Arterial lesions in major knee trauma: pedal pulse a false sign of security?

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications

Introduction

Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications.

Methods

A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury.

Results

Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital.

Conclusion

Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications.

How to cite this article

Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.

Team Approach: Treatment of Traumatic Dislocations of the Knee

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Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee.

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Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category.

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Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

National Athletic Trainers' Association Position Statement: Immediate Management of Appendicular Joint Dislocations

OBJECTIVE

To provide certified athletic trainers (ATs) with recommendations and guidelines for the immediate management of patients with joint dislocations.

BACKGROUND

One of the primary responsibilities of ATs is to provide immediate injury care for active individuals. Although ATs are confronted with managing patients who have many kinds of injuries, the onsite management of a joint dislocation presents challenges in evaluation and immediate treatment. The critical concern in managing a dislocation is deciding when a joint can be reduced onsite and when the patient should be splinted and transported for reduction to be performed in the hospital or medical setting. Factors that influence the decision-making process include the following: whether the AT possesses a documented protocol that is supported by his or her supervising physician(s), employer documents, and respective state regulations; the AT's qualifications and experience; the dislocated joint; whether the dislocation is first time or recurrent; the patient's age and general health; and whether associated injuries are present.

RECOMMENDATIONS

These guidelines are intended to provide considerations for the initial care of specific joint dislocations. They are not intended to represent the standard of care and should not be interpreted as a standard of care for therapeutic or legal discussion.

Location of civilian ballistic femoral fracture indicates likelihood of arterial injury

BACKGROUND

We evaluated whether the location of a ballistic femoral fracture helps predict the presence of arterial injury. We hypothesized that fractures located in the distal third of the femur are associated with a higher rate of arterial injury.

METHODS

We conducted a retrospective review of electronic medical records at our level I trauma centre and found 133 consecutive patients with femoral fractures from civilian gunshots from 2002 to 2007, 14 of whom sustained arterial injury. Fracture extent was measured with computerized viewing software and recorded with a standard technique, calculating proximal, distal, and central locations of the fracture as a function of overall length of the bone. Analyses were conducted with Student's t, Chi-squared, and Fisher's exact tests.

RESULTS

The location of any fracture line in the distal third of the femur was associated with increased risk of arterial injury (P<0.05). The odds ratio for the presence of arterial injury when the proximal fracture line was in the distal third of the femur was 5.63 (95% confidence interval, 1.7-18.6; P<0.05) and when the distal fracture line was in the distal third of the femur was 6.72 (95% confidence interval, 1.78-25.44; P<0.05).

CONCLUSIONS

A fracture line in the distal third of the femur after ballistic injury is six times more likely to be associated with arterial injury and warrants careful evaluation. Our data show that fracture location can help alert clinicians to possible arterial injury after ballistic femoral fracture.

Vascular and nerve injury after knee dislocation: a systematic review

BACKGROUND

Vascular injury is a devastating complication of acute knee dislocation. However, there are wide discrepancies in the reported frequency of vascular injury after knee dislocations, as well as important differences among approaches for diagnosis of this potentially limb-threatening problem.

QUESTIONS/PURPOSES

We determined (1) the frequency of vascular and neurologic injury after knee dislocation and whether it varied by the type of knee dislocation, (2) the frequency with which surgical intervention was performed for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury.

METHODS

We searched the MEDLINE(®) literature database for studies in English that examined the clinical sequelae and diagnostic evaluation after knee dislocation. Vascular and nerve injury incidence after knee dislocation, surgical repair rate within vascular injury, and amputation rate after vascular injury were used to perform a meta-analysis. Other measures such as diagnostic modality used and the vessel injured after knee dislocation were also evaluated.

RESULTS

We identified 862 patients with knee dislocations, of whom 171 sustained vascular injury, yielding a weighted frequency of 18%. The frequency of nerve injuries after knee dislocation was 25% (75 of 272). We found that 80% (134 of 160) of vascular injuries underwent repair, and 12% (22 of 134) of vascular injuries resulted in amputation. The Schenck and Kennedy knee dislocation classifications with the highest vascular injury prevalence were observed in knees that involved the ACL, PCL, and medial collateral liagment (KDIIIL) (32%) and posterior dislocation (25%), respectively. Selective angiography was the most frequently used diagnostic modality (61%, 14 of 23), followed by nonselective angiography and duplex ultrasonography (22%, five of 23), ankle-brachial index (17%, four of 23), and MR angiography (9%, two of 23).

CONCLUSIONS

This review enhances our understanding of the frequency of vascular injury and repair, amputation, and nerve injuries after knee dislocation. It also illustrates the lack of consensus among practitioners regarding the diagnostic and treatment algorithm for vascular injury. After pooling existing data on this topic, no outcomes-driven conclusions could be drawn regarding the ideal diagnostic modality or indications for surgical repair. In light of these findings and the morbidity associated with a missed diagnosis, clinicians should err on the side of caution in ruling out arterial injury.

Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries

Knee dislocations are relatively uncommon but potentially catastrophic injuries. In athletes, these injuries generally result from high-energy traumatic mechanisms such as collisions in football and rugby, high-velocity falls in skiing, and falls from heights in gymnastics and extreme sports. Knee dislocations are frequently associated with coincident neurological or vascular injuries. Recognition of vascular injury is particularly challenging because vascular compromise may not be immediately associated with clinical signs of ischemia and may result from injuries without complete or evident dislocation. This article reviews the rationale behind selective angiography, adjunctive vascular testing, and the need for observation after multiligament knee trauma. An algorithm for the diagnosis of vascular injuries is presented.

Neurologic and vascular injuries associated with knee ligament injuries

BACKGROUND

Multiple ligament knee injuries are commonly associated with neurovascular complications such as popliteal artery, common peroneal nerve, and tibial nerve injuries.

HYPOTHESIS

While the importance of identifying these complications in association with bicruciate and triligamentous injuries has been well established, it is important to recognize that any biligamentous and some single ligament knee injuries present with neurological and vascular complications as well.

STUDY DESIGN

Literature review.

CONCLUSION

Popliteal artery injuries require immediate intervention to help prevent limb loss. Peroneal and tibial nerve injuries can be a significant cause of morbidity and, therefore, require an understanding of their natural history, anatomy, and pathophysiologic implications to maximize functionality.

CLINICAL RELEVANCE

This review explores the types, mechanisms, and classifications of common neurovascular complications of knee ligament injuries, discusses their diagnosis, and reviews the therapeutic options available to optimize patient outcomes.

Management of the acute knee dislocation: the Pittsburgh experience

Traumatic dislocation of the knee is among the most severe form of ligament injury to the lower extremity. While the incidence of knee dislocations is low, this injury is associated with a high rate of complications including amputation. There is potential for a traumatic knee dislocation to present to the emergency department after spontaneous or in-field reduction. This requires a vigilant, comprehensive, and systematic approach to the injured knee and extremity to avoid limb-threatening oversights. At the University of Pittsburgh a comprehensive algorithm has been developed to facilitate accurate and efficient diagnosis and treatment of complex traumatic knee injuries. The following manuscript includes a detailed review of the literature and explains our specific approach to this diagnostic dilemma.

Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis

BACKGROUND

This systematic review aimed at evaluating the diagnostic accuracy of pulse examination in detecting surgical arterial lesions associated with knee dislocation.

METHODS

MEDLINE, CINAHL, and SportDiscus databases were searched in all languages to review articles concerning human knee dislocation and associated vascular injuries.

RESULTS

We reviewed 116 articles. Seven met our inclusion criteria, providing detailed data on 284 injuries. Pooled data demonstrated that abnormal pedal pulses present a sensitivity of 0.79 (95% confidence interval [CI], 0.64-0.89), a specificity of 0.91 (95% CI 0.78-0.96), a positive predictive value of 0.75 (95% CI, 0.61-0.83), and a negative predictive value of 0.93 (95% CI, 0.85-.96).

CONCLUSION

Our findings suggest that the isolated presence of abnormal pedal pulses on initial examination of patients with knee dislocations is not sensitive enough to detect a surgical vascular injury. On the basis of this meta-analysis, an algorithm for the evaluation of these patients is presented.

Peroneal osteocutaneous flap raised on reconstructed popliteal artery for delayed union following open tibial fractures

Two cases of delayed union following type IIIC open tibial fracture were treated by a pedicled peroneal osteocutaneous flap raised on reconstructed popliteal vessels. Dissection of the peroneal vessels from the already traumatized extremity was tedious, but this technique provided a reliable vascularized skin and bone graft that was indispensable for the fracture healing. Peroneal osteocutaneous flaps raised on the reconstructed popliteal artery have not been reported to date; they appear to be a good alternative to free osteocutaneous flaps for non-union of the proximal tibia.