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 – the angle of 450, under which the similar muscles draw the distal fragment downwards, not along the leg axis horizontally
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.