, closed reduction external fixation; CRPP, closed reduction percutaneous pinning; OREF, open reduction external fixation; ORIF, open reduction internal fixation.

injuries in the adult patient. There have been few studies that
have analyzed LE vascular ischemia in children and
adolescents, and these articles have not looked at the
initiation of a collaborative, multidisciplinary, care team
and protocol to allow quick and accurate diagnosis and
treatment of pediatric LE ischemia.10–12 In pediatric hospi-
tals, there usually is a mismatch between the availability of
microvascular surgeons capable of small vessel anastomosis
and arterial repair and the urgent need for these services.6
Additionally, the potential for an insidious presentation of
vascular trauma in children and adolescent patients is well
recognized, and potentially increases rates of amputation
and limb dysfunction.12 As such, it is important to have
a multidisciplinary team of experts available who are quite
familiar with the diagnosis and management of pediatric LE
ischemic vascular injuries, including pediatric trauma sur-
geons, pediatric general surgeons, emergency medicine
physicians, orthopedic surgeons, and microvascular sur-
geons. Such is the opportunity garnered by implementation
of an LEVP at pediatric trauma centers.
Some authors have advocated for the decreased use of
preoperative radiographic diagnostic studies (eg, angiography
and arteriograms) in cases of apparent LE vascular ische-
mia.8,13 The use of angiography has been shown to cause
delays in revascularization of the LE without demonstrating
appreciable advantages in terms of limb salvage.14 These
studies have concluded that limb salvage rates are similar in
patients who undergo angiography and those who do not with
the exception that those who undergo angiography are subject
to delays in revascularization, and thus have higher rates or
morbidity postoperatively. As such, the current recommenda-
tions obviate the need of radiographic diagnostic studies to
allow prompt revascularization procedures and minimize
morbidity. Additionally, in children, angiography itself may
pose a risk of vascular injury and vasospasm.15
Since the initiation of our LEVP, we have not required
preoperative radiographic vascular studies at our children’s
hospital compared with the use of such studies in 20% of
cases before protocol initiation. This is most likely because
of the increased staff surgeon knowledge and confidence with

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. www.jorthotrauma.com | 243

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Gans et al
diagnosing these injuries and the need for urgent treatment,
reducing attendant radiation exposure and/or delay caused by
radiographic assessment. At our institution, the emergency
medicine and trauma surgery teams are generally the first to
examine the patient on arrival to our trauma bay. Any concern
for LE vascular injury on physical examination induces mea-
surement of an Ankle-Brachial Index (ABI). Patients with
ABI .0.9 are managed with serial neurovascular examina-
tion, whereas ABIs ,0.9 are reflexively treated with bedside
LE arterial duplex ultrasound. If no vascular injury is identi-
fied, the patient is managed with serial neurovascular exam-
ination; however, if vascular injury is confirmed, the LEVP is
activated. The success of duplex ultrasonographic scanning in
diagnosis of extremity vascular trauma is quite high, with
100% sensitivity and specificity,16 and as such, we advocate
its use in place of time-consuming angiography.
The strength of this study is that we systematically
included consecutive patients from our trauma database over
a 13-year period that presented with both LE musculoskeletal
and vascular injuries. Because this study was performed in
a retrospective fashion, the risk of Hawthorne effect was
negligible, and we believe that the significant improvements
seen in patient management were indeed true. Limitations of
this study include its retrospective nature. Additionally, the
rarity of traumatic combined musculoskeletal and vascular LE
injuries limits the number of patients that we could study in
our analysis of our vascular trauma protocol. However, to the
best of our knowledge, this is the largest cohorts of patients
with combined LE musculoskeletal and vascular injuries in
the literature,10 and the first to analyze an LEVP at a free-
standing children’s hospital. Further, we found a clinically
significant difference in time to definitive vascular surgical
care and in the preoperative use of radiographic vascular
studies allowing a decrease in the proportion of cases being
revascularized beyond the 6- to 8-hour critical period to 0%.
After initiation of the LEVP, all procedures were performed
by vascular repair-capable surgeons participating in the LEVP
at our children’s hospital, and no patient was transferred to
another hospital. Based on the information in this study, the
establishment of an LEVP at major institutions may benefit
the outcomes of patients with these critical vascular injuries.
However, because this is the first study to evaluate the use of
such a protocol, further investigation as to its utility is war-
ranted in the future. Nonetheless, to the best of our knowl-
edge, this is the largest cohort of pediatric patients with LE
vascular injuries for investigating the use of an LE vascular
care protocol.
A 2009 meta-analysis concluded that successful limb
salvage has increased in recent years because of an increased
index of suspicion for vascular injuries and better cooperation
between orthopedic and vascular surgeons.17 Multispecialty
team approaches are warranted in treating these severely
injured children, particularly in cases where amputation
244 | www.jorthotrauma.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 29, Number 5, May 2015
may have been considered in an adult with similar injuries,
because of the improved neurological and functional recovery
seen in pediatric patients, even when significant neurovascu-
lar injury is present.15 Since the initiation of the LEVP,
trauma, orthopedic, and microvascular staff surgeon confi-
dence in the flow of care has improved because of appropriate
coverage for these devastating injures resulting in an
improved ability to address and care for these severe, limb
threatening, injuries, supporting the movement to initiate
LEVPs in pediatric trauma centers. To potentially improve
the timeliness of vascular care and better match the skills of
the practitioner to the injury, pediatric centers should consider
implementation of an LEVP within their institutions.
REFERENCES
1. Miller HH, Welch CS. Quantitative studies on the time factor in arterial
injuries. Ann Surg. 1949;130:428–438.
2. Mullenix PS, Steele SR, Andersen CA, et al. Limb salvage and outcomes
among patients with traumatic popliteal vascular injury: an analysis of
the National Trauma Data Bank. J Vasc Surg. 2006;44:94–100.
3. Wascher DC. High-velocity knee dislocation with vascular injury. Treat-
ment principles. Clin Sports Med. 2000;19:457–477.
4. DiChristina DG, Riemer BL, Butterfield SL, et al. Femur fractures with
femoral or popliteal artery injuries in blunt trauma. J Orthop Trauma.
1994;8:494–503.
5. Ockert S, Winkler M, Richter A, et al. Vascular injuries after extremity
trauma [in German]. Zentralbl fur Chir. 2002;127:689–693.
6. Payatakes AH, Zagoreos NP, Fedorcik GG, et al. Current practice of
microsurgery by members of the American Society for Surgery of the
Hand. J Hand Surg. 2007;32:541–547.
7. Zaraca F, Ponzoni A, Stringari C, et al. Lower extremity traumatic vas-
cular injury at a level II trauma center: an analysis of limb loss risk
factors and outcomes. Minerva Chir. 2011;66:397–407.
8. Braten M, Helland P, Myhre HO, et al. 11 Femoral fractures with vas-
cular injury: good outcome with early vascular repair and internal fixa-
tion. Acta Orthop Scand. 1996;67:161–164.
9. Green NE, Allen BL. Vascular injuries associated with dislocation of the
knee. J Bone Joint Surg Am. 1977;59:236–239.
10. Desai P, Audige L, Suk M. Combined orthopedic and vascular lower
extremity injuries: sequence of care and outcomes. Am J Orthop (Belle
Mead NJ). 2012;41:182–186.
11. Friedman RJ, Jupiter JB. Vascular injuries and closed extremity fractures
in children. Clin Orthop Relat Res. 1984:112–119.
12. Dalsing MC, Cikrit DF, Sawchuk AP. Open surgical repair of children
less than 13 years old with lower extremity vascular injury. J Vasc Surg.
2005;41:983–987.
13. Howard PW, Makin GS. Lower limb fractures with associated vascular
injury. J Bone Joint Surg Br. 1990;72:116–120.
14. Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage fol-
lowing fractures with vascular injury: a systematic review and new man-
agement algorithm. J Plast Reconstr Aesthet Surg. 2009;62:571–579.
15. Nazem M, Beigi AA, Sadeghi AM, et al. Non iatrogenic paediatric
vascular trauma of the extremities and neck. Afr J Paediatr Surg.
2009;6:35–39.
16. Fry WR, Smith RS, Sayers DV, et al. The success of duplex ultrasono-
graphic scanning in diagnosis of extremity vascular proximity trauma.
Arch Surg. 1993;128:1368–1372.
17. Fowler J, Macintyre N, Rehman S, et al. The importance of surgical
sequence in the treatment of lower extremity injuries with concomitant
vascular injury: a meta-analysis. Injury. 2009;40:72–76.
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.