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Popliteal vessel injury caused by a plastic bullet
Injury: the British Journal of Accident Surgery (1987) Vol. 16/No. 6
428
To remove all screws is logistically demanding and potentially dangerous but it may be prudent to remove
On examination there was reduced sensibility in the C5 and C6 dermatomes, weakness of the elbow and wrist, loss of intrinsic muscle action in the hand and absent triceps and biceps jerks in the left arm. There was a pulsatile mass in the
with acute onset of severe pain in the shoulder with
infraclavicular fossa with a bruit. Emergency arteriography
neurological
showed a false aneurysm of the axillary artery (Fig. 1). Operation confirmed this and showed that the medial and lateral cords of the brachial olexus were tented over the b-cm swelling. Proximal and distal control of the axillary artery was obtained and the aneurysm was incised. The screw was loose
in the centre of the aneurysm, with a defect in the arterial wall
corresuondine to the size of the screw head. The screw was removed andThe defect was repaired with a vein patch. There was immediate recovery of sensibility with a slower but progressive recovery of power.
DISCUSSION It is likely that this complication will be seen more frequently as the number of patients undergoing this operation increases. The predisposing factors would appear to be related to non-union of the coracoid and migration of the loose screw. The previous three recorded cases (Artz et al., 1972; Fee et al., 1978; Iftikhar et al., 1984) show that a bruit or pulsatile mass may not always be detectable clinically and that this complication may appear some years after the operation (6 months to 6Y2 years). Delay in treatment can lead to irrecoverable neurological damage.
loose
screws
arteriography.
and
those
symptoms
that and
have
migrated.
signs, should
have
Patients urgent
If the diagnosis is confirmed operation
should be performed
without
delay.
Acknowledgements I should like to thank Mr A. R. Turnbull, Mr P. J. Morrison and Dr M. Noakes for their permission to report this case.
REFERENCES Artz T. and Huffer J. M. (1072) A major complication of the modified Bristow procedure for recurrent dislocation of the shoulder: A case report. J. Bone Joint Surg. 54A. 1293. Fee H. J., McAvoy J. M. and Dainko E. A. (1978) Pseudoaneurysm of the axillary artery following a modified Bristow operation: Report of a case and review. J. Cur-
diovasc. Surg. 19, 65. Iftikhar T. B., Kaminski R. S. and Silva 1. (1984) Neurovascular complications of the modified Bristow procedure: A case report. J. Bone Joint Surg. 66A. 951. Paper accepted 22 January
1987.
Rcyuests for rep7nr.s .shou/d he oddre.s.wd 10: M. J. Clancy. Dcrriford Hospital. Radiodiagnostic Department, PLh XDH.
Derriford Road. Plymouth
Popliteal vessel injury caused by a plastic bullet B. G. Best and A. A. B. Barros D’Sa Vascular Unit, Royal Victoria Hospital,
Belfast
INTRODUCTION SINCE 1975 plastic bullets have been used in Northern Ireland for crowd control during rioting. Two reviews have reported the types of injury caused by rubber and plastic bullets (Miller et al., 1975; Rocke, 1983). Popliteal vascular injury in this province arising from urban civil strife has invariably been penetrating in character (Barros D’Sa, 1982), whereas blunt injury to these vessels commonly follows road traffic accidents, especially those involving motorcycles. To our knowledge, this is the first reported case of injury of both popliteal artery and vein by a plastic bullet. CASE REPORT On Easter Monday.
during rioting in Portadown. a 48-yearold man was hit on the back of the right knee by a plastic bullet. The range from which the missile was fired is not known. He was admitted to the local district hospital 1 hour later .with a painful haematoma in the popliteal space. At first, pedal pulses were noted to be normal but 2 hours later the foot became pale and cold and pulses became impalpable. He was transferred to the vascular surgical unit of the Royal Victoria Hospital. Belfast.
Fig. 1. a, Plastic bullet injury popliteal space. b, Preoperative angiogram shows occluded popliteal artery._c, Postoperative * . r. angrograpny snows patent grart.
Case reports
429
On admission, his cardiovascular state was satisfactory. Characteristic bruising and abrasion were noted in the popliteal fossa (Fig. la). The limb beyond the knee was ischaemic but the calf muscles were soft and it was assumed that the intrafascial pressure had not risen. A femoral arteriogram was immediately performed, revealing occlusion of the upper popliteal artery (Fig. lb). The popliteal vessels were approached through a medial longitudinal incision. A 6-cm length of the upper part of the popliteal artery was thrombosed. Two linear, full thickness tears as well as a proximal intimal tear were observed. The adjacent popliteal vein was also lacerated at two sites. The damaged segment of artery was resected and a reversed vein graft taken from the upper part of the long saphenous vein of the opposite uninjured leg was interposed by means of oblique end-to-end anastomoses. The vein tears were repaired by lateral suture, maintaining a good calibre. Intraluminal shunting across injured vessel segments, which is normal practice in our department (Barros D’Sa, 1982), seemed unnecessary in this case. Fasciotomy was not required. He made an uncomplicated recovery. Three months later digital subtraction angiography showed a functioning popliteal artery of normal configuration (Fig. lc), and Doppler ultrasound studies confirmed normal pressures and pulse waveforms at the right ankle. There was no clinical evidence of venous insufficiency. Interestingly, at the site of impact of the plastic bullet, he has developed a keloid scar of a shape which exactly resembles the original bruise. COMMENT
For some years, sivil disturbances have been a feature of Northern Ireland, but have been witnessed increasingly in other parts of the United Kingdom, especially within large conurbations. Police forces there have had to familiarize themselves with a variety of methods of riot control, including the use of plastic Requests for reprints should be addressed to: A. A. B. Hospital,
Belfast
BT12
bullets. Casualty officers unaccustomed to seeing patients who have sustained plastic bullet wounds should be made aware of the nature and potential seriousness of such injuries. The consequences of lower limb injuries, even in the absence of fractures, are serious as large areas of soft tissue damage and necrosis may occur. This case illustrates the possibility of limb-threatening popliteal vascular injury complicating blunt injury by a plastic bullet, initially presenting as an apparently innocuous bruise. Vessels in other areas, such as the neck and upper limb, must also be regarded as vulnerable to such injury. When the site of injury appears to be in close proximity to underlying blood vessels the patient concerned should be admitted for observation in order to observe peripheral pulses and blood flow. The principles of vascular surgical technique employed in the repair of popliteal vessels have been discussed (Barros D’Sa, 1982), and are aimed at lowering morbidity, enhancing uncomplicated recovery and ensuring survival of the limb.
REFERENCES Barros D’Sa A. A. B. (1982) A decade of missile-induced vascular trauma. Ann. R. CON. Surg. Engl. 64, 38. Miller R, Rutherford W. H., Johnston S. et al. (1975) Injuries caused by rubber bullets-a report on 90 patients. Br. J. Surg. 62, 480. Rocke L. (1983) Injuries caused by plastic bullets compared with those caused by rubber bullets. Lancer i, 919. Paper accepted 22 January 1987.
Barros D’Sa, MD,FKCS, Consultant
Vascular
Surgeon,
Vascular
Unit,
Royal Victoria
6BA.
A Salter type 3 fracture of the proximal epiphysis of the humerus R. L. te Slaa and A. J. G. Nollen Department
of Orthopaedic
Surgery, St Joseph Hospital, Eindhoven,
INTRODUCTION
INJURIES of the proximal epiphysis of the humerus are relatively uncommon. According to Neer and Horwitz (1965) they constitute 3 per cent of all epiphyseal injuries. There are two types of epiphyseal plate injuries at the proximal end of the humerus. In infants and young children complete separation of the epiphysis (Salter type 1) occurs with the greatest frequency. In older children and adolescents Salter type 2 injuries predominate (Salter and Harris, 1963; Dameron, 1969; Sherk, 1975). In the literature we could find no reports of Salter type 3 fractures of the proximal epiphysis of the humerus (Aitken, 1963; Neer, 1965; Dameron, 1969; Siebler, 1984; Baxter, 1986). The following case
The Netherlands
illustrates this type of fracture and is, to our knowledge, the first report of this injury. CASE HISTORY An 11-year-old boy was seen in May 1986 after falling from his bicycle onto his right shoulder. He was a healthy boy with a swollen and painful right shoulder. There were no abnormal neurological signs. All movements of the shoulder were limited by pain. The radiographs (Fig. 1) showed a Salter type 3 fracture-separation of the proximal epiphysis of the humerus, with marked displacement of the medial fragment. Closed reduction failed and open reduction was performed, using an anterolateral exposure of the shoulder. The medially and ventrally dislocated fragment was reduced into an anatomical and stable position without fixation (Fig. 2). The pa-
428
To remove all screws is logistically demanding and potentially dangerous but it may be prudent to remove
On examination there was reduced sensibility in the C5 and C6 dermatomes, weakness of the elbow and wrist, loss of intrinsic muscle action in the hand and absent triceps and biceps jerks in the left arm. There was a pulsatile mass in the
with acute onset of severe pain in the shoulder with
infraclavicular fossa with a bruit. Emergency arteriography
neurological
showed a false aneurysm of the axillary artery (Fig. 1). Operation confirmed this and showed that the medial and lateral cords of the brachial olexus were tented over the b-cm swelling. Proximal and distal control of the axillary artery was obtained and the aneurysm was incised. The screw was loose
in the centre of the aneurysm, with a defect in the arterial wall
corresuondine to the size of the screw head. The screw was removed andThe defect was repaired with a vein patch. There was immediate recovery of sensibility with a slower but progressive recovery of power.
DISCUSSION It is likely that this complication will be seen more frequently as the number of patients undergoing this operation increases. The predisposing factors would appear to be related to non-union of the coracoid and migration of the loose screw. The previous three recorded cases (Artz et al., 1972; Fee et al., 1978; Iftikhar et al., 1984) show that a bruit or pulsatile mass may not always be detectable clinically and that this complication may appear some years after the operation (6 months to 6Y2 years). Delay in treatment can lead to irrecoverable neurological damage.
loose
screws
arteriography.
and
those
symptoms
that and
have
migrated.
signs, should
have
Patients urgent
If the diagnosis is confirmed operation
should be performed
without
delay.
Acknowledgements I should like to thank Mr A. R. Turnbull, Mr P. J. Morrison and Dr M. Noakes for their permission to report this case.
REFERENCES Artz T. and Huffer J. M. (1072) A major complication of the modified Bristow procedure for recurrent dislocation of the shoulder: A case report. J. Bone Joint Surg. 54A. 1293. Fee H. J., McAvoy J. M. and Dainko E. A. (1978) Pseudoaneurysm of the axillary artery following a modified Bristow operation: Report of a case and review. J. Cur-
diovasc. Surg. 19, 65. Iftikhar T. B., Kaminski R. S. and Silva 1. (1984) Neurovascular complications of the modified Bristow procedure: A case report. J. Bone Joint Surg. 66A. 951. Paper accepted 22 January
1987.
Rcyuests for rep7nr.s .shou/d he oddre.s.wd 10: M. J. Clancy. Dcrriford Hospital. Radiodiagnostic Department, PLh XDH.
Derriford Road. Plymouth
Popliteal vessel injury caused by a plastic bullet B. G. Best and A. A. B. Barros D’Sa Vascular Unit, Royal Victoria Hospital,
Belfast
INTRODUCTION SINCE 1975 plastic bullets have been used in Northern Ireland for crowd control during rioting. Two reviews have reported the types of injury caused by rubber and plastic bullets (Miller et al., 1975; Rocke, 1983). Popliteal vascular injury in this province arising from urban civil strife has invariably been penetrating in character (Barros D’Sa, 1982), whereas blunt injury to these vessels commonly follows road traffic accidents, especially those involving motorcycles. To our knowledge, this is the first reported case of injury of both popliteal artery and vein by a plastic bullet. CASE REPORT On Easter Monday.
during rioting in Portadown. a 48-yearold man was hit on the back of the right knee by a plastic bullet. The range from which the missile was fired is not known. He was admitted to the local district hospital 1 hour later .with a painful haematoma in the popliteal space. At first, pedal pulses were noted to be normal but 2 hours later the foot became pale and cold and pulses became impalpable. He was transferred to the vascular surgical unit of the Royal Victoria Hospital. Belfast.
Fig. 1. a, Plastic bullet injury popliteal space. b, Preoperative angiogram shows occluded popliteal artery._c, Postoperative * . r. angrograpny snows patent grart.
Case reports
429
On admission, his cardiovascular state was satisfactory. Characteristic bruising and abrasion were noted in the popliteal fossa (Fig. la). The limb beyond the knee was ischaemic but the calf muscles were soft and it was assumed that the intrafascial pressure had not risen. A femoral arteriogram was immediately performed, revealing occlusion of the upper popliteal artery (Fig. lb). The popliteal vessels were approached through a medial longitudinal incision. A 6-cm length of the upper part of the popliteal artery was thrombosed. Two linear, full thickness tears as well as a proximal intimal tear were observed. The adjacent popliteal vein was also lacerated at two sites. The damaged segment of artery was resected and a reversed vein graft taken from the upper part of the long saphenous vein of the opposite uninjured leg was interposed by means of oblique end-to-end anastomoses. The vein tears were repaired by lateral suture, maintaining a good calibre. Intraluminal shunting across injured vessel segments, which is normal practice in our department (Barros D’Sa, 1982), seemed unnecessary in this case. Fasciotomy was not required. He made an uncomplicated recovery. Three months later digital subtraction angiography showed a functioning popliteal artery of normal configuration (Fig. lc), and Doppler ultrasound studies confirmed normal pressures and pulse waveforms at the right ankle. There was no clinical evidence of venous insufficiency. Interestingly, at the site of impact of the plastic bullet, he has developed a keloid scar of a shape which exactly resembles the original bruise. COMMENT
For some years, sivil disturbances have been a feature of Northern Ireland, but have been witnessed increasingly in other parts of the United Kingdom, especially within large conurbations. Police forces there have had to familiarize themselves with a variety of methods of riot control, including the use of plastic Requests for reprints should be addressed to: A. A. B. Hospital,
Belfast
BT12
bullets. Casualty officers unaccustomed to seeing patients who have sustained plastic bullet wounds should be made aware of the nature and potential seriousness of such injuries. The consequences of lower limb injuries, even in the absence of fractures, are serious as large areas of soft tissue damage and necrosis may occur. This case illustrates the possibility of limb-threatening popliteal vascular injury complicating blunt injury by a plastic bullet, initially presenting as an apparently innocuous bruise. Vessels in other areas, such as the neck and upper limb, must also be regarded as vulnerable to such injury. When the site of injury appears to be in close proximity to underlying blood vessels the patient concerned should be admitted for observation in order to observe peripheral pulses and blood flow. The principles of vascular surgical technique employed in the repair of popliteal vessels have been discussed (Barros D’Sa, 1982), and are aimed at lowering morbidity, enhancing uncomplicated recovery and ensuring survival of the limb.
REFERENCES Barros D’Sa A. A. B. (1982) A decade of missile-induced vascular trauma. Ann. R. CON. Surg. Engl. 64, 38. Miller R, Rutherford W. H., Johnston S. et al. (1975) Injuries caused by rubber bullets-a report on 90 patients. Br. J. Surg. 62, 480. Rocke L. (1983) Injuries caused by plastic bullets compared with those caused by rubber bullets. Lancer i, 919. Paper accepted 22 January 1987.
Barros D’Sa, MD,FKCS, Consultant
Vascular
Surgeon,
Vascular
Unit,
Royal Victoria
6BA.
A Salter type 3 fracture of the proximal epiphysis of the humerus R. L. te Slaa and A. J. G. Nollen Department
of Orthopaedic
Surgery, St Joseph Hospital, Eindhoven,
INTRODUCTION
INJURIES of the proximal epiphysis of the humerus are relatively uncommon. According to Neer and Horwitz (1965) they constitute 3 per cent of all epiphyseal injuries. There are two types of epiphyseal plate injuries at the proximal end of the humerus. In infants and young children complete separation of the epiphysis (Salter type 1) occurs with the greatest frequency. In older children and adolescents Salter type 2 injuries predominate (Salter and Harris, 1963; Dameron, 1969; Sherk, 1975). In the literature we could find no reports of Salter type 3 fractures of the proximal epiphysis of the humerus (Aitken, 1963; Neer, 1965; Dameron, 1969; Siebler, 1984; Baxter, 1986). The following case
The Netherlands
illustrates this type of fracture and is, to our knowledge, the first report of this injury. CASE HISTORY An 11-year-old boy was seen in May 1986 after falling from his bicycle onto his right shoulder. He was a healthy boy with a swollen and painful right shoulder. There were no abnormal neurological signs. All movements of the shoulder were limited by pain. The radiographs (Fig. 1) showed a Salter type 3 fracture-separation of the proximal epiphysis of the humerus, with marked displacement of the medial fragment. Closed reduction failed and open reduction was performed, using an anterolateral exposure of the shoulder. The medially and ventrally dislocated fragment was reduced into an anatomical and stable position without fixation (Fig. 2). The pa-