Severe head injury combined with orthopedic and vascular trauma of the limbs.

From 1982 to 1992, 2766 brain injury patients were admitted to the University Hospital San Cecilio of Granada, Spain. In 873 cases head injury was concomitant with other injuries but the association of severe head injury and combined orthopedic and vascular trauma of the limbs was observed only in 23 cases (incidence 2%). Thirteen patients were scheduled for revascularization, and of these secondary amputation was mandatory in two cases to keep rising intracranial pressure under control. Except for epidural hematomas which constitute an absolute neurosurgical emergency, combined orthopedic and vascular trauma of the limbs can be treated before head injury. However, we prefer to work with two operating teams simultaneously. Physical examination and judicious arteriography provide means for prompt diagnosis and treatment of the injured limb. The compartment syndrome should be anticipated and fasciotomy should be used routinely. Vascular repairs normally using reverse autogenous vein are the first priority, but we must always bear in mind the deleterious effects of the revascularization syndrome which expose the brain to a second aggression, and amputation, when necessary, should be undertaken to reduce mortality.