Popliteal artery damage in closed injuries of the knee

Sudden Death of a Young Hemophiliac by Low-Velocity Blunt Knee Trauma in Bullock Cart Run-Over Fatality

A young bullock cart driver was pushing bulls hard in stunt and frolic. The cart sped up and he lost control and toppled in front of the iron wheel, which ran over his lower limb around the knee. Concomitant hemophilia further complicated the popliteal artery bleed, and the patient succumbed within hours of injury, despite medical aid. Sudden death is rare in congenital or acquired hemophilia. Popliteal artery injuries usually threaten the limb in high-velocity blunt or penetrating trauma in comparison to other peripheral arteries. However, fatality after popliteal artery injury in low-velocity blunt trauma is rare. Bullock cart is a very slow mode of transport. But animals can show unpredictable and aggressive behavior when driven in carts, which poses considerable risk of fatality to driver and occupants if they sustain vascular or regional injuries. As there is scarce literature about bullock cart-related injuries, this paper focuses on bullock cart run-over fatalities and sudden death in young hemophiliacs.

Acute Thrombotic Occlusion of the Popliteal Artery following Knee Dislocation: A Case Report of Management, Local Unit Practice, and a Review of the Literature

Arterial complications following traumatic knee injury are relatively rare but mandate timely recognition and treatment to avoid significant comorbidity and medicolegal ramifications. In this report we describe a case of acute thrombotic occlusion of the popliteal artery occurring after knee dislocation, successfully repaired by intimal fixation and a limited venous patch reconstruction. We present a review of local practice in screening vascular injuries following knee dislocation, aligned with a review of the literature and considerations for practice.

Popliteal artery injury associated with blunt trauma to the knee without fracture or dislocation

Popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. Concern about arterial injury and early recognition of the possibility of arterial injury is crucial for the salvage of the extremity. This article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating injury, knee dislocation, fracture, or high-velocity trauma mechanism. The importance of a detailed vascular examination of a blunt trauma patient is emphasized.

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 injury associated with blunt trauma without dislocation of the knee

Failure to recognize popliteal artery injury and restore vessel continuity of flow after blunt trauma is a major cause of lower extremity amputation and morbidity. A high index of suspicion and early recognition of the injury are paramount for limb salvage. We experienced a rare case of poplitial artery occlusion with the presence of arterial pulses due to collateral circulation after blunt trauma. Expeditious revascularization was achieved by using posterior approach, allowing two surgical teams to work simultaneously. This case illustrates that, even in the absence of knee dislocation, surgeons must always consider the possibility of a popliteal artery damage whenever a blunt trauma near the knee.

Popliteal artery pseudoaneurysm after isolated hyperextension of the knee

We report an unusual case of a traumatic pseudoaneurysm of the popliteal artery after an isolated blunt hyperextension injury to the knee. A 56-year-old man presented with a 1-month history of left knee pain that occurred after a fall onto his buttocks with hyperextension of the knee while transferring a relative out of a wheelchair. A large pulsatile mass in the posterior aspect of the left knee was palpated on physical examination, although he had warm distal extremities and 2+ distal pulses bilaterally. Magnetic resonance angiography revealed a 7.6 × 6.2 × 4.9 cm left popliteral artery pseudoaneurysm, which was subsequently treated with aneurysm exclusion with end to end reverse saphenous vein graft bypass. The development of a popliteal artery pseudoaneurysm after blunt knee injury without dislocation, fracture, or ligament injury is extremely unusual, but requires prompt treatment to avoid the potential complications of permanent functional impairment and limb loss.

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.

The acutely dislocated knee: evaluation and management

Acute knee dislocations are uncommon orthopaedic injuries. Because they often spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee, resulting in multidirectional instability. Associated meniscal, osteochondral, and neurovascular injuries are often present and can complicate management. The substantial risk of associated vascular injury mandates that vascular integrity be confirmed by angiography in all suspected knee dislocations. Evaluation and initial management must be performed expeditiously to prevent limb-threatening complications. Definitive management of acute knee dislocation remains a matter of debate; however, surgical reconstruction or repair of all ligamentous injuries likely can help in achieving the return of adequate knee function. Important considerations in surgical management include surgical timing, graft selection, surgical technique, and postoperative rehabilitation.

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.

Missile injuries of the knee joint

The results of the treatment of missile injuries of 170 knees in 162 patients are analyzed. The injuries were caused by infantry weapon missiles in 52(32.1%) and by fragments of mine or explosive devices in 110(67.9%) patients. The most frequent were penetrating injuries of the joint with multifragment fractures which in 15.8% cases were associated with injuries of the neurovascular bundle. Stabilization of bone fragments was required in 111(65.3%) knees. Stabilization was done by external fixation in 42(37.8%) and by plaster of Paris in 69(62.2%) knees. Additional mini osteosynthesis was required in 13(30.9%) knees stabilized by external fixation and in 3(4.3%) knees stabilized by plaster of Paris. Amputations were performed in 13(7. 6%) injured knees. During the postoperative period local and general complications occurred in 27(16.6%) patients. The most frequent local complications were suppurative articular infections requiring repeated surgery. Soft tissue defect covering was necessary in 53(33. 1%) patients. The poor late results were present in missile fractures of the knee. The most frequent were degenerative changes with bone defects. The possible surgical solutions in such cases are arthrodesis or total endoprosthesis implantation.

The multiple ligament injured knee

Knee dislocations are complex cases requiring careful initial management to prevent devastating consequences caused by limb ischemia from vascular injury. Initial treatment includes gentle reduction and neurovascular assessment including an arteriogram and vascular reconstruction when necessary. Evaluation by examination and MR imaging will help define all ligamentous and associated pathology. All combined instabilities are repaired or reconstructed at the time of surgery. Early intervention within 3 weeks is preferred, as acute reconstruction is technically easier and more predictable than chronic reconstruction. Allografts are particularly helpful in these complex and time consuming knee injuries. Postoperative rehabilitation consists of initial immobilization followed by a supervised rehabilitation program emphasizing range of motion and strengthening.

Traumatic popliteal artery thrombosis and compartment syndrome of the leg following blunt trauma to the knee: a discussion of treatment and complications

Blunt trauma to the knee has been associated with both musculoskeletal and neurovascular injury to the leg. Popliteal artery thromboses secondary to such trauma can be complicated by a compartment syndrome. The loss of distal pulses in the leg following blunt knee trauma should always be attributed to a suspected vascular lesion and not to the presence of the compartment hypertension. We present a case in which the diagnosis of a popliteal artery thrombosis was delayed because the loss of distal pulses was initially attributed to the compartment syndrome.

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

In major knee trauma fractures and/or dislocations can be associated with arterial lesions. Two case reports demonstrate the difficulties in the diagnosis of intimal lesions in the popliteal artery. The presence of a pedal pulse present at the time of admission can be a false sign of security. The importance of prompt diagnosis and treatment is emphasized. The use of arteriography is discussed.