5. What is/are the surgical managements that you will do for this patient?

Trauma to the popliteal vessels is potentially dangerous, and limb loss may result,
especially with delayed diagnosis. Three anatomic factors contribute to the seriousness of the
outcome: proximity of the artery to bone, superficial position of the artery and consequent lack
of protection, and frequent associated injury to associated collateral blood vessels. Serious
surgical managements should be done immediately.

The goal of surgical management is limb salvage. Patients with life-threatening injuries
should undergo a damage control approach, and a small number of patients with devastating
injuries will require amputation.

1. Damage control surgery — when emergent surgery is indicated to control life-

threatening bleeding in the extremity fractures should be quickly reduced and stabilized
with splinting or in-line traction. Tourniquets and dressings may need to remain in place
on the affected extremity.

Priorities include definitive control of bleeding sites with vascular ligation or placement
of a vascular shunt, debridement of devitalized or grossly contaminated tissue, and quick
stabilization of any fractures, if possible.

2. Vascular ligation — In general, ligation (arterial or venous) is best tolerated with distal
or minor vascular injury. There is some degree of redundancy of circulation in the
forearm and leg. Ligation of any one of the three vessels of the leg (anterior tibial,
peroneal, posterior tibial) is a damage control option provided that either the anterior or
posterior tibial vessel is patent to provide in-line flow to the foot.

3. Vascular shunting — A less morbid damage control approach (compared with ligation)
for patients with extremity vascular injury is vascular shunting, a technique that has been
available for over 50 years. A vascular shunt is a synthetic tube that is inserted into the
vessel and secured proximally and distally. Vascular shunts are typically used for larger,
more proximal arteries and veins such as the femoral, popliteal, and brachial vessels.

4. Revascularization — Ischemia due to vascular injury is a major risk factor for

amputation, and, ideally, the injury will be identified and treated within six hours to
minimize ischemic nerve and muscle damage

6. What are the possible complications of this type of penetrating popliteal injury and possible
post-operative complication?

Patients with severe lower extremity injuries have a high incidence of complications, including;

 Wound complications (infection, necrosis, nonunion, osteomyelitis) - Wound

problems, due to ischemia or infection, are the most common complications of severe
 extremity injury and can result in wound breakdown, exposure of bone or vascular
grafts, and secondary infection. The presence of infection affects the type and timing
of soft tissue wound closure and the progress of bony union, and increases the risk for
late amputation. Preventive measures include prophylactic antibiotics and early
wound debridement.

 Venous thromboembolism - Deep venous thrombosis (DVT) and pulmonary

embolism (PE) occur in up to 40 and 20 percent of injured patients, respectively. The
most important risk factors are likely related directly to the extremity injury and
immobilization. Up to one-half of documented deep vein thromboses affect the
proximal lower extremity veins. Venous repair does not appear to increase the
incidence of venous thromboembolic complications based on a review of 103 venous
injuries.
 Rhabdomyolysis and myoglobinuria — Muscle cell death (rhabdomyolysis) and
myoglobinuria can result from severe extremity trauma, crush injury, compartment
syndrome, and revascularization. Rhabdomyolysis presents with elevated serum
muscle enzymes (including creatine kinase), red to brown urine due to myoglobinuria
if there is persistent renal function, and electrolyte abnormalities. Peak serum creatine
kinase levels depend upon the volume of muscle breakdown and the muscle mass of
the patient.
 Heterotopic ossification — Bone healing can be complicated by the formation of
ectopic bone within skeletal soft tissues (heterotopic ossification) in patients with
severe extremity injuries. Risk factors for heterotopic ossification include increasing
burden of disease (increasing injury severity score), traumatic brain injury, and severe
extremity trauma, which are associated with a heightened inflammatory response. As
a result, mesenchymal osteogenic progenitor cells are activated and deposit
mineralized bone within the soft tissues.
 Compartment syndrome
 Permanent nerve damage ( Tibial and common peroneal nerve) resulting to sensory
loss
 Pseudoaneurysms
 Hypovolemic shock due to blood loss
 Late complication including amputation is the presence of extremity injury is a
significant determinant in the patient's long-term functional recovery after major
trauma. Patient characteristics that are associated with poorer outcomes include older
age, female gender, non-white race, lower education level, living in a poor household,
current or previous smoking, and poor health status before the injury. Blunt extremity
injuries are associated with a higher rate of amputation. For below-knee arterial
injuries, the number and location of affected vessels impact the likelihood of
amputation.
 Most of these complications require or prolong hospitalization or require additional
operative treatment.

References

(n.d.). Retrieved from https://www.uptodate.com/contents/surgical-management-of-severe-extremity-

injury

Miles, J. T., De la Rocha, A. G., & Baird, R. J. (1977, March 19). 3. Current approaches to popliteal artery
repair. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1879205/