𝗖𝗔𝗦𝗘 02

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L𝗶𝗺𝗯 𝗦𝗮𝗹𝘃𝗮𝗴𝗲 𝗔𝗳𝘁𝗲𝗿 𝗦𝘂𝗽𝗲𝗿𝗳𝗶𝗰𝗶𝗮𝗹 𝗙𝗲𝗺𝗼𝗿𝗮𝗹 𝗔𝗿𝘁𝗲𝗿𝘆 𝗜𝗻𝗷𝘂𝗿𝘆 𝗶𝗻 𝗮 𝟭𝟲-𝗬𝗲𝗮𝗿-𝗢𝗹𝗱 𝗠𝗼𝘁𝗼𝗿𝗰𝘆𝗰𝗹𝗲 𝗥𝗶𝗱𝗲𝗿

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A 16-year-old boy was transferred from a regional hospital following a road traffic collision while riding a motorcycle.

Initial assessment revealed a head injury, suspected abdominal trauma, and a displaced left distal femoral shaft fracture. Fortunately, NCCT brain imaging was normal, serial FAST examinations were negative, and no life-threatening intra-abdominal injuries were identified.

However, attention was quickly drawn to the left lower limb.

The limb was cold with absent distal pulses, raising immediate concern for acute arterial injury and limb-threatening ischemia.

Following exclusion of immediately life-threatening injuries, the patient was transferred directly to the operating theatre.

The orthopedic team first stabilized the fracture using an external fixator. Simultaneously, the contralateral great saphenous vein was mapped and prepared in anticipation of possible vascular reconstruction.

Exploration of the superficial femoral artery through a medial approach revealed thrombosis at the level of the femoral fracture.

Following arteriotomy, Fogarty thrombectomy produced excellent inflow and back bleeding. At first glance the artery appeared externally intact. However, the presence of localized thrombosis precisely at the fracture level strongly suggested an occult intimal injury.

This represents an important principle in vascular trauma surgery:

𝗔 𝘁𝗵𝗿𝗼𝗺𝗯𝗼𝘀𝗲𝗱 𝗮𝗿𝘁𝗲𝗿𝘆 𝗮𝘁 𝘁𝗵𝗲 𝘀𝗶𝘁𝗲 𝗼𝗳 𝗮 𝗳𝗿𝗮𝗰𝘁𝘂𝗿𝗲 𝘀𝗵𝗼𝘂𝗹𝗱 𝗯𝗲 𝗮𝘀𝘀𝘂𝗺𝗲𝗱 𝘁𝗼 𝗵𝗮𝘃𝗲 𝗮𝗻 𝗶𝗻𝘁𝗶𝗺𝗮𝗹 𝗶𝗻𝗷𝘂𝗿𝘆 𝘂𝗻𝘁𝗶𝗹 𝗽𝗿𝗼𝘃𝗲𝗻 𝗼𝘁𝗵𝗲𝗿𝘄𝗶𝘀𝗲.

Rather than relying on thrombectomy alone and risking early re-thrombosis, approximately 3 cm of the injured arterial segment was resected and reconstructed using a reversed contralateral great saphenous vein interposition graft.

The reconstruction demonstrated excellent inflow, back bleeding, and distal perfusion following completion of the anastomoses.

By the time revascularization was achieved, ischemic time had exceeded six hours. Given the high risk of reperfusion-related compartment syndrome, prophylactic fasciotomy was performed.

The anterior and lateral compartments demonstrated good contractility. The posterior compartments (superficial and deep) initially appeared dusky with reduced muscle response but gradually recovered healthy color and improved contractility following restoration of arterial flow.

The fasciotomy wounds were intentionally left open for planned delayed closure.

Immediately following reperfusion, the patient developed significant physiological instability. Blood pressure dropped to approximately 80/50 mmHg, oxygen saturation decreased, and aggressive resuscitation became necessary. Blood products were administered intraoperatively, and the patient required postoperative intensive care support.

This dramatic response was consistent with severe ischemia-reperfusion physiology following prolonged limb ischemia.

Creatine kinase levels were markedly elevated in the postoperative period but gradually declined over the following days. The patient was successfully extubated and continued to improve clinically.

Most importantly, limb viability was preserved. Distal perfusion was restored, motor function was maintained, and no major vascular complications occurred.

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𝗞𝗲𝘆 𝗟𝗲𝗮𝗿𝗻𝗶𝗻𝗴 𝗣𝗼𝗶𝗻𝘁𝘀

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Exclude life-threatening injuries before treating limb-threatening injuries.

A cold pulseless limb associated with a femoral fracture should be considered a vascular emergency.

A macroscopically normal artery may conceal a significant intimal injury.

Skeletal stabilization before definitive vascular reconstruction provides a safer and more durable repair.

Prophylactic fasciotomy should be strongly considered when ischemia time exceeds six hours.

Revascularization saves limbs, but the physiological consequences of reperfusion can be profound and should always be anticipated.

This case highlights the importance of coordinated trauma, orthopedic, vascular, anesthesia, ICU, and nursing care in achieving successful limb salvage following major vascular trauma.

Patient identity protected. Images shared for educational purposes with appropriate consent.