Blunt Lower-Extremity Trauma and Popliteal Artery Injuries

Abstract

Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage.Design: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months).Setting: Single-institution, academic level I trauma center.Patients: Medical records of patients presenting emergently with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified.Interventions: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone.Main Outcome Measures: Limb salvage rate and necessity for vascular surgical intervention based on an-giographic data in patients with normal neurovascular examination results.Results: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (PϽ.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention.Conclusions: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.

Vascular Injury After Occult Knee Dislocation Presenting as Compartment Syndrome

“…The complete absence of pulses is an uncommon and very late finding in compartment syndrome; whereas absent pulses seen immediately after blunt lower extremity trauma mandate immediate evaluation for vascular injury. Absent pulses are 58 -80% specific for vascular injury in blunt trauma (6,(13)(14)(15)(16)(17). Ultimately, it was thought that the compartment syndrome was a complication resulting from the popliteal artery injury.…”

“…Absent pedal pulses or signs of distal ischemia mandate immediate angiography with vascular surgery consultation. Failure to revascularize within 6 -8 h results in an unacceptably high amputation rate (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). Peroneal nerve injuries are less common than popliteal artery injuries because the nerves are not as tightly anchored; however, when nerve injury is present, a concomitant vascular injury must be suspected as it is more likely to be present.…”

Popliteal artery trauma associated with trampoline injury

“…Several studies have reported a strong correlation between physical findings and abnormalities observed on catheter angiography. 1,7,14 Furthermore, another study has concluded that the selective use of lower limb angiography, based on physical findings, is sufficient in patients with severe blunt lower limb injury. 10 Non-invasive imaging modalities such as arterial duplex examination and CT angiography allow accurate assessment of arterial trauma without the need for invasive catheter angiography and its inherent complications.…”

Current Concepts of Polytrauma Management

“…• intracranial bleeding sources: aside from acute epidural hematoma from arterial bleeding sources (see above), dural sinus bleeding may represent a major source of intracranial hemorrhage requiring immediate surgical intervention by trepanation and craniotomy [65]. • penetrating and blunt vascular injuries, "mangled extremity": arterial injuries with clinical signs of limb ischemia due to blunt or penetrating trauma require immediate surgical management without further diagnostics [72][73][74]. The "Mangled Extremity Severity Score" (MESS) has been established as a guideline for early determination whether limb salvage is achievable as opposed to early amputation, with an established "cutoff" level of the MESS at 7 points [75][76][77][78][79].…”