Abstract
BACKGROUND: Patients with fractures or dislocation about the knee are at increased risk of vascular injury and subsequent limb loss. Our objectives were to: a) determine the amputation rate; and b) identify risk factors in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries. METHODS: We conducted a retrospective case-control study of 30 patients with popliteal artery injuries with ipsilateral tibia fractures at a level 1 trauma centre. Primary and delayed amputation rates were determined. Risk factors tested for significance (Fischer's Exact) included: mechanism of injury, limb viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularisation. RESULTS: Primary amputation was performed in seven and delayed in ten patients (overall rate 57%). The 'miserable triad' of a proximal tibia fracture (OTA 41) with signs of threatened viability, and delay to revascularisation > 6 hours from injury or >2 hours from presentation was predictive of amputation (p = 0.036 and p = 0.018 respectively), and almost quadrupled the amputation rate. CONCLUSIONS: We should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. This provides a target for trauma teams even with uncertain time of injury.
Highlights
Vascular injury following extremity trauma is uncommon with a reported incidence of less than 1%;1-5 patients with fractures and dislocations about the knee represent a subgroup of individuals that are at increased risk.[1,6]
We hypothesised that a delay to the operating room of 6 hours or more from the time of injury places these patients at increased risk of limb loss
The ‘miserable triad’ of a proximal tibia fracture with clinical signs of threatened viability and a delay to operating room (OR) of ≥6 hours from injury or ≥2 hours from presentation resulted in a statistically significant increased risk of limb loss, suggesting that every attempt should be made to intervene with this subgroup of patients within 6 hours of injury or 2 hours of presentation to hospital in order to improve outcome
Summary
Vascular injury following extremity trauma is uncommon with a reported incidence of less than 1%;1-5 patients with fractures and dislocations about the knee represent a subgroup of individuals that are at increased risk.[1,6] Popliteal vascular trauma carries the highest risk of limb loss of any peripheral vascular injury[7,8,9] with amputation rates reported between 11% and 28% for penetrating and blunt trauma respectively.[6]. Our primary objective was to determine the amputation rate in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries presenting to a level 1 trauma unit draining a large geographical region. Our objectives were to: a) determine the amputation rate; and b) identify risk factors in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries. Risk factors tested for significance (Fischer’s Exact) included: mechanism of injury, limb viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularisation. Conclusions: We should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. This provides a target for trauma teams even with uncertain time of injury
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