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

Abstract

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.

Vascular and Nerve Injury After Knee Dislocation: A Systematic Review

“…Its use also adds to healthcare costs and increases the time for surgical treatment if performed in cases where there is hard evidence of vascular injury (distal ischemia, active hemorrhage, or expanding pulsatile hematoma) [38]. Some studies have also found false-positive results with the use of angiography ranging from 2.4% to 7%, leading to unnecessary surgical procedures and possible iatrogenic arterial or neurologic injury [23,36,38]. For these reasons, many authors now favor a number of selective angiography tests.…”

Practical Management of Knee Dislocations: A Selective Angiography Protocol to Detect Limb-Threatening Vascular Injuries

“…22,26 This is thought to be the result of an unrecognized non-flow-limiting intimal tear, which occurred at the time of the injury, that either progressed to a flow-limiting tear or resulted in thrombosis. Duplex ultrasonography offers another noninvasive and less expensive alternative to arteriography with a comparable accuracy in detecting traumatic vascular injury, though no study specific to knee dislocations has been performed.…”

“…In fact, estimates suggest that this may occur in as many as 5%-15% of knee dislocations through delayed expansion of an intimal tear. 5,6,20,[22][23][24] …”

Initial Evaluation of the Acute and Chronic Multiple Ligament Injured Knee

“…However, it is important to note that physical examination alone is inadequate to rule out the possibility of a limb-threatening vascular injury as distal pulses can be maintained by collateral flow, and numerous reports exist in which signs of significant vascular injuries developed in patients with initially normal pulses. [34][35][36][37][38][39][40][41] Therefore, the ABI should be evaluated by obtaining the Doppler systolic arterial pressure at the level of the ankle of the injured limb and dividing this value by the Doppler systolic arterial pressure of the ipsilateral upper extremity at the level of the brachial artery. An ABI >0.90 is considered normal based on the work by Mills et al, which prospectively evaluated the use of ABI following knee dislocation, and found that the patients who required vascular surgical intervention had an ABI <0.90.…”

“…4,20,46,47 In the protocol reported by Nicandri et al, arterial duplex ultrasonography is obtained on all patients who require surgical reconstruction as it is proposed that this test may increase the sensitivity of a selective angiography protocol and may decrease the risk of occlusion of the popliteal artery immediately following ligament reconstruction, which has been reported. 20,39,48,49 Future studies may help delineate the appropriate role for arterial duplex ultrasonography.…”