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Query: UMLS:C0030552 (paresis)
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From 1969 to 1971 the authors treated 1360 injured patients, eight of which suffered serious injuries of the thigh; fractured femur complicated by a severed Femoral Popliteal Artery, and lesions of the Sciatic Nerve. Six patients were injured at work, one in an automobile accident, and one was a gunshot victim. In approximately 1000 fractures one is complicated by an injured neurovascular bundle. The clinical picture of such a case is characteristic. The arteriograph is used only to locate the lesion. Reconstruction of the artery must be accomplished some eight to twelve hours following the injury. In all of the authors' cases, this was done one to eight hours following the trauma. After twelve hours, ischemic necrosis of the soft tissue (musculature) sets in requiring amputation. The remaining segment of the damaged artery is usually resected. In one case, a segment 8 cm. long was removed. Following the termino-terminal anastomosis, the injured extremity was placed in a flexed position whlich alleviated the tension on the sutures. The result of vein autographs are worse than those of the termino-terminal anastomoses. Thrombosis later begins to restrict blood flow through the reconstructed artery, but by this time, adequate collateral circulation has been established. The limb has thus been saved. Heparin is administrated immediately before and during the operation in a dosage of 5000 units per 500 ml. of physiological solution. Postoperatively, it is not used as it acts on the fibrin thrombi, and not on the thrombocyte thrombi which are formed postoperatively in the areas where the tunica intima has been damaged. Heparin is indicated in the prophylaxis of venous thrombosis. In these cases in which the femur was fractured, the question asked is whether to perform the osteosynthesis and anastomosis simultaneously, or to perform the former at a later time. The authors chose both methods for various reasons. Only a few cases permitted the authors to decide which approach would be better. Usually they performed a temporary fixation of the bone with Rusch's Pin, and sutured the artery. Four months later, a compressive osteosynthesis using an L-plate, was performed. In four cases, the Sciatic Nerve was injured, which, according to the circumstances was sutured either immediately, or 3 to 4 weeks later. In 3 patients, good functional results were obtained. Three cases resulted in a contracture of the knee, two of which also had residual Sciatic Paresis. One case resulted in permanent venous stasis (edema of the legs, and two cases results in amputation.
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PMID:[Injuries of the thigh bone with a destruction of the neuro-vascular bundle]. 99 30

Venous thromboembolism is a common and potentially fatal disease. If properly used, anticoagulation therapy is effective in preventing recurrence of venous thromboembolism and in improving survival. Symptomatic patients with an objective diagnosis of acute deep vein thrombosis (DVT) or pulmonary embolism (PE) should receive immediate systemic heparin anticoagulation at dosages sufficient to rapidly prolong the activated partial thromboplastin time into the laboratory-specific therapeutic range; this range corresponds to a plasma heparin concentration of 0.2 to 0.4 IU/ml (as measured by protamine sulfate titration), or 0.3 to 0.7 anti-Xa IU/ml. An oral vitamin K antagonist (e.g. warfarin) should be started within 24 hours after starting heparin; the starting dose should be the estimated patient-specific daily dose with no loading dose. Heparin and warfarin anticoagulation should be overlapped for at least 4 to 5 days and until the international normalized ratio (INR) is within the therapeutic range (2.0 to 3.0) on 2 measurements made at least 24 hours apart. The duration of warfarin anticoagulation should be individualized based on the respective risks of venous thromboembolism recurrence and anticoagulant-related bleeding. In general, warfarin should be continued for at least 3 months, and longer for patients with recurrent or idiopathic venous thromboembolism, malignant neoplasm, neurologic disease with extremity paresis, obesity, or laboratory evidence of a lupus anticoagulant/anticardiolipin antibody, homozygous carrier or combined heterozygous carrier for the factor V R506Q (Leiden) and prothrombin G20210A mutations, and possibly deficiency of either antithrombin, protein C, or protein S. Low molecular weight heparin (LMWH) is effective and well tolerated as acute therapy for patients with DVT or stable PE, and does not require laboratory monitoring or dose adjustment. Outpatient LMWH therapy is also well tolerated and cost effective for most patients with DVT, and possibly for selected patients with PE.
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PMID:Current management of acute symptomatic deep vein thrombosis. 1472 51