Blunt Popliteal Artery Injury

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Blunt Popliteal Artery Injury
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A 23-year-old woman involved in a motor vehicle
crash with injuries that include

• Closed head injury
• Pelvic fracture
• Multiple long-bone fractures
• Extraperitoneal bladder injury
• Decreased blood flow to right foot

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Pule Exam

• SITE Right Left
• Fem 2/2 2/2
• Pop dop 2/2
• DP 0 2/2
• PT Dop 2/2
• Foot Cold Warm

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Blunt Popliteal Injuries
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Blunt Popliteal Injuries

• Orthopedic Injuries
• Distal Femur Fracture
• Knee Dislocation
• Proximal Tibia Fracture
• Vascular Injuries
• Blunt Trauma endothelial injury causing
  thrombus formation
• Vasospasm

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History

• High amputation rates
• WWII 72 amputation rate with ligation
• Korean Conflict 32 amputation

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Morbidity

• Compartment syndrome
• Limb survival is threatened by delays in
  diagnosis and treatment, particularly when limb
  perfusion is compromised for more than 6 hours.
• Extensive musculoskeletal and skin injuries
  poor prognosis.
• Crush injuries with open tibial fractures likely
  to cause loss of the lower leg.

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Physical Exam Hard Signs

• 91-95 sensitivity for injuries requiring
  intervention.
• Bruit or thrill, suggests AV fistula
• Active or pulsatile hemorrhage
• Pulsatile or expanding hematoma
• Signs of limb ischemia
• Diminished or absent pulses
• (patients with major vascular injuries
  requiring repair may have normal pulses distal to
  the injury)

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Physical Exam Soft Signs

• Much less useful predicting injuries requiring
  intervention.
• Hypotension or shock
• Neurological deficit
• Stable or small hematoma
• Proximity of the wound to major vascular
  structures

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Etiology

• Gunshot wounds, cause 70-80 of all vascular
  injuries requiring intervention.
• Stab wounds (5-15 of cases)
• Blunt trauma (5-10 of cases) Presence of
  fracture increases risk.
• Iatrogenic injury (5 of cases) Cardiac
  catheterization and line placement

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Evaluation

• The arterial pressure index useful when pulses
  appear normal.
• Systolic blood pressure in the affected extremity
  is divided by systolic pressure in the normal
  extremity.
• lt 90 is abnormal.
• Sensitivity 44-95, depending on circumstances,
  need intervention

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Duplex Ultrasonography

• Ultrasound promising noninvasive technique
• Investigating injuries with a high-risk mechanism
  or location, but without any obvious indication
  for surgical management.
• Sensitivity of ultrasound can be up to 95-100
  for diagnosing vascular injuries that lack hard
  signs but still require intervention with high
  index of suspicion.
• Extremely operator dependent.
• The negative predictive value as low as 50.

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Angiography

• Gold Standard for evaluation of vascular injuries
  in trauma.
• Disadvantages include cost, time delay, and a
  0.6 major complication rate.
• Only 1 to1.5 of angiograms in patients lacking
  hard signs will reveal injuries requiring
  intervention.

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Treatment3

• Prehospital Care
• Stabilize the extremity in anatomic position.
• Control hemorrhage with direct pressure.
• Emergency Department Care
• Immediately reduce displaced or angulated
  fractures of the elbow and knee to relieve
  tension on neurovascular structures.
• Consult vascular and orthopedics

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When do you lose the leg?

• Harrell study no limbs were lost if pulse was
  detected or Doppler signal
• Neither pulse nor doppler signal 14 of 23 limbs
  were lost
• Severe soft tissue injury is a predisposing
  factor in limb loss 13 of 26 limbs lost

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Knee Dislocation4

• Sisk and King reviewed 61 acute dislocations
  21 had associated popliteal artery trauma
• When suspected, arteriography and surgical
  exploration are mandatory
• Observation only is often a disaster

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Predictors of Amputation

• Greater than 2 long bone fractures
• Tibial arteries one, two, and three vessel
  injuries 20, 33, and 100 amp rates
• Blunt injury
• Pulseless extremity
• Distal vacular injuries complex fracture