Injuries to the popliteal artery among the young

CASE REPORTS

Injuries

to the Popliteal Artery the Young REPORT

DONALDS. MILLER, M.D.,

PH.D.

OF SIX

Among

CASES

ANDROBERT FREEARK,

M.D.,

Chicago, Illinois

autogenous vein graft, six patients or 10.3 per cent required amputation. The rate during World War II when ligation was the prevailing treatment was 49 per cent. The experiences [r r] of WorId War II and the Korean conffict changed this method to a direct suturing of vesseIs or to prosthetic repIacement. Direct surgical approach became precise [r6]. A high percentage of recoveries without the loss of a limb and with a high incidence of viability has been had from immediate direct repair or replacement and repair (homoplastic grafts, vein grafts or prosthesis) among the younger patients. Isolated cases of traumatic popliteal arteries have been reported. Denman and his coworkers [ry] reported the unusual case of an aneurysm of the poplitea1 artery caused by an osteochondroma of the femur. Stevenson and Zuska [r8] reported the case of an aneurysm of the popIitea1 artery occurring after a perforation by solitary exostosis of the femur. Cifford and his associates analyzed a large study of one hundred cases of poplitea1 aneurysms [r9J. JuIian and his co-workers [9] used vessel grafts for this artery. They state that a traumatic incidence of popIitea1 aneurysm occurs in one of 100 patients and that the patient is Ieft with a less than normal circulatory system, even when Iumbar sympathectomy and extirpation of the artery are performed. The popliteal artery is we11 hidden posteriorly in the intercondyIar space of the femur. It is covered by fascia, fat and muscle and is protected anteriorly by the popbteus muscle

From Cook County Hospital, Chicago, Illinois.

EFORE World War II, an occasional reference to the popliteal artery appeared in conjunction with trauma. Most publications, however, reIated it to aneurysma diIatations and obliterative diseases, i.e., syphilitic and arteriosclerotic aneurysms. During WorId War II, particuIarIy during the Korean conflict and since then in civiban practice, more reports h ave dealt with direct and indirect trauma to the popliteal artery [I-S]. Some publications give particular attention to prosthetic replacements [9,10]. DeBakey and Simeone [II], more than any others, studied the major arterial injuries during the Korean co&l ict and reported the morbidity and mortality. Comparative figures between World War I and World War II [rz] show better diagnosis in WorId War II and consequently better results through immediate surgical intervention [12]. Both WorId War I and World War II yielded improvements in the technical repair of arteries. Records of the Korean conflict reveal that vascular teams specialized in these types of injuries. Hughes [r3] reported that of the tota major vascular repairs done in Korea in 1953, thirty-seven of 21 I were in the popliteal artery. Injuries to major arteries comprised I per cent of the battIe casualties. In civilian life about 20 per cent of amputations are necessitated by vascuIar injuries [r4]. Jahnke and Howard [r5] reported that of fifty-eight arterial injuries repaired by direct suture of the end to end anastomosis or by

B

633

American

Journal

oJ Surgetv.

Volume

104, October

196~

MiIIer

and Freeark TABLE

INJURIES Patient and Age hr.)

Present report: R. C., 5

Condition

Laceration

of the artery

B. F., 9

Vasospasm

J. S.,

Laceration

of the artery

E. G., 16 L. S., 16

Vasospasm Vasospasm

(?)

L. w.,

Thrombosis

IO

‘9

Cited: E. C., 26 P. J., 28

TO THE

of the artery

Thrombosis of the artery Laceration (iatrogenic)

I

POPLITEAL

suture

None

Ligation of artery

None

Reduction Reduction Iocation Reduction location; plant

of fracture of knee dis-

None None

of knee disvenous trans-

Sympathectomy

. suture

End-ResuIt

None

Fasciotomy

Repair;

-

Associated Treatment

Treatment

Repair;

ARTERY

ViabIe limb; severe VoIkmann’s contracture ViabIe Iimb; miId VoIkmann’s contracture; uIceration ViabIe Iimb; moderate VoIkmann’s contractme ViabIe Iimb (normaI) ViabIe limb; neurotrophic changes ViabIe limb; amputation Iater

Sympathectomy Sympathectomy contempIated

Amputation ViabIe limb; intermittent claudication

Iatrogenic Iacerations of the artery through meniscectomy incisions (Fig. 3) should be prevented by the carefu1 selection of a regular knife such as the SmilIie (Fig. 3) rather than a long-bIaded or long-handled knife. Immediate repair of such an injury is imperative. Figure 3 illustrates an experimenta iatrogenic leg on a cadaver, showing the necessity of avoiding the use of long knives. An actual case in point demonstrating iatrogenic neurovascuIar injury may be cited, aIthough it is not incIuded in the series of six cases reported herein, because of the patient’s age. A twentyeight year old white woman (Table I, P. J.) presented with an iatrogenic Iaceration of the popliteal artery. She had undergone an operation eIsewhere one month after a rotational knee injury in 1957. Apparently exsanguination had folIowed Iaceration of the artery by the surgica1 knife, necessitating blood repIacement and repair of the popIiteaI artery. Because of her age, the intermittent cIaudication syndrome wiI1 remain and is worsening; a Iimp remains and neurovascuIar phenomena persist. On September 9, 1961, the osciIIometric reading was onIy x to fs unit maximum on the left caIf, 2 units on the right. Sympathectomy is being considered. EarIy diagnosis is essentia1 to saving the Iife and Iimb of the patient with an injury to the popIitea1 area. Pallor, ischemia and pecuIiar

and its covering fascia. Notwithstanding this conceaIment, the popIitea1 artery is subject to trauma of various types such as (I) dislocation of the knee, (2) fracture of the upper sixth of the tibia, (3) direct trauma to the popliteal space, and (4) indirect trauma to the popIitea1 space. (TabIe I.) Even minor trauma to a Iimb may cause irritation to the popIitea1 artery with such consequences as thromboses, as it did in two of our unreported cases in which the patients were forty-three and forty-four years of age. The Iikelihood of viability with return to norma circuIation is obviousIy greater among younger than among older patients in whom a traumatized popIitea1 artery Ieads to ischemia and gangrene of the Ieg in 70 per cent of patients; nevertheless, residua1 disabilities (Fig. I) among the young and comparatively young may ensue in the form of trophic nutritiona changes of the skin, fibrosis of the muscIe and changes in bone (atrophic, cortica1 and growth). In a twenty-six year old patient not reported on here in detai1 but listed in TabIe I as E. C., sympathectomy was performed for the reIief of intense pain after repair of the popIitea1 artery which had been injured during a jumping accident. Ischemia and pain remained intractable, necessitating amputation at the knee. UIceration of the stump required a second amputation above the knee. (Fig. 2.) 634

Injuries

to the PopIiteaf

Artery

Among the Young

FTC;. 1. End results in ten patients with injury of the poplitcxl artery (including several adult patients). Seven of total cases reported and cited herein are inctudrd and represent lacerations. spasms, gunshot wound, iatrogenic injury of the artery and indirect trnum:l to poplitcal :irter>

accomplished by making an ample incision aIong the subsartorial sheath into the popliteal space to expose the artery for investigation, adequate repair, replacement or excision. Dislocations of the knee and direct trauma

stocking anesthesia and clinical loss of p&es are early diagnostic signs in children. Diagnosis from subjective symptoms may be more diffrcult in this group. Arteriography is heIpfu1 in doubtful cases of obstruction of the popliteal artery from injury. For young children the method of arteriography may be “open” IIecessary . The important early repair of the artery is

FIG. 3. Iatrogenic injury of poplitea1 artery associated with meniscectomy. Drawing of experimental iatrogenic kg represents dangerous contact bctwcvn knife and popliteal artery.

Method of traumatic thrombosis of popIitea1 artery: patient jumped over a puddle of water. Inset: thrombosis of popIitea1 artery, FIG.

2.

635

Miller a nd Freeark to the inner space of the thigh and posterior popIitea1 area may produce stupor of the artery or vasospastic states. This condition requires immediate exposure, careful washings

length and severe equinovarus deformity, atrophy of the calf, contracture of gastrocnemius and soleus muscles, internal rotation and a tiptoe gait. An eIectromyogram reveaIed a lesion of the lower motor neuron of the gastrocnemius, tibialis anterior and posterior muscles. The quadriceps and vasti groups remained normaI. Roentgenogram reveaIed the foollowing aIterations resuIting from the injury: atrophy of bone, thinning of the meduIIary and cortica1 areas and pecuIiar changes in the fibuIar structure. The arteriogram reveaIed some redirection of the arterial blood suppIy in the posterior and anterior tibiaIis arteries.

with warm compresses, and sympathectomy to prevent thromboses and their sequelae. Investigation of the intramura1 area is necessary to ascertain whether or not intimal fracture has occurred; if so, immediate repair is indicated. Injuries to the poplitea1 artery, either by direct or indirect means, are not common among the young. We are reporting on six patients, a11 of whom were under twenty years of age. Reports concerning the adoIescent are few. Three in our series were adoIescents, two were sixteen years oId; the other, nineteen years old. Three cases were in children, aged five, nine and ten years. CASE

CASE II. B. F., a nine year old Negro boy, was admitted to the Cook County Hospital on September 4, 1959, after he had been struck by a truck. He had an intra-abdominal injury, a deformity of the right thigh and ffexion deformity of the knee. Roentgenograms visualized the fracture of the right femur at the middle third with angulation and overriding. Flexion contraction of the knee was present. A contracture similar to VoIkmann’s contraction had occurred. Because of continued bIood in the urine, nephrectomy was necessary on September 5. SubsequentIy, an incision of the posterior popIitea1 area disclosed vasospasm of the popIitea1 artery as the cause of the pecuIiar stocking anesthesia and the neurotrophic uIcer of the first toe. On January 7, 1960, the patient was readmitted to the pediatric orthopedic section because of trophic changes of the foot and Ieg and gangrene of the fifth toe. This is a case of vasospasm of the popIitea1 artery. ExpIoration brought improvement notwithstanding the residua1 neurotrophic changes and gangrene of the smaI1 toe. FoIIow-up examination 3n August 20, 1961, revealed continued stocking anesthesia from above the maIIeoIar areas, including the entire foot. The length of the Ieg was I cm. shorter than the norma Ieft Ieg. An eIectromyo;ram showed invoIvement of a lower motor neuron of the right gastrocnemius, right tibiaIis mticus and peroneus. The quadriceps were intact. Changes in the bone appeared roentgenographcaIIy. An arteriogram of the popliteal artery showed satisfactory filling of the popIitea1 artery md fair IiIIing of the anterior and posterior arteries.

REPORTS

CASE I. R. C., a five year oId Negro boy, was admitted to the Cook County HospitaI on JuIy 25, 1959, because of a bIunt injury from falling bricks to the posterior aspect of the right knee joint. The retropophteal space was enIarged, and the limb was becoming cold and painfu1. The thigh, knee and proxima1 soft tissue of the leg were somewhat swoIlen. The patient was unabIe to move his ankIe or toes; the foot was immobile. The knee was somewhat unstabIe, and the pateIIa was baIIotabIe. AIthough the femora1 pulse was satisfactory, the right popIitea1 artery couId not be felt. Three days after admission, a sympathetic bIock was performed by the night surgeon. Improvement was questionabIe. Two hours Iater, a cauda1 block gave an unsuccessful end resuIt. SeveraI hours Iater an expIoratory operation of the posterior tibia1 and popIitea1 area was performed through a posterior IongitudinaI incision. The torn popliteal artery (I .5 cm. separation) was discIosed. A short segment of the artery was excised, both proxima1 and dista1 portions were mobiIized, and a direct anastomosis was performed with a No. 6-o suture. This resuIted in dista1 arterial puIsations. Only the skin was cIosed over the top, and the knee was pIaced in moderate ffexion. A we11 padded posterior molded case was applied, the foot having been placed in a neutra1 right angle position. Heparin (IO mg. four times a day) and 500 cc. of blood were used. One week later the Ieg was warm, the skin pink, and sensation in the foot was fair. Post-tibia1 and dorsalis pedis p&es were not feIt, but this may have been because of edema. Improvement continued, aIthough the scar became keIoida1 with some fibrosis in the posterior area of the knee joint. FoIlow-up examination two years Iater (August 20, 1961) discIosed $4 inch shortening of actua1 leg

CASE III. J. S., a ten year oId Negro boy, was admitted to St. Bernard’s Hospital on July 20, rg57, after a seIf-inflicted accidental gunshot injury LOthe posterior aspect of the Ieft knee. The knee was thick, fuI1 and under tension. Three days after rdmission, during debridement, severat smaI1 pieces If the buIIet were removed, and the wound was :Iosed. Mention of the popIitea1 artery was not nade at that time. Three months Iater the patient was admitted to :he Cook County HospitaI because of a trophic

636

Injuries

to the PopIiteaI

Artery

Among the Young

months, the knee joint had become fibrosed with 30 degree Rexion, and a severe equinus deformity of the foot ensued. Edema and anesthesia prrsisted. The patient had to use a hip caliper for about four year-s. During that time an ankle fusion was performed. At several examinations the skin had trophic uIcerations and was discoIorcd, and edema of the foot and ankle and immobility of the foot were present. The skin was being irritated especially by the hip caliper, so that the patient required rest periods, soaks in soap suds and mild compression to combat the edema. A ncurocirculatory phenomenon was residual.

ulcer of the skin of the posterior aspect of the was moderate. OsciIlopopliteal area. Drainage metric index was zero below the knee and the dorsaIis pedis pulse was absent, Surgical incision of the popliteal area and an arteriogram indicated interruption of the popliteal artery. Separation of the artery measured z inches. It was technicaIIy impossible to mobilize the segments. CIots were removed from the posterior popliteal spaces and the wound was closed. Gradually during the next year flexion contracture of the knee took pIace and resisted correction. Pulses remained absent; sensory supply was lost over the Iower anterior portion of the leg and foot, and over the medial aspect of the leg. Motions of the extensor digitorum Iongus and extensor haIIucis Iongus muscles were minimal. Attempts to improve the IIexion deformity of the knee were unsuccessfuI. Tenotomy of the tendo achillis and capsuIot.omy to correct the fixed equinus deformity were performed. Attempted correction of the knee joint failed. Arthrodesis was undertaken. A Charnley type knee fusion was satisfactory, with a IO degree flexion. The patient is now able to bear weight without pain or discomfort, although he limps. Follow-up examination on August IO, 1961, showed satisfactory knee fusion and alignment. Shortening was $4 inch.

CASE VI. L. W., a nineteen year old boy, was crushed between two bumpers of an automobile. His right knee joint was dislocated. Emergency attempts at reduction of the dislocation at Southtown Hospital were unsuccessfu1 and anothrr attempt was made the folIowing day. On examination the foot was coId and puseless, and edema was moderate. The patient was treated for shock with bIood transfusions, vasodiIators and antibiotics. Two and a half days after admittance, sympathectomy was performed and the popIitca1 artery explored. The injury was intramural; a thrombus measuring 5 cm. caused circulatory impairment and consequent Ioss of puIse. A saphenous vein was used to bridge the gap, and the patient was placed in a Ioose posterior molded cast for two weeks. Pulses returned feebly, and &or graduaIly improved. The patient left the hospital after six weeks with a circuIar cast from groin to toes. Careful examination demonstrated the continued presence of edema and immobility with some loss of dorsiflexion and pIantar llexion of the foot. Some sensory loss of the stocking anesthesia type occurred below the knee to the foot. For the next year and a half, circulatory impairment continucd. FIesion of the knee joint incrcascd to 40 and 50 degrees. Laterai and anteroposterior instability were prominent. A hip caliper was ordered to protect the knee joint and to a\,oid painful weight bearing. Because of continued instability of the knee, formation of trophic and nutritional ulcers of the skin, pecuIiar mottling and Toss of sensation associated with a painful knee joint, fusion of the knee was performed through an anterior parapateIIar incision. The joint was exposed, cartiIage removed and two pins \\crc inserted in staggered positions. On the tenth postoperative day, the patient had a temperature of 104’~. The wound had become infected, and Staphylococcus aureus was recovered. The patient received antibiotics, fluids and blood replaccmcnt; notwithstanding this treatment, the however, wound drained for six months thereafter. The neurovascular complication became progressively worse. One year later, an amputation above the

&SF. IV. E. G., a sixteen year old girl, was struck by an automobile on September 8, 1939. A supracondylar fracture of the right femur, multiple lacerations and a cerebral concussion comprised the diagnosis on admittance to the hospitat. The leg was paIe and puIseIess. The fracture was dispIaced at the fractured site. Roentgenograms revealed a supra-epiphyseal fracture dislocation of the right femur. Immediate Steinmann pin traction a.t the tibia1 tubercle site was performed with earIy r-eplacement of fragments. Normal circulatory appearance with improvement of color, return of puises and movement of the Iimb resulted. After six weeks of such traction a spica cast was applied. Satisfactory reduction, alignment and earIy formation of caIIus had taken pIace. The patient compIeteIy recovered from the fracture and associated vascuIar injury which was diagnosed as traumatic vasnspnstic femoral poplitea1 artery.

CASL. v. L. S., a sixteen year old boy, was in an automobile accident in which his Ieft knee was dislocated. With the patient under genera1 anesthesia the disIocation was reduced and the knee joint placed in a circuIar cast from groin to toes, with a IO degree Bexion. The Iimb became swoIIen. The case was bivaIved two days Iater. The circulation was precarious, observable as paIIor, genera1 stocking anesthesia and intermittent pulsation of both dorsa1 peda1 and posterior tibia1 areas. In two 637

MiIIer al Id Freeark knee was performed and a prosthesis months later. The patient is doing without complications at this writing.

SUMMARY

AND

ordered two we11 and is

produces thrombosis of the femora1 poplitea1 arterial system. 8. Notwithstanding patency of major blood vesseIs after operation of any type, trophic or nutritional changes may aIter normal skin in the form of dryness, eczema, bullous lesions and ulcers. More deepIy, irreparable muscIe fibrosis may result and lead to deformities of the foot. Sensory and motor changes do not follow sensory IeveIs but manifest themseIves as vague stocking anesthesia types. In most cases cold sensitivity and Iow exercise tolerance are apparent. 9. Although young peopIe have a more resourcefu1 vascular system, in every patient some aIteration of circuIation must have taken pIace to have produced the various end results: Volkmann’s-like contracture (atrophy or scarring of muscle, and deformity of feet) ; neurotrophic changes of the limb; intermittent claudication, especially difficulty in walking in one case, and nutritional disturbances of the skin.

CONCLUSIONS

I. Injury to the poplitea! artery is comparatively rare because of the protected posi-

tion of the artery. When injury occurs, earIy diagnosis and immediate surgica1 treatment are mandatory. Arteriograms aid in Iocalizing the site of the tear or Iaceration. If facilities are avaiIabIe, arteriograms should be taken as part of the compIete documentation of the case; moreover, postoperative arteriograms, electromyogram and carefu1 cIinica1 examination are heIpfu1 in teaching 2, The probIem of injuries of the popIitea1 artery of young patients has been presented in terms of historica awareness and a report on six patients, ranging in age from tive to nineteen years. Two supplemental cases in adults are cited to exemphfy iatrogenic Iaceration in one case, and the uhimate need for amputation in the other. 3, SurgicaI correction of injuries of the popIiteal artery in the young resuhs in satisfactory cohateral circuIation, without gangrene of the limb but with evidence of ischemic fibrosis. The six cases reported herein differ from those in even somewhat oIder patients, as in the two additional cases cited, in that in older patients ischemia or gangrene more commonly ensues. whether by blunt or 4. PopIiteal injuries, open trauma, should be treated by direct exposure and either repair or replacement prosthesis or vein grafts. It appears that grafts offer better end results. 5. Incisions for exposure of the popIitea1 artery shouId be carefully weighed to prevent ugIy keIoida1 scars and tissue breakdown. Only in the young is fusion possible after complete severance of the pophteal artery (Case III). 6. Appropriate surgical exposure with the patient under careful anesthesia, the administration of heparin and vasodilators, appropriate postoperative positioning of the wound and follow-up physical therapy encourage satisfactory end resuIts within the Iimitations of what may be anticipated. The prognosis can never be whohy favorabIe. In no singIe case in our series was a perfect or norma circuIatory apparatus an end result. 7. Minor trauma about the knee occasionally

REFERENCES I. BRYANT,

M. F. Acute arterial injuries in industry. 3. Georgia M. A., 45: 426, 1956. 2. FERRARA. B. E. and CAIN. W. F. SuraicaI ma’naaement of major arterial injuries; experience w&h eight cases. J. South Carolina M. A., 54: 273, ‘958. 3. FISH, G. D., JR. and HOCHHAUSER,M. Laceration of popIitea1 artery due to brunt trauma; a case report. Am. .I. Surg., 94: 651, 1957. 4. HUDSON, 0. C. Traumatic aneurysm of the popIiteal artery due to osteochondroma. Am. .f. Surg., go: 528, 195s. 5. LESSER, A. G. and GREELEY, C. E. FemopopIiteaI arteriovenous aneurysm caused by fractured osteochondroma of the femur. J. A. M. A., 167: 1830, 1958. 6. MILROY, P. Aneurysms of the popliteal artery from perforation by acanceIIous exostosis of the femur; report of a case. J. Bone ~7 Joint Surg., 35-B: 27% ‘953. 7. MOORE, T. C. Acute arteriat obstruction due to traumatic circumferential intimal fracture. Ann. Surg., 148: III, 1958. 8. RAFFENSPERCER,J. G. and HINKAMP, J. Compound dislocation of the knee with popIitea1 artery injury. Arch. Surg., 79: 799, 1959. 9. JULIAN, C., DYE, W. S., JAVID, H. and GROVE, W. J. Use of vessel grafts in the treatment of popIitea1 aneurysms. Surgery, 38: 970, 1955. IO. LORD, J. W., JR. Clinical behavior and operative management of popIitea1 aneurysms. J. A. M. A., 163: 1102, 1957. I I. DEBAKEY. M. E. and SIMEONE. F. A. BattIe injuries of the arteries of WorId War II. An anaIysis of 2,471 cases. Ann. Surg., 234: 534, 1946.

638

Injuries

to the Popliteal

Artery

12. ELI\IN, D. C. and DEBAKEY, hf. E. Surgery in M’orld War II, p. 68. Department of the Army, O&e of the Surgeon General, Washington, D. C., 1055. I 3. HU;HES, C. W. Primary repair of wounds of major arteries; an analysis of experience in Korea in 1953. Ann. SW&, 141 : 297, 1955. rq. BA~INSON,H. T. Surgical treatment of aneurysms of arteriosclerotic origin. Minnesota Med., 38: 922, 1955. l+. JAHNKE, E. J., JR. and HOWARD, J. M. Primary repair of major arterial injuries; report of fiftyeight battle casualties. Arch. Surg., 66: 646, 1953. 16. MORRIS, G. C., JR., BEALL, A. C., JR., ROOF, W. R.

639

Among the Young

and DEBAKEY, M. E. Surgical cxpericnce with 220 acute arteria1 injuries in civilian practice. Am. J. Surg., 99: 775, 1960. 17. DENMAK, S. R., SHINDLER,T. O., HAMPTON, J. and HANSON, L. Aneurysm of the popliteal artery caused by osteochondroma of the femur. J. Bone P* Joint Surg., 41-A: 1526, 1959. 18. STEVENSON, C. A. and ZUSKA, J. J. Aneurysm of the popliteal artery from perforation by a solitary exostosis of the femur; a case report. J None (0’~ Joint Surg., 39-A: 431, 1957. 19. GIFPORD, R. W., JK., HINES, E. A., JH. and JAMES, J. M. Analysis and foIIow-up study of one hundred pop&a1 aneurysms. Surgeyy, 33: 284, 1953.