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Thu Jul 31 07:14:33 BST 2008

Norman

I agree with you - ABI or comparative pulse pressures (side to side)
<0.9 is in need of further evaluation. One's finger is not always
sensitive enough to feel such a subtle deficit. Maybe Eric F has very
sensitive fingers, but he "poopood" the use of non-invasive testing. I,
however, believe in it. Norman, the pulses were reported present
bilaterally if I recall Sal's original post.

Regards
Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: McSwain, Norman E Jr. [mailto:trauma-list-bounces at trauma.org] On
Behalf Of McSwain, Norman E Jr.
Sent: 31 July 2008 02:11
To: Trauma &amp
Subject: RE: Fw: popliteal angiography for asymptomatic knee
dislocations

The question of the initial PxEx has not been answered. What were the
pulses? and what was the ABI?

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

  _____  

From: trauma-list-bounces at trauma.org on behalf of Errington Thompson 
Sent: Wed 7/30/2008 5:22 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Fw: popliteal angiography for asymptomatic knee
dislocations
Rob -

I think that you are right.  The question is what would have happened if
Sal
elected to watch that injury?  Would it have clotted off?  Would it
re-model
and had been fine?

E

Errington C. Thompson, MD
Trauma/Surgical Critical Care
Talk Show Host - WPEK
www.whereistheoutrage.net
Asheville, NC

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Robert F. Smith
Sent: Wednesday, July 30, 2008 10:44 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Fw: popliteal angiography for asymptomatic knee
dislocations

This is the abstract of Eric's study on this particular injury and the
utility of physical exam as a screening tool. I realize I'm not the
student
of or contributor to the literature as many of this list's members. But
have
his many studies on peripheral, and later, more central vascular
injuries
been refuted? Not to speak for him but it's as if the bugaboo of missed
injury can never be refuted, even if there were no missed injuries in
several studies with pretty good follow up for our patient population.

Rob Smith

1: J Trauma. 2002 Feb;52(2):247-51; discussion 251-2.

Confirmation of the safety and accuracy of physical examination in the
evaluation
of knee dislocation for injury of the popliteal artery: a prospective
study.

Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg ER.

Department of Surgery, University of Florida Health Science Center,
Jacksonville,
Florida 32209, USA.

BACKGROUND: Knee dislocation, which poses a significant risk for injury
of
the
popliteal artery, prompts many surgeons to evaluate these patients with
arteriography routinely. Our hypothesis was that physical examination
alone
(without arteriography) accurately confirms or excludes surgically
significant
vascular injuries associated with knee dislocation. METHODS: All
patients
diagnosed with a knee dislocation by an attending orthopedic surgeon
between
January 1990 and January 2000 were prospectively managed by protocol at
our
Level
I trauma center according to their physical examination. Those with hard
signs
(active hemorrhage, expanding hematoma, absent pulse, distal ischemia,
bruit/thrill) underwent arteriography followed immediately by surgical
repair if
indicated. Patients with no hard signs (negative physical examination)
were
admitted for 23 hours, underwent serial physical examination, and then
followed
as outpatients. RESULTS: There were 35 knee dislocations in 35 patients
during
this 10-year period. The average age was 31 years; 18 dislocations were
on
the
right knee and 17 were on the left. Two patients died from closed head
injuries
and multisystem trauma. Eight patients were found to have hard signs
(positive
physical examination) either at presentation (six patients) or during
their
hospitalization after reduction of their dislocation (two patients). All
eight
patients demonstrated a loss of pulses only. Six of these patients
showed
occlusion of the popliteal artery on arteriography and underwent
surgical
repair
without complication (five vein grafts, one primary repair), one
demonstrated
spasm of the popliteal artery, and one showed a normal artery that
required
no
treatment. None of the 27 patients with negative physical examination
during
their hospitalization ever developed limb ischemia, needed an operation
for
vascular injury, or experienced limb loss. Sixteen patients were
available
for
follow-up (46%). Twelve patients with negative physical examination
(44%)
were
contacted (mean, 13 months; range, 2-35 months), and four of the eight
patients
with positive physical examination (50%) and surgical repair were
contacted
(mean, 19 months; range, 6-49 months). None of the patients in either
group
developed any vascular-related symptoms or suffered from a vascular
repair
complication over the follow-up interval. CONCLUSION: This limited
series
suggests that the presence or absence of an injury of the popliteal
artery
after
knee dislocation can be safely and reliably predicted, with a 94.3%
positive
predictive value and 100% negative predictive value. Arteriography
appears
to be
unnecessary when physical examination is negative but may avert negative
vascular
exploration when physical examination is positive. This approach
substantially
reduces cost and resource use without adverse impact on the patient.

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: Wednesday, July 30, 2008 9:09 AM
To: trauma-list at trauma.org
Subject: Fwd: Fw: popliteal angiography for asymptomatic knee
dislocations

We are very aggressive in early angiographic evaluation of potential 
popliteal arterial injury with knee dislocations, even in the absence of
hard  signs.
   What has been written for femoral and brachial artery  injury does
not
necessarily apply to the popliteal artery in that a missed  injury can
result in
loss of the lower leg.      AND  the medical legal consequences are
significant.    I know  that some highly visible persons have had stents
placed in their
popliteal  arteries for aneurysms, but these persons are quite older
than
the
young trauma  patient.    

For the injury shown, we would do a direct revascularization via a
saphenous
vein graft, probably a jump from distal femoral to distal popliteal,
and
not
interfere with the ligaments around the knee.  

k

____________________________________

-----Original Message-----
From: "Timothy Craig Hardcastle"  <TimothyHar at ialch.co.za>

Date: Wed, 30 Jul 2008 08:09:07
To:  Trauma &amp; Critical Care mailing  list<trauma-list at trauma.org>
Subject: RE: popliteal angiography for  asymptomatic knee dislocations

Sal

Call me old fashioned,  but it is considered negligent by the
authorities
in South Africa to not  angio the posterior knee disloc. I know the
counter literature, but your  case illustrates the problem - I've seen
an
occlusion on day 7 of one not  angio'ed by a peripheral rural hospital.
Luckily we could save the  leg.

No experience with stent-grafts in Pop vessels personally, but  the
experience with long-term patency and the need for a  secondary
intervention with stents for thoracic outlet penetrating injuries  (see
the work of DF du Toit et. al.) shows that the asymptomatic  occlusion
rates are fairly high. In the pop segment there is poor  collaterals and
I would be worried about long-term problems.

I  suppose the thrombolysis may work, although the question is whether
you  have recruited any previously dubious muscle?

Regards,
Tim
Dr  Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS  (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical  Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli  Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal:  PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu  Natal

timothyhar at ialch.co.za

-----Original  Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of sjasmd at aol.com
Sent: 30 July 2008 06:36
To:  trauma-list at trauma.org
Subject: popliteal angiography for asymptomatic knee  dislocations

I would have enjoyed more discussion of the pros and  cons of performing
angiography for asymptomatic knee dislocations. It would  seem from the
few posts that there are some who still perform angiography.  We had
begun to dismiss this procedure because of an overwhelming amount  of
fairly good data published in the past decade that showed that signs  of
vascular injury are almost always present when angiography is  positive
in detecting popliteal artery injury and that detecting injury in  the
absence of signs by angiography is uncommon.

We recently saw an  obese ?patient who dislocated her knee anteriorly
who
underwent angiography  three days after the injury because the
orthopedic
service wanted  angiography prior to planning knee repair.
Angiography showed intraluminal  thrombus and intimal flaps with
thrombus
on them?in the midpopliteal  artery. Luminal diameter was compromised
about 80%. Distal run-off  angiography showed occlusion of the entire
posterior tibial artery and  embolism of the midportion of the peroneal.
The anterior tibial artery was  normal. see attached

We elected to place a stent graft over?the injured  segment and trap the
thrombus under it.?We introduced? a 22 mm atrium stent  and applied it
exactly at the site of the injury. Anatomical appearance  returned with
good flow.

patient was discharged the next day and  will undergo elective
reconstruction of the knee.

any  comments?
about use of angiography for knee dislocations
about use of  stent graft in popliteal artery
about use of thrombolysis for the peroneal  embolism

thanks

SAL  SCLAFANI

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Fw: popliteal angiography for asymptomatic knee dislocations