Mortality and Limb Loss in Isolated Lower Extremity Vascular Trauma: Analysis of the National Trauma Data Bank

Abstract

Objective: Lower extremity injury is common; however, the influence of arterial injury on devastating patient and limb outcomes can be confounded by associated injuries. We analyzed isolated lower extremity injuries with a vascular component. Methods: We reviewed trauma incidents from the National Trauma Data Bank (2002-2006) with isolated lower extremity injury codes and specified arterial injury distal to the external iliac. Demographics, injury patterns, clinical characteristics, and outcomes (death, amputation) during initial hospitalization were collected. Multivariate regression was used to identify risk factors for limb loss. Results: There were 651 isolated lower extremity injuries with arterial component. Death or limb loss occurred in 59 (9.1%), with 18 deaths (2.8%). Half of deaths involved injury to the common femoral artery (CFA), and 15 (83%) involved injury to the CFA or superficial femoral artery (SFA). Death was more frequent in CFA/SFA (13 of 291, 4.5%) than popliteal/tibial (5 of 360, 1.4%) injuries (P = .02). Penetrating injuries were present in 14 deaths (78%). Patients who died had mean initial SBP of 59.7 mm Hg, and seven (39%) had no blood pressure on arrival. Mean GCS was 4.5, and 14 (78%) arrived with a GCS of 3 despite the absence of head injury. There were 42 (6.5%) amputations, 27 above knee and 15 below knee. The popliteal artery was injured in 22 (52%), with injury isolated to the popliteal or tibial arteries in 30 (71%). Amputation was more frequent in popliteal/tibial (30 of 360, 8.3%) than in CFA/SFA (12 of 291, 4.1%) injury (P = .03), and in blunt (20 if 220, 9.1%) than in penetrating (22 of 431, 5.1%) injury (P = .05). Multiple arterial injuries (OR, 5.2; 95% CI, 1.7-15.6; P = .003), and fracture (OR, 2.2; 95% CI, 1.1-4.2; P = .02) independently predicted amputation, whereas nerve injury did not (Table).TableUnivariate predictors of amputationPredictorNo amputation (n = 609)Amputation (n = 42)PNo. (%)No. (%)CFA113 (19.0)7 (16.7).76SFA175 (28.7)6 (14.3).04Popliteal212 (34.8)22 (52.4).02AT or PT125 (20.5)13 (31.0).11Multiple vessel15 (2.5)5 (11.9)<.001Vein injury161 (26.4)12 (29.0).76Fracture180 (30.0)22 (52.4).002Nerve injury63 (10.3)4 (9.5).87Blunt mechanism200 (32.8)20 (47.6).05 Open table in a new tab Conclusions: Isolated lower extremity trauma with vascular injury has a nearly 10% rate of mortality or limb loss. Mortality is associated with penetrating mechanism and early shock likely resulting from prehospital proximal arterial hemorrhage. In contrast, early limb loss is more common with blunt distal vascular injury, likely related to the difficulty in reconstructing these vessels and associated limb injuries. Nerve injury did not predict limb loss but may result in delayed amputations not captured in this acute outcomes data set.