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REVERSIBLE ACUTE ISCHEMIA CAUSED BY ARTERY COMPRESSED BY A BONE FRAGMENT
Makhambetchin M.M., Stepanov A.A.
Scientific and Research Institute of Traumatology and Orthopedics of the Republic of Kazakhstan, Nur-Sultan, the Republic of Kazakhstan
Leg fractures
as part of concomitant injury consist of 25 % of all fractures of long bones
[1, 2]. A fracture of the proximal part of the femoral bone is quite rare
injury, with incidence < 1 % in adults and children [3-10]. The combination
of such fractures with popliteal artery injuries are even rarer [5, 8].
Generally, arterial injuries in lower extremity fractures encounter in 01.-0.8
% [11-13]. Burkhart S.S. and Guled U. refer
to literature data, which shows the incidence of this combination in 7.1-7.7 %
[3, 8]. According to Harrell DJ et al., the incidence of popliteal arterial
injuries with fractures near the knee consists of 3 % vs. 16 % for posterior
dislocations of the leg [14].
One
of the first publications, which describes gangrene in superior oblique
fracture of the tibia, is Fractures and
Joint Injuries (Watson-Jone R.) [15]. In this article, the author indicates
that this type of fracture is the most dangerous from the point of vascular
injuries. Gangrene appeared in 5 cases among 7 cases of fractures of such type.
High incidence of amputations, also because of delay in surgical intervention,
is mentioned by other authors [5, 13, 14, 16, 18, 20-25]. Segal D. et al. and Green
NE, Swiontkowski MF indicate the association between duration of ischemia and
prognosis of its consequences: for duration of ischemia up to 6 hours, the
probability of limb preservation is 90 %, if ischemia lasts more than 8 hours,
amputation is often inevitable [16, 26].
Vascular
injuries in the popliteal region is one of the most complex diagnostic and
therapeutic problems for trauma surgeons [14, 27-30]. The rarity of combination
of a fracture in the proximal one-third of the tibia with an arterial injury
decreases the alertness of physicians in relation to this pathology, and
determines late diagnosis and treatment, timeliness of which is important for
achievement of good results [16, 18-20, 22, 30, 31, 32].
We
present a clinical case of the popliteal artery compression by a bone fragment,
with subsequent reversible acute ischemia (AI) of the extremity.
Objective – to present a clinical case with
the popliteal artery compressed by a tibial bone fragment, with development of
acute ischemia in the leg, and to show a possible mechanism of displacement of
a fragment in skeletal traction with sufficient load.
Clinical follow-up
The patient gave her informed consent for participation in the study, and
for publication of the clinical case.
The patient, age of 64, female, was transported from the site of a road
traffic accident in 30 minutes from trauma. The diagnosis was made after
examination: "Concomitant injury. Closed abdominal injury. Intraabdominal bleeding.
Closed chest injury. Closed fracture of ribs 5-7 to the right. Subcutaneous
hematomas of the chest wall and anterior abdominal wall. Closed fracture of
proximal one-third of both legs of left leg with displacement (Fig. 1).
Traumatic, hemorrhagic shock of degree 3".
Figure 1. X-ray image of left leg in two planes. A fracture of both bones in upper one-third with
displacement
At the moment of admission, skin surface and temperature of the feet were
equal. Pulse was evident on the periphery of both lower extremities, with
arterial pressure of 100/60 mm Hg. There were not any indications for
ultrasonic examination of blood flow of extremities. The left leg differed from
the right one only with local edema in the upper one-third.
Before urgent surgery, arterial pressure was 60/30. Surgery was
conducted: laparotomy, stomach laceration suturing, ligation of vessels of
transverse colon mesentery, removal of ruptured gall bladder. According to
damage control, manipulations were performed only for hemostasis; external
draining was not conducted. Intraabdominal bleeding was severe (3 l).
Hemoglobin decreased to 60 g/l. Hemotransfusion and vasopressors were used.
The left leg was immobilized with ladder splint during surgery. A
tactical error was made: the trauma surgeon with external apparatus appeared at
the moment of completion of surgery; due to critical condition of the patient,
the anesthesiologist refused from subsequent stay of the patient in the surgery
room, and application of the external apparatus was postponed. After surgery,
skeletal traction was initiated with weight of 6 kg. After surgery, at the
background of unstable hemodynamics and use of vasopressors, pulsation on the
periphery of both lower extremities was not palpated. Skin surfaces and temperature
of both legs were equal.
In 12 hours after admission, the left leg and the foot were pale and cool as compared to the right ones. Some regions
of marbleness and slight cyanosis of the leg and the foot appeared. At the
background of vasopressors, pulsation was absent on the periphery of both lower
extremities.
Significant blood loss, hypovolemia, and ongoing hypotonia were observed.
The fractures of the leg bones were characterized by significant factors of
risk of acute compartment syndrome (ACS). The symptoms of AI of the left leg
and foot were more evident for acute arterial obstruction than for ACS. The
skin of marble color supposed acute arterial obstruction rather than ischemia
from ACS, the early signs of which include paleness, gloss, tensity, skin
tension, woody density along tensioned fascial compartment [33, 34, 35]. The
late symptoms of ACS include paleness of skin surfaces, contractures, absent
pulse on periphery of an extremity, paresis [33, 34, 35]. Diagnosis ACS was
excluded on the basis of clinical course and terms of development of ischemia.
Ultrasonic examination of the lower extremities was conducted: preserved
blood flow in the right leg, and non determined - in the left one. The vascular
surgeon estimated the situation as AI of the left leg and foot at the
background of insufficient reposition and immobilization of fragments, and
increasing edema of soft tissues. Considering the unstable hemodynamics
supported by two vasopressors, it was decided to correct the elevated position
of the leg first of all, and to apply the external apparatus with correction of
displacement of fragments. The cause of delay in application of the external
apparatus is indicated previously.
After cancellation of skeletal traction, after transition of the left hip
to full horizontal position, and application of the external apparatus, the
marble color and cyanosis of the skin completely disappeared within 10-15 minutes,
and the temperature of both extremities equalized. The pulse oxymeter showed
saturation, which was absent before cancellation of skeletal traction.
Saturation gradually increased to 95 % (Fig. 2, 3).
Figure 2. X-ray image after application
of external fixation apparatus
Figure 3. External fixation apparatus applied to hip and
leg. Skin of left leg and foot with unusual color.
On the third day from admission, hemodynamics stabilized, vasopressors
were cancelled, symmetrical pulsation appeared on peripheral arteries of both
lower extremities. Extubation was on the 6th day. Respiratory insufficiency was
persistent over the long time owing to lung contusion.
On the 23rd day after admission, the surgery was conducted: bridgelike
plate osteosynthesis of the tibial bone (Fig. 4). The postsurgical period was
without complications. The wound healed with primary tension. The blood flow was
symmetrical in both lower extremities. Peripheral vascular pulsation was evident.
The patient was discharged on the 10th day after surgery (on 33rd day after
admission).
Figure 4. X-ray image after osteosynthesis
Recovery of blood flow was without surgical intervention for vessels. At the background of severe traumatic shock, the efficiency of external fixation was confirmed as compared to other techniques of temporary immobilization.
DISCUSSION
PubMed and eLIBRARY databases were searched for articles with description
of AI after various injuries to the popliteal artery and leg fractures. 51
articles were selected. The articles reviewing the cases with penetrating
injuries as the cause of popliteal artery damage were excluded. Also the review
did not include cases describing leg dislocation or ACS as the single cause of
AI.
The distal part of the popliteal artery is near to posterior superior
surface of the tibial bone. Connective tissue septa, which fixes a vessel, hold
it near knee joint capsule, that increases probability of a vascular injury [9,
22]. Due to anatomic location and arteries surrounded by fibrous fornix and
tendinous ends of muscles, the popliteal and anterior tibial arteries are
exposed to injuries after fractures or leg dislocations [8, 22]. After
fractures, a bone fragment can cause a direct injury to arterial stem. Another
possible cause of arterial injury in closed fractures is partial destruction of
arterial wall with thrombosis at fracture level [22].
Acute disorder of blood circulation in the leg and the foot in closed
tibial fractures is mainly related to a
direct mechanic vascular injury [13, 16-19, 31] or to ACS [6, 8, 11, 15, 23, 24, 31, 35, 36]. Popescu G.I. et al. describe 44 cases of AI in extremity fractures [39].
There were tibial bone fractures in 12 cases. Among various types of arterial
injuries, compression and spasm were confirmed only in 8 cases without
detalization of injury mechanisms. Hematoma was identified in 1 case, resulting
in spontaneous hemostasis and AI. Noerdlinger MA et al., and McGuigan JA et al.
describe fractures in the lower one-third of the tibial bone complicated by AI
after development of popliteal artery thrombosis. However, origin of thrombosis
factors is not described, and the main attention is given to AI diagnosis and
reconstructive surgery [6, 37]. Downs AR, MacDonald P., as well as
Wagner W.H., report on incidence of various arterial injuries. Arterial
dissection or thrombosis were the most common causes of AI [38, 41]. Seybold EA, and Busconi
BD report a case with late diagnosis of popliteal artery thrombosis since
absence of pulse on arteries of the feet was associated with ACS [34]. Causey
MW reported on AI as result of intima dissection [32].
Occlusion
of arteries of the lower extremities after low energy trauma is rare, and
delayed course, requiring for limb salvage, is even rarer complication [27, 32,
42, 43]. In many reports [5, 19, 25, 27, 30-32, 42, 44],
a problem of delayed diagnosis of arterial injuries, which are not identified
at admission and in the nearest time, is mentioned. The authors of the reports
accentuate that the popliteal artery injury is possible each time when an
injury near the knee is found [5, 11, 19, 25, 27, 30-32, 42, 44].
Clinical cases of delayed AI in fractures in this location are often associated
with arterial thrombosis in the leg [32, 42]. Alshammari D. et al. describe a
case of diagnosis of popliteal artery injury in 12 hours after trauma [31].
Peripheral pulse was palpated, but it disappeared on the surgical table during
preparation for osteosynthesis. Revision showed dissection of the popliteal
artery requiring for shunting for blood circulation recovery.
Gable
DR et al. state that pulse is not absolutely appropriate value for exclusion of
an arterial injury [29]. High probability of a missed injury to the popliteal
artery requires for arteriography or ultrasonic examination. The authors report
a case with urgent vascular surgery with laceration of traumatic pseudoaneurysm
of the popliteal artery. Kim JW et
al. observed a rare case of popliteal artery occlusion with presence of
arterial impulses owing to collateral perfusion after a closed injury [45].
This case shows that surgeons must always consider the probability of popliteal
artery injury in a closed injury near the knee joint, even in absence of leg
dislocation.
Segal D. et al. made a conclusion: "the extremity with
infrapopliteal arterial stroke in combination with tibial bone fracture can be
preserved only with patency of anterior or posterior tibial artery. Poor
clinical results correlate with a degree of a bone injury, but not with
specific arterial injury [16].
A literature review shows that restoration of blood circulation in the
leg with AI was achieved only with surgery. Bonnevialle P. carried out a
retrospective analysis of 29 fractures of the distal femur and the proximal leg
with popliteal artery injury, and showed that vessel restoration was almost
always achieved with shunting [46]. Pourzand A. et al. analyzed 60 cases of
popliteal artery injuries, and reported that blood flow could be restored with
only surgical techniques: shunting in 63 %, anastomosis in 32.3 %, lateral
restoration in 4.8 % [18].
Considering the features of bone fractures in children, particularly
fractures of epiphysiolysis type, popliteal artery injuries in damages of the
proximal one-third of the tibial bone are more common for children. Bukhart S.S.
et al. investigated the experience of the well-known Meyo Clinic. In their
article, they showed that most proximal leg fractures were in adolescents [3].
Clement ND, and Goswami A. presented some interesting epidemiological data,
which showed the peak value of epiphyseal fractures of the leg at the age of
12-14 [35]. Wozasek GE et al. report on 30 cases of proximal epiphysis
injuries. Among all cases, 3 cases were complicated by peripheral ischemia. In
one case, ischemic injuries caused amputation above knee level [47]. The scheme
of epiphysiolysis with popliteal artery injury is presented in the chapter 82
of Operative Pediatric Surgery,
Second Edition 2014 by McGraw-Hill Education
[48].
Among
51 selected reports, the closed fracture of the tibial bone with AI is
mentioned in 25. 8 of 25 articles presented cases with children and
adolescents. Burkhart S.S. et al. presented two cases of AI of the leg and the
foot at the background of a fracture of the upper one-third of the tibial bone
in two children. Both cases were completed by extremity amputation [3]. Shelton
WR and Canale ST report on two cases of popliteal artery injuries in tibial
bone fracture through proximal epiphyseal cartilage with backward displacement
of distal fragment without clarification of an injury pattern and its consequences
[49].
Among
25 articles, only one [50] includes the word combination popliteal artery compression. The full name of the article is
"Compression of the popliteal artery as result of detachment of the
superior part of the tibial bone. A case report". The article is in Chinese.
The abstract and the main text are not available for translation. Since it
refers to epiphyseal detachment, one may suppose that this case is not
associated with an adult patient.
If
one translates English word entrapped
as ущемление in Russian, then two more
articles have the words artery entrapped and
proximal tibial fracture [22, 36].
Fukuda A. et al. reported a case with entrapment-capture of the anterior tibial
artery by a distal fragment of the tibial bone with transverse lateral
displacement. This displacement caused transverse tension of the popliteal
artery with disordered blood flow. The blood flow was restored only with
surgery with revision of the popliteal artery and with ligation of the anterior
tibial artery due to an injury to its intima [22]. The second article is not
available free despite of the publishing date (1986).
Katsenis
DL et al. show the evident picture of angiography with disordered patency of
the popliteal artery over fracture site of the tibial bone. However, the
mechanism of artery obstruction, and its consequences are not clarified, and
the article is mainly dedicated to techniques of fracture fixation [51].
Therefore,
the literature review did not show any reports on reversible AI after artery
compression by a tibial bone fragment in adults. Recovery of blood flow in the leg
in our patient, and change in its position can be explained by the pattern of
the tibial bone fracture; the oblique fracture of the upper one-third of the
tibial bone in skeletal traction in our patient acquired the characteristics of
extension fracture with posterior displacement of the end of the peripheral
fragment. The tailor's muscle, musculus gracilis and semitendinous muscle are fixed to
internal surface of the upper one-third of the tibial bone (Fig. 5).
Figure 5. Points of adherence of m. Sartorius, m. Gracilis,
m. Semitendinosus in upper one-third of leg
The site of fixation of these muscles in this patient was below, immediately after the oblique line of the fracture. Reflexive contraction of these muscles in fractures, and 45° angle of the leg to contraction vector displaced the end of the peripheral fragment backwards (downwards), resulting in popliteal artery compression by a fragment (Fig. 6). Watson-Jones R. mentions in his monography: "A peripheral fragment of the tibial bone displaces upwards (along the extremity). Its sharp end damages the popliteal artery at site of its bifurcation at the level where it is fixed. Considering this danger, one should delay application of plaster bandage for 3 days. If pulse is not palpated, one should perform novocaine blockade and be ready for artery exposure". There were not crossing or injury to popliteal artery walls by a peripheral fragment in our study. The conflict of the peripheral fragment with the artery consisted in only compression or position of the weight on traction splint despite of adequate weight.
Figure 6. Scheme of position of lower limb in damping
device. Three sources of adherence of m. Sartorius, m. Gracilis and m. Semitendinosus
are indicated in upper one-third of tibial bone: 1 – site of popliteal artery
compressed by end of a peripheral fragment; 2 – 450 angle, which
promotes downward displacement of peripheral fragment in traction of muscles
upwards along the extremity
Arterial
compression was also promoted by reverse pressure to the musculus gastrocnemius
from material, which was tensioned on the splint, with pressure from the leg
mass. During extremity extension, traction of the peripheral fragment by these
muscles was not at the angle, but directly along hip axis, and posterior
displacement of the fragment (downwards) was corrected along with its
compression onto the artery (Fig. 7a, b).
Figure 7. X-ray image of left leg after application of
external fixing device shows correction of angle displacement of peripheral
fragment (a). The figure shows that popliteal artery is free from compression
by peripheral fragment (b)
Changes in skin color and foot temperature could be caused by microcirculation disorder owing to elevated position of the extremity at the background of centralization of blood flow (non-corrected traumatic shock), but not by acute ischemia of the extremity from local causes. Absence of pulsation on periphery of both lower extremities supposes the presence of this mechanism. Moreover, absence of such clinical symptoms of AI in some patients with polytrauma who receive vasopressors and skeletal traction, and ultrasonic data of vessels of both legs with normal blood flow in anterior and posterior tibial arteries to the right, and absent blood flow in these arteries to the left, testify the mechanism of AI development described by us. The elevated position of the extremity, and peripheral vasospasm were additional factors, which worsen AI.
CONCLUSION
The
optimal variant of management of such patients with similar combination of a tibial
bone fracture is external fixation simultaneously with the last stage of
laparotomy. Another prevented tactical error in management of our patient could
be continued dynamic follow-up or late transfer of the extremity to external
immobilization. The latter one could result in irreversible ischemic injuries
with loss of the extremity or to more serious life-threatening complications.
This
case shows the necessity for timely application of the external fixator as
temporary immobilization in patients with polytrauma, and need and possibility
to use surgical measures of orthopedic profile for treatment of vascular
complications of a fracture.
Information on financing and conflict of interest
The study was conducted without sponsorship.
The author declare the absence of any clear or
potential conflicts of interests relating to publication of this article.
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