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Popliteal vasculature injuries in paediatric trauma patients
Injury, Int. J. Care Injured 43 (2012) 1709–1711
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Popliteal vasculature injuries in paediatric trauma patients S.A. Jones, D.C. Roberts, N.M.P. Clarke * Child Health, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 June 2012
Popliteal-artery injuries in the paediatric-trauma patient are uncommon, difficult to diagnose and with prolonged ischaemia lead to substantial complications. We report three cases of popliteal-vasculature injury in paediatric-trauma patients with diverse mechanisms of injury: blunt trauma, penetrating injury and a Salter–Harris I fracture. We present a range of the significant sequelae that can result from paediatric popliteal-artery injury, both physically and psychologically. It is imperative that clinicians have a high index of suspicion when confronted with paediatric patients with trauma around the knee and that popliteal-vasculature injuries are diagnosed early. If insufficiencies are detected, further imaging should be considered, but surgical exploration should not be delayed in the presence of ischaemia. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Popliteal Paediatric Vascular Trauma
Introduction Vascular injuries in paediatric-trauma patients are relatively rare with an incidence of 0.6%; of these, only 5% are poplitealartery injuries.1,2 Paediatric-popliteal artery injuries can be particularly difficult to diagnose and challenging to manage. Prolonged ischaemia time may lead to substantial, long-lasting complications with associated physical and psychological morbidity. Due to their supposed rarity, there is little documented in the literature with regard to optimal management. Interventional radiology is commonplace in the diagnosis of adults with suspected vascular injury, yet there are little data regarding its application in the paediatric trauma-patient setting. We describe three cases of popliteal-vasculature injury following trauma around the knee in paediatric patients with diverse mechanisms of injury. Patients and methods Case 1 Miss J, aged 10 years, fell whilst swinging from a tree sustaining a large laceration to the posterior aspect of her right calf with extensive muscle damage including visible tendons. A weak dorsalis pedis pulse instigated a computed tomography (CT) angiogram, which showed a normal popliteal artery to the level of
* Corresponding author at: MP817, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel.: +44 02380 796140; fax: +44 02380 796141. E-mail address: [email protected] (N.M.P. Clarke). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.06.012
her tibial plateau and a subsequent gap that refilled with three vessel runoff (Fig. 1). Whilst awaiting theatre, a complete loss of all peripheral pulses together with an evolving ischaemic foot was noted. Surgical exploration was performed immediately and on exposure, the popliteal artery was thrombosed over a 3-cm segment. The long saphenous vein was used to perform an end-to-end anastomosis resulting in immediate reperfusion. She subsequently required a further debridement and definitive treatment by way of a latissimus dorsi free flap and split-skin graft to cover the vein graft. She has been left with extensive scarring and has required psychological input to deal with the cosmetic appearance of the scar. Case 2 Master L, aged 10 years, accidentally sustained a penetrating injury to his popliteal fossa with a knife. His leg became swollen and he underwent duplex imaging the following day that demonstrated both popliteal artery and vein transections. Despite prompt transfer to the mainland, there was a delay of 24 h from injury to surgery. Repair consisted of direct suturing of the vein and a patch repair of the popliteal artery using the long saphenous vein. One month later, he developed a Volkmann’s ischaemic contracture of his right knee (fixed flexion 208) and ankle (308 fixed equinus). The knee contracture resolved following a period of traction and physiotherapy. He later underwent a right gastrocnemius recession to correct the equinus deformity. At 2-year followup, he had residual gastrocnemius tightness and mild toe-clawing, but no functional limitations.
[(Fig._1)TD$IG]
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S.A. Jones et al. / Injury, Int. J. Care Injured 43 (2012) 1709–1711
Fig. 1. CT angiogram of right leg demonstrating a 3 cm arterial insufficiency (sagittal section and reformatted 3D view).
Case 3 Miss L, aged 11 years, sustained a Salter–Harris I distal femoral fracture when her right leg was caught in a swing. Closed reduction and K-wire fixation of the fracture were carried out on the same day as the injury. The following day patchy distal hypoaesthesia was noted, but it was not until later that a reduction in toe movement and loss of pulses were identified. An angiogram confirmed popliteal-artery insufficiency (Fig. 2) secondary to thrombosis. Fasciotomies were performed and nonviable necrotic muscle was excised from the anterior, superficial
[(Fig._3)TD$IG]
posterior and lateral compartments, which resulted in profound foot and ankle weakness. A partial physeal arrest resulted in shortening of the limb combined with a valgus deformity of the knee. Subsequent epiphysiodeses and osteotomies were required. The foot remains weak 4 years following injury secondary to neurological compromise and extensive muscle resection (Figs. 2 and 3).
[(Fig._2)TD$IG]
Fig. 2. Lateral radiograph of the displaced Salter–Harris I distal femoral fracture.
Fig. 3. Angiogram with popliteal arterial insufficiency (crossed k-wires in situ).
S.A. Jones et al. / Injury, Int. J. Care Injured 43 (2012) 1709–1711
Discussion These cases demonstrate the significant sequelae that can result from popliteal-vasculature injury in the paediatric population. This injury is uncommon. Meagher et al. reported 53 traumatic vascular injuries in children, none of which were popliteal.3 Of the published cases of paediatric popliteal injury presented in the literature, the majority are following gunshot wounds.2,4 This vascular injury may be difficult to diagnose, with a delay in definitive treatment affecting long-term outcomes. The sequelae of popliteal artery injury can be severe, both physically and psychologically, especially in the paediatric population. It is therefore imperative that these injuries are diagnosed early. In case 1, despite early recognition of inadequate peripheral perfusion necessitating an urgent CT angiogram, the initial findings of patent three-vessel runoff subsequently changed whilst awaiting definitive treatment. Clinicians must be aware that whilst initial investigations may be reassuring, it is a dynamic environment and therefore regular monitoring must take place. Limb observations and Doppler assessment of peripheral pulses should be undertaken by trained staff, prompting senior review if deficiencies are detected. Similarly for case 3, although definitive treatment was carried out promptly, deficiencies later developed, again highlighting the importance of performing and documenting regular limb observations. For case 2, although there was an unavoidable delay in transferring to the mainland for definitive treatment, investigations were only instigated following leg swelling, hours after the initial injury. In the case of a penetrating injury to the popliteal fossa, one must be alert to potential vascular injuries, prompting further immediate investigation. This case does highlight that in centres where a CT angiogram may not be on-site, close discussion with radiology is advised with regard to alternative initial investigations. Volkmann’s ischaemia in the lower limb, which occurred in our second case, is uncommon within the paediatric population. Seddon published such a case that occurred secondary to poplitealartery injury following a displaced Salter–Harris II fracture of the distal femur.5 Salter–Harris I fractures of the distal femoral physis, as in our third case, that cause vascular injury are even rarer. Czitrom et al. described only two Salter–Harris I fractures out of a total of 53 distal femoral physeal injuries, neither of which were displaced or caused arterial injury.6 Although rare, there are reports of proximal tibial physeal fractures following hyperextension injuries leading to vascular compromise or compartment syndrome; the popliteal artery is tethered at this level by its major branches, leaving it vulnerable to disruption.7,8 We suggest that clinicians should be aware of popliteal artery injury in all paediatric trauma patients presenting with trauma to the lower extremities. Vascular imaging is important in aiding quick diagnosis and it is essential that neurovascular status be clearly documented, both at admission and throughout the
1711
treatment course. Palpable distal pulses at presentation do not obviate the need for vascular imaging.4 CT angiography has become more popular in aiding diagnosis of paediatric-traumatic vascular injury.9 It is non-invasive, fast and readily available. However, some schools of thought suggest that routine arteriography is unnecessary in the evaluation of the patient with lower-extremity trauma and potentially increases ischaemia time.10,11 An ankle-brachial pressure index of less than 0.9 has a high sensitivity and specificity and is another useful tool in the clinical armamentarium.12 Conclusion We highlight the importance of prompt clinical examination and recognition of the early signs of ischaemic damage. Regular limb observations should be initiated, documented and acted on as appropriate. If insufficiencies are detected, further imaging should be considered. However, imaging should not delay surgical exploration in the presence of ischaemia. We conclude that, although uncommon, popliteal-vasculature injury must be considered in all paediatric cases presenting with trauma around the knee, where the overall goal is to avoid or at the very least minimise potentially devastating complications. Conflict of interest statement There are no conflicts of interest in the publication of this manuscript. References 1. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. Journal of Pediatric Surgery 2010;45(7):1404–12. 2. Reed MK, Lowry PA, Myers SI. Successful repair of pediatric popliteal artery trauma. American Journal of Surgery 1990;160(3):287–90. 3. Meagher Jr DP, Defoe WW, Mattox KL, Harberg FJ. Vascular trauma in infants and children. Journal of Trauma 1979;19(7):532–6. 4. Holcomb 3rd GW, Meacham PW, Dean RH. Penetrating popliteal artery injuries in children. Journal of Pediatric Surgery 1998;23(9):859–61. 5. Seddon HJ. Volkmann’s ischaemia in the lower limb. JBJS 1966;4(48B):627–36. 6. Czitrom AA, Salter RB, Willis RB. Fractures involving the distal epiphyseal plate of the femur. International Orthopaedics 1981;4(4):269–77. 7. Mubarak SJ, Ryul Kim J, Edmonds EW, Pring ME, Bastrom TP. Classification of proximal tibial fractures in children. Journal of Children’s Orthopaedics 2009;3(3):191–7. 8. Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. Journal of Bone and Joint Surgery 1979;61(7):996–1002. 9. Lineen EB, Faresi M, Ferrari M, Neville HL, Thompson WR, Sola JE. Computed topographic angiography in pediatric blunt traumatic vascular injury. Journal of Pediatric Surgery 2008;43(3):549–54. 10. Abou-Sayed H, Berger DL. Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography. Archives of Surgery 2002;137(5):585–9. 11. Fabian TC, Turkleson ML, Connelly TL, Stone HH. Injury to the popliteal artery. American Journal of Surgery 1982;143(2):225–8. 12. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: prospective study. Journal of Trauma 2004;56(6):1262–5.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Popliteal vasculature injuries in paediatric trauma patients S.A. Jones, D.C. Roberts, N.M.P. Clarke * Child Health, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 June 2012
Popliteal-artery injuries in the paediatric-trauma patient are uncommon, difficult to diagnose and with prolonged ischaemia lead to substantial complications. We report three cases of popliteal-vasculature injury in paediatric-trauma patients with diverse mechanisms of injury: blunt trauma, penetrating injury and a Salter–Harris I fracture. We present a range of the significant sequelae that can result from paediatric popliteal-artery injury, both physically and psychologically. It is imperative that clinicians have a high index of suspicion when confronted with paediatric patients with trauma around the knee and that popliteal-vasculature injuries are diagnosed early. If insufficiencies are detected, further imaging should be considered, but surgical exploration should not be delayed in the presence of ischaemia. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Popliteal Paediatric Vascular Trauma
Introduction Vascular injuries in paediatric-trauma patients are relatively rare with an incidence of 0.6%; of these, only 5% are poplitealartery injuries.1,2 Paediatric-popliteal artery injuries can be particularly difficult to diagnose and challenging to manage. Prolonged ischaemia time may lead to substantial, long-lasting complications with associated physical and psychological morbidity. Due to their supposed rarity, there is little documented in the literature with regard to optimal management. Interventional radiology is commonplace in the diagnosis of adults with suspected vascular injury, yet there are little data regarding its application in the paediatric trauma-patient setting. We describe three cases of popliteal-vasculature injury following trauma around the knee in paediatric patients with diverse mechanisms of injury. Patients and methods Case 1 Miss J, aged 10 years, fell whilst swinging from a tree sustaining a large laceration to the posterior aspect of her right calf with extensive muscle damage including visible tendons. A weak dorsalis pedis pulse instigated a computed tomography (CT) angiogram, which showed a normal popliteal artery to the level of
* Corresponding author at: MP817, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel.: +44 02380 796140; fax: +44 02380 796141. E-mail address: [email protected] (N.M.P. Clarke). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.06.012
her tibial plateau and a subsequent gap that refilled with three vessel runoff (Fig. 1). Whilst awaiting theatre, a complete loss of all peripheral pulses together with an evolving ischaemic foot was noted. Surgical exploration was performed immediately and on exposure, the popliteal artery was thrombosed over a 3-cm segment. The long saphenous vein was used to perform an end-to-end anastomosis resulting in immediate reperfusion. She subsequently required a further debridement and definitive treatment by way of a latissimus dorsi free flap and split-skin graft to cover the vein graft. She has been left with extensive scarring and has required psychological input to deal with the cosmetic appearance of the scar. Case 2 Master L, aged 10 years, accidentally sustained a penetrating injury to his popliteal fossa with a knife. His leg became swollen and he underwent duplex imaging the following day that demonstrated both popliteal artery and vein transections. Despite prompt transfer to the mainland, there was a delay of 24 h from injury to surgery. Repair consisted of direct suturing of the vein and a patch repair of the popliteal artery using the long saphenous vein. One month later, he developed a Volkmann’s ischaemic contracture of his right knee (fixed flexion 208) and ankle (308 fixed equinus). The knee contracture resolved following a period of traction and physiotherapy. He later underwent a right gastrocnemius recession to correct the equinus deformity. At 2-year followup, he had residual gastrocnemius tightness and mild toe-clawing, but no functional limitations.
[(Fig._1)TD$IG]
1710
S.A. Jones et al. / Injury, Int. J. Care Injured 43 (2012) 1709–1711
Fig. 1. CT angiogram of right leg demonstrating a 3 cm arterial insufficiency (sagittal section and reformatted 3D view).
Case 3 Miss L, aged 11 years, sustained a Salter–Harris I distal femoral fracture when her right leg was caught in a swing. Closed reduction and K-wire fixation of the fracture were carried out on the same day as the injury. The following day patchy distal hypoaesthesia was noted, but it was not until later that a reduction in toe movement and loss of pulses were identified. An angiogram confirmed popliteal-artery insufficiency (Fig. 2) secondary to thrombosis. Fasciotomies were performed and nonviable necrotic muscle was excised from the anterior, superficial
[(Fig._3)TD$IG]
posterior and lateral compartments, which resulted in profound foot and ankle weakness. A partial physeal arrest resulted in shortening of the limb combined with a valgus deformity of the knee. Subsequent epiphysiodeses and osteotomies were required. The foot remains weak 4 years following injury secondary to neurological compromise and extensive muscle resection (Figs. 2 and 3).
[(Fig._2)TD$IG]
Fig. 2. Lateral radiograph of the displaced Salter–Harris I distal femoral fracture.
Fig. 3. Angiogram with popliteal arterial insufficiency (crossed k-wires in situ).
S.A. Jones et al. / Injury, Int. J. Care Injured 43 (2012) 1709–1711
Discussion These cases demonstrate the significant sequelae that can result from popliteal-vasculature injury in the paediatric population. This injury is uncommon. Meagher et al. reported 53 traumatic vascular injuries in children, none of which were popliteal.3 Of the published cases of paediatric popliteal injury presented in the literature, the majority are following gunshot wounds.2,4 This vascular injury may be difficult to diagnose, with a delay in definitive treatment affecting long-term outcomes. The sequelae of popliteal artery injury can be severe, both physically and psychologically, especially in the paediatric population. It is therefore imperative that these injuries are diagnosed early. In case 1, despite early recognition of inadequate peripheral perfusion necessitating an urgent CT angiogram, the initial findings of patent three-vessel runoff subsequently changed whilst awaiting definitive treatment. Clinicians must be aware that whilst initial investigations may be reassuring, it is a dynamic environment and therefore regular monitoring must take place. Limb observations and Doppler assessment of peripheral pulses should be undertaken by trained staff, prompting senior review if deficiencies are detected. Similarly for case 3, although definitive treatment was carried out promptly, deficiencies later developed, again highlighting the importance of performing and documenting regular limb observations. For case 2, although there was an unavoidable delay in transferring to the mainland for definitive treatment, investigations were only instigated following leg swelling, hours after the initial injury. In the case of a penetrating injury to the popliteal fossa, one must be alert to potential vascular injuries, prompting further immediate investigation. This case does highlight that in centres where a CT angiogram may not be on-site, close discussion with radiology is advised with regard to alternative initial investigations. Volkmann’s ischaemia in the lower limb, which occurred in our second case, is uncommon within the paediatric population. Seddon published such a case that occurred secondary to poplitealartery injury following a displaced Salter–Harris II fracture of the distal femur.5 Salter–Harris I fractures of the distal femoral physis, as in our third case, that cause vascular injury are even rarer. Czitrom et al. described only two Salter–Harris I fractures out of a total of 53 distal femoral physeal injuries, neither of which were displaced or caused arterial injury.6 Although rare, there are reports of proximal tibial physeal fractures following hyperextension injuries leading to vascular compromise or compartment syndrome; the popliteal artery is tethered at this level by its major branches, leaving it vulnerable to disruption.7,8 We suggest that clinicians should be aware of popliteal artery injury in all paediatric trauma patients presenting with trauma to the lower extremities. Vascular imaging is important in aiding quick diagnosis and it is essential that neurovascular status be clearly documented, both at admission and throughout the
1711
treatment course. Palpable distal pulses at presentation do not obviate the need for vascular imaging.4 CT angiography has become more popular in aiding diagnosis of paediatric-traumatic vascular injury.9 It is non-invasive, fast and readily available. However, some schools of thought suggest that routine arteriography is unnecessary in the evaluation of the patient with lower-extremity trauma and potentially increases ischaemia time.10,11 An ankle-brachial pressure index of less than 0.9 has a high sensitivity and specificity and is another useful tool in the clinical armamentarium.12 Conclusion We highlight the importance of prompt clinical examination and recognition of the early signs of ischaemic damage. Regular limb observations should be initiated, documented and acted on as appropriate. If insufficiencies are detected, further imaging should be considered. However, imaging should not delay surgical exploration in the presence of ischaemia. We conclude that, although uncommon, popliteal-vasculature injury must be considered in all paediatric cases presenting with trauma around the knee, where the overall goal is to avoid or at the very least minimise potentially devastating complications. Conflict of interest statement There are no conflicts of interest in the publication of this manuscript. References 1. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. Journal of Pediatric Surgery 2010;45(7):1404–12. 2. Reed MK, Lowry PA, Myers SI. Successful repair of pediatric popliteal artery trauma. American Journal of Surgery 1990;160(3):287–90. 3. Meagher Jr DP, Defoe WW, Mattox KL, Harberg FJ. Vascular trauma in infants and children. Journal of Trauma 1979;19(7):532–6. 4. Holcomb 3rd GW, Meacham PW, Dean RH. Penetrating popliteal artery injuries in children. Journal of Pediatric Surgery 1998;23(9):859–61. 5. Seddon HJ. Volkmann’s ischaemia in the lower limb. JBJS 1966;4(48B):627–36. 6. Czitrom AA, Salter RB, Willis RB. Fractures involving the distal epiphyseal plate of the femur. International Orthopaedics 1981;4(4):269–77. 7. Mubarak SJ, Ryul Kim J, Edmonds EW, Pring ME, Bastrom TP. Classification of proximal tibial fractures in children. Journal of Children’s Orthopaedics 2009;3(3):191–7. 8. Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. Journal of Bone and Joint Surgery 1979;61(7):996–1002. 9. Lineen EB, Faresi M, Ferrari M, Neville HL, Thompson WR, Sola JE. Computed topographic angiography in pediatric blunt traumatic vascular injury. Journal of Pediatric Surgery 2008;43(3):549–54. 10. Abou-Sayed H, Berger DL. Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography. Archives of Surgery 2002;137(5):585–9. 11. Fabian TC, Turkleson ML, Connelly TL, Stone HH. Injury to the popliteal artery. American Journal of Surgery 1982;143(2):225–8. 12. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: prospective study. Journal of Trauma 2004;56(6):1262–5.