Carrillo, Eddy H

Davare, Dafney L

Ditchek, Jordan J

Eyerly-Webb, Stephanie

Kiffin, Chauniqua

Solomon, Rachele J

Weiner, Eric J

Journal of Surgical Case Reports

English

Eric J Weiner

Jordan J Ditchek

Rachele J Solomon

Stephanie Eyerly-Webb

Chauniqua Kiffin

Eddy H Carrillo

Dafney L Davare

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A unique case of popliteal artery transection after a motorcycle collision

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2017A unique case of popliteal artery transection after amotorcycle collisionEric J. WeinerWashington University School of Medicine in St. LouisJordan J. DitchekMemorial Ragional HospitalRachele J. SolomonMemorial Regional HospitalStephanie Eyerly-WebbMemorial Regional HospitalChauniqua KiffinMemorial Regional HospitalSee next page for additional authorsFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationWeiner, Eric J.; Ditchek, Jordan J.; Solomon, Rachele J.; Eyerly-Webb, Stephanie; Kiffin, Chauniqua; Carrillo, Eddy H.; and Davare,Dafney L., ,"A unique case of popliteal artery transection after a motorcycle collision." Journal of Surgical Case Reports.11,. 1-3.(2017).https://digitalcommons.wustl.edu/open_access_pubs/6360AuthorsEric J. Weiner, Jordan J. Ditchek, Rachele J. Solomon, Stephanie Eyerly-Webb, Chauniqua Kiffin, Eddy H.Carrillo, and Dafney L. DavareThis open access publication is available at Digital Commons@Becker: https://digitalcommons.wustl.edu/open_access_pubs/6360Journal of Surgical Case Reports, 2017;11, 1–3doi: 10.1093/jscr/rjx222Case ReportC A S E R E PORTA unique case of popliteal artery transection aftera motorcycle collisionEric J. Weiner1, Jordan J. Ditchek2, Rachele J. Solomon3,Stephanie Eyerly-Webb3, Chauniqua Kifﬁn4, Eddy H. Carrillo4,and Dafney L. Davare4,*1Washington University School of Medicine, St. Louis, MO, USA, 2Department of Radiology, Memorial RegionalHospital, Hollywood, FL, USA, 3Ofﬁce of Human Research, Memorial Regional Hospital, Hollywood, FL, USA,and 4Division of Acute Care Surgery and Trauma, Memorial Regional Hospital, Hollywood, FL, USA*Correspondence address. Division of Acute Care Surgery and Trauma, Memorial Regional Hospital, 3501 Johnson Street, Hollywood, FL 33021, USA.Tel: +1-954-265-5969; Fax: +1-954-265-2933; E-mail: DDavare@mhs.netAbstractPopliteal artery injuries may have devastating consequences if not recognized in a timely fashion. The risk of delayed diag-nosis of a vascular injury is particularly high in blunt trauma to the lower extremity. We present a case of popliteal arteryinjury that is unusual in two respects: severity (a complete transection in the setting of a blunt injury) and lack of clinicaland radiographic signs of the commonly associated musculoskeletal injuries.INTRODUCTIONPopliteal artery injury is relatively rare, and a delay in diag-nosis and treatment can signiﬁcantly increase morbidity[1–3]. The ligamentous ﬁxation and anatomical proximity tothe femur, tibial plateau and joint capsule render the poplit-eal artery susceptible to high-energy blunt and penetratingtrauma [4]. The association between popliteal artery injuryand tibiofemoral dislocations with or without spontaneousreduction, as well as femur fractures has been well described[2, 4–6]. In these cases, physical exams characteristically showsevere cruciate ligament instability, and imaging studies dem-onstrate fractures, subluxations and/or soft tissue swelling[2, 5, 6].Previous case series on popliteal artery injury followingtrauma have described intimal tears or ruptures of the poplitealartery upon exploration, but no complete transections [7]. Wepresent a unique case of a complete left popliteal arterytransection following a motorcycle collision (MCC), without anyassociated fracture or evidence of a tibiofemoral dislocation.CASE REPORTA 29-year-old male presented to the trauma center following aMCC. The Glasgow Coma Score was 5 at the scene, requiringimmediate intubation. The systolic blood pressure was 98/50mmHg, and the heart rate was 120 beats per minute. On phys-ical examination, breath sounds were decreased to auscultationon the left, and a left chest wall deformity was noted. The leftlower extremity was swollen and tense, and distal left lowerextremity pulses were absent. A chest tube was inserted intothe left hemithorax. Intravenous ﬂuids and blood were admi-nistered, achieving only a transient improvement in vital signs.A focused assessment with sonography for trauma was nega-tive. Radiographs of the left femur and left knee (Fig. 1a–c)Received: July 18, 2017. Accepted: October 24, 2017Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.For commercial re-use, please contact journals.permissions@oup.com1demonstrated no evidence of fracture or dislocation. Due tocontinued hemodynamic instability and clinical evidence ofleft lower extremity compartment syndrome, the patient wastaken emergently to the operating room.The patient underwent fasciotomy of the left thigh with noreturn of his pulses. Following this, an intraoperative arteriogramwas performed (Fig. 2), demonstrating extensive extraluminalextravasation of contrast from the popliteal artery and no opaci-ﬁcation of arteries distal to the knee; these ﬁndings are consist-ent with popliteal artery transection. The patient had a left lowerleg fasciotomy and vascular bypass, from the superﬁcial femoralartery to the distal popliteal artery, using a contralateral saphe-nous vein graft, with successful restoration of distal pulses.In addition to this injury, the patient suffered a traumaticbrain injury, bilateral hemopneumothoraces and a spinal cordinjury. Once stable, the patient was transferred to inpatientrehabilitation on hospital day 20.DISCUSSIONTibiofemoral knee dislocation is a rare and serious injury thatoccurs in ~0.02–0.1% of all musculoskeletal injuries [8]. Theseknee dislocations occur in both high- and low-energy blunt andpenetrating traumas and often spontaneously reduce in theﬁeld [8]. Physical examination of the knee for ligamentousinstability can alert the physician to the possibility of an occultknee dislocation [9]. It is imperative to recognize the clinicalsigns and symptoms of these dislocations, as they are asso-ciated with a signiﬁcant incidence (20–40%) of concomitantpopliteal artery injury, with ~1.6–13% of cases requiring acutepopliteal artery repair [2, 8, 9]. Delayed diagnosis and treatmentof a popliteal artery injury increases patient morbidity.Popliteal artery injuries have been traditionally treatedwith open surgical repair and fasciotomy, although recentadvances have allowed for endovascular repair in select patients.Endovascular techniques are generally implemented in hemo-dynamically stable patients to treat vascular injuries such asthrombosis, pseudoaneurysm, dissection, hematoma and arterio-venous ﬁstula, and have been demonstrated to be successful spe-ciﬁcally in instances of popliteal artery trauma [10–12]. A studyusing data from the National Trauma Data Bank to compare out-comes of open versus endovascular repair showed similar short-term clinical outcomes and hospitalization length between thetwo groups, and a lower rate of fasciotomy in the endovasculargroup [13].In severe lower extremity trauma, clinical or radiographic evi-dence of distal femoral fracture or tibiofemoral dislocation shouldprompt careful vascular evaluation, which will often reveal theconcomitant popliteal artery injury. In milder injuries, physicalexamination may demonstrate evidence of ligamentous instabil-ity, and radiographs may reveal only subtle ﬁndings such as non-displaced fracture, subluxation, joint effusion/lipohemarthrosisand soft tissue swelling. In these cases, a high clinical suspicionfor popliteal artery injury must still be maintained. In fact, evenin the absence of clinical or radiographic evidence of signiﬁcantinjury, vigilant evaluation for vascular injury is still warranted, astibiofemoral dislocation often spontaneously reduces in the ﬁeld,leaving little or no detectable deformity at the time the patient isFigure 1: Portable frontal view of the left femur (a) obtained in the trauma baydemonstrates no evidence of acute fracture. Subsequent AP (b) and cross-tablelateral (c) radiographs of the left knee demonstrate no evidence of acute frac-ture or dislocation.Figure 2: Intraoperative arteriogram of the left lower extremity demonstratesopaciﬁcation of the superﬁcial femoral artery (short arrow). There is extensiveextraluminal extravasation of contrast (long arrows) from the popliteal artery,and non-visualization of the distal vessels, consistent with complete transec-tion of the popliteal artery.2 | E.J. Weiner et al.clinically evaluated. Finally, in cases where no clinical history isavailable and the mechanism of injury is unknown, a severe vas-cular injury such as arterial transection should be considered as apotential cause of refractory hypotension.CONFLICT OF INTEREST STATEMENTNone declared.REFERENCES1. Gable DR, Allen JW, Richardson JD. Blunt popliteal arteryinjury: is physical examination alone enough for evalu-ation? J Trauma Acute Care Surg 1997;43:541–4.2. Perron AD, Brady WJ, Sing RF. Orthopedic pitfalls in the ED:vascular injury associated with knee dislocation. Am JEmerg Med 2001;19:583–8.3. Yahya MM, Mwipatayi BP, Abbas M, Rao S, Sieunarine K.Popliteal artery injury: Royal Perth experience and literaturereview. ANZ J Surg 2005;75:882–6.4. Witz M, Witz S, Tobi E, Shnaker A, Lehmann J. Isolated com-plete popliteal artery rupture associated with knee disloca-tion. Knee Surg Sports Traumatol Arthrosc 2004;12:3–6.5. Kapur S, Wissman RD, Robertson M, Verma S, Kreeger MC,Oostveen RJ. Acute knee dislocation: review of an elusiveentity. Curr Probl Diagn Radiol 2009;38:237–50.6. Seroyer S, Musahl V, Harner C. Management of the acuteknee dislocation: the Pittsburgh experience. Injury 2008;39:710–8.7. Gupta R, Quinn P, Rao S, Sleunarine K. Popliteal artery trau-ma: a critical appraisal of an uncommon injury. Injury 2001;32:357–61.8. Sillanpää PJ, Kannus P, Niemi ST, Rolf C, Felländer-Tsai L,Mattila VM. Incidence of knee dislocation and concomitantvascular injury requiring surgery: a nationwide study.J Trauma Acute Care Surg 2014;76:715–9.9. Steele HL, Singh A. Vascular injury after occult knee dis-location presenting as compartment syndrome. J Emerg Med2012;42:271–4.10. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Caronno R,Laganà D, et al. Endovascular treatment for traumatic injur-ies of the peripheral arteries following blunt trauma. Injury2007;38:1091–7.11. Hutto JD, Reed AB. Endovascular repair of an acute bluntpopliteal artery injury. J Vasc Surg 2007;45:188–90.12. Megalopoulos A, Siminas S, Trelopoulos G. Traumatic pseu-doaneurysm of the popliteal artery after blunt trauma: casereport and a review of the literature. Vasc Endovascular Surg2007;40:499–504.13. Tan T-W, Armstrong FD, Zhang WW. Review of surgicaltreatment of popliteal artery injury: outcomes of open vsendovascular repair. Vasc Dis Manag 2016;13:E176–82.Popliteal artery transection | 3

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A unique case of popliteal artery transection after a motorcycle collision

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