Complications of Extremity Vascular Injuries in Conflict Kate V. Brown, BM BCh, MRCS, Arul Ramasamy, MRCS, Nigel Tai, MS, FRCS, Judith MacLeod, Mark Midwinter, MD, and Jon C. Clasper, DPhil Introduction: The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, second- ary amputation, and graft thrombosis). Aim: The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury. Methods: A prospectively main- tained trauma registry was retrospectively reviewed for all UK military casualties with extremity injuries (Abbreviated In- jury Score >1) December 8, 2003 to May 12, 2008. Demographics and the details of their vascular injuries, management, and outcome were documented using the trauma audit and medical notes. Results: Thirty-four patients (34%)—37 limbs (30%)— had sustained a total of 38 vas- cular injuries. Twenty-eight limbs (22.6%) had an associated fracture, 9 (7.3%) did not. Twenty-nine limbs (23.4%) required immedi- ate revascularization to preserve their limb: 16 limbs (13%) underwent an initial Damage Control procedure, and 13 limbs (10.5%) un- derwent Definitive Surgery. Overall, there were 25 limbs (20.2%) with complications. Twenty-two were in the 28 limbs with open fractures, 3 were in the 9 limbs without a fracture ( p < 0.05). There was no significant difference in the complication rate with re- spect to upper versus lower limb and dam- age control versus definitive surgery. Conclusion: We have demonstrated that prognosis is worse after military vascu- lar trauma if there is an associated fracture, probably due to higher energy transfer and greater tissue damage. Key Word: Gunshot wound. J Trauma. 2009;66:S145–S149. A s with previous conflicts, the limbs remain the most common sites of combat injuries in current military operations in Iraq and Afghanistan. 1 The high-energy injuries seen after blast or gunshot wounds are associated with significant damage to soft tissue and bones, 2–4 and vascular injury is also relatively common with military wounds, particularly to the extremities. 5,6 Considerable advances have been made in the manage- ment of military vascular injuries, during conflicts in Korea, Vietnam, and more recently, Iraq and Afghanistan. 5,7–12 As a result, reconstruction of damaged vessels to preserve life and limb is now routine practice. 5,7,8 –12 Unfortunately, complications (infection, graft thrombo- sis, secondary amputation) after vascular repair for trauma are relatively common, particularly in the presence of an associated fracture. This is true for both civilian 13 and military wounds. 14,15 Unlike, most civilian vascular injuries, military wounds are heavily contaminated 16,17 hence, the combination of military injury, an open fracture and an associated vascular injury is likely to have a significant complication rate. This could influ- ence the outcome after limb salvage surgery. The purpose of this study was to review our experience with, and study the complication rate after, extremity vascular injury in conflict. In particular, the aim was to analyze how the complication rate was influenced by the presence or absence of a bony injury, when limb salvage was attempted. MATERIALS AND METHODS As part of an ongoing study of military personnel who have sustained life and limb threatening injuries in Iraq and Afghanistan, we specifically reviewed, retrospectively, those casualties who had sustained vascular injuries. The database for United Kingdom (UK) service personnel injured on op- erational tour (JTTR) was commenced from December 8, 2003, so this was chosen as our start date and all injured military personnel are entered prospectively. Data collection finished when this study began on April 12, 2008. The data- base collects all patient demographics, mechanism of injury and clinical parameters from point of wounding, the Emer- gency Department and the Operating Room including medi- cations administered. Casualties were identified by using the database and searching in the limb category for those with Abbreviated Injury Score (AIS) 2. AIS = 1 is for minor wounds only so would not include any patient with a signif- icant extremity injury, involving either bone or vascular structures. All casualties had their trauma audit and clinical records reviewed. The latter includes their notes from oper- ational theater (Field Hospital) and their in-patient notes from Selly Oak Hospital, Birmingham, where all UK service per- sonnel are evacuated for definitive care. Basic demographic data collected included patient age, sex, date and timings of injury, mechanism of injury, and the time delay from wounding to surgery. Specific patterns of Submitted for publication November 17, 2008. Accepted for publication January 16, 2009. Copyright © 2009 by Lippincott Williams & Wilkins From the Academic Department of Military Surgery and Trauma, Royal College of Defence Medicine, Birmingham, United Kingdom. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Department of the Army or the Department of Defense. Address for reprints: Ms. Kate Brown, BM BCh (Oxon), Institute of Research and Development, Birmingham Research Park, Birmingham B15 2 SQ, United Kingdom; email: katevbrown@aol.com. DOI: 10.1097/TA.0b013e31819cdd82 The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 66 • Number 4 S145