ABSTRACT
Knee dislocations can cause extensive soft tissue disruption including vascular insufficiency to the leg secondary to popliteal artery injury. Physical exam may miss vascular injury and possible late occlusion, but there is controversy regarding use of angiography to evaluate patients after dislocation. Magnetic resonance angiography (MRA) has been shown to be equally effective as angiography in evaluating vascular injury and to have fewer complications than angiography. Patients with knee dislocations routinely receive magnetic resonance imaging (MRI) to assess ligament integrity. The purpose of our study was to determine whether it may be prudent and convenient to obtain an MR angiogram at the same time as an MRI scan, with less morbidity and discomfort than with conventional angiography. Sixteen patients with frank and occult knee dislocations were prospectively evaluated over 2 years. After reduction, a physical exam was performed including ankle brachial index (ABI). With ABI < 0.90, emergent vascular surgery consult and angiogram was performed. Patients with ABI > 0.90 were observed for 3 days with serial physical exams, and MRI/MRA was performed as soon as possible. Sixteen dislocations were identified. Two of 16 (12.5%) had abnormal ABIs and received an angiogram and subsequent revascularization. Two had normal exams, but refused MRA. Twelve had normal exams and received MRI/MRA showing a normal popliteal artery with no adverse events. ABI had 100% sensitivity for vascular injury; however, there remains concern among treating surgeons about missing an occult injury such as an intimal tear. Because MRA has been shown to be as accurate and useful as angiography, we may be able to evaluate ligamentous and vascular injury simultaneously with less morbidity than that with conventional angiography.
KEYWORDS
Knee dislocation - arterial injury - MRA - angiography
REFERENCES
-
1
Rihn J A, Groff Y J, Harner C D, Cha P S.
The acutely dislocated knee: evaluation and management.
J Am Acad Orthop Surg.
2004;
12
334-346
-
2
Treiman G S, Yellin A E, Weaver F A et al..
Examination of the patient with a knee dislocation. The case for selective arteriography.
Arch Surg.
1992;
127
1056-1062
discussion 1062-1063
-
3
Twaddle B C, Bidwell T A, Chapman J R.
Knee dislocations: where are the lesions? A prospective evaluation of surgical findings in 63 cases.
J Orthop Trauma.
2003;
17
198-202
-
4
Green N E, Allen B L.
Vascular injuries associated with dislocation of the knee.
J Bone Joint Surg Am.
1977;
59
236-239
-
5
Abou-Sayed H, Berger D L.
Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography.
Arch Surg.
2002;
137
585-589
-
6
Applebaum R, Yellin A E, Weaver F A, Oberg J, Pentecost M.
Role of routine arteriography in blunt lower-extremity trauma.
Am J Surg.
1990;
160
221-224
discussion 224-225
-
7
Kaufman S L, Martin L G.
Arterial injuries associated with complete dislocation of the knee.
Radiology.
1992;
184
153-155
-
8
Kendall R W, Taylor D C, Salvian A J, O'Brien P J.
The role of arteriography in assessing vascular injuries associated with dislocations of the knee.
J Trauma.
1993;
35
875-878
-
9
McDonough Jr E B, Wojtys E M.
Multiligamentous injuries of the knee and associated vascular injuries.
Am J Sports Med.
2009;
37
156-159
-
10
Mills W J, Barei D P, McNair P.
The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.
J Trauma.
2004;
56
1261-1265
-
11
Sisto D J, Warren R F.
Complete knee dislocation. A follow-up study of operative treatment.
Clin Orthop Relat Res.
1985;
198
94-101
-
12
Stannard J P, Sheils T M, Lopez-Ben R R, McGwin Jr G, Robinson J T, Volgas D A.
Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography.
J Bone Joint Surg Am.
2004;
86
910-915
-
13
Stayner L R, Coen M J.
Historic perspectives of treatment algorithms in knee dislocation.
Clin Sports Med.
2000;
19
399-413
-
14
Varnell R M, Coldwell D M, Sangeorzan B J, Johansen K H.
Arterial injury complicating knee disruption. Third place winner: Conrad Jobst award.
Am Surg.
1989;
55
699-704
-
15
Wascher D C, Dvirnak P C, DeCoster T A.
Knee dislocation: initial assessment and implications for treatment.
J Orthop Trauma.
1997;
11
525-529
-
16
Wascher D C.
High-velocity knee dislocation with vascular injury. Treatment principles.
Clin Sports Med.
2000;
19
457-477
-
17
McCoy G F, Hannon D G, Barr R J, Templeton J.
Vascular injury associated with low-velocity dislocations of the knee.
J Bone Joint Surg Br.
1987;
69
285-287
-
18
McCutchan J D, Gillham N R.
Injury to the popliteal artery associated with dislocation of the knee: palpable distal pulses do not negate the requirement for arteriography.
Injury.
1989;
20
307-310
-
19
Welling R E, Kakkasseril J, Cranley J J.
Complete dislocations of the knee with popliteal vascular injury.
J Trauma.
1981;
21
450-453
-
20
Dennis J W, Jagger C, Butcher J L, Menawat S S, Neel M, Frykberg E R.
Reassessing the role of arteriograms in the management of posterior knee dislocations.
J Trauma.
1993;
35
692-695
discussion 695-697
-
21
Gable D R, Allen J W, Richardson J D.
Blunt popliteal artery injury: is physical examination alone enough for evaluation?.
J Trauma.
1997;
43
541-544
-
22
Good L, Johnson R J.
The dislocated knee.
J Am Acad Orthop Surg.
1995;
3
284-292
-
23
Hollis J D, Daley B J.
10-year review of knee dislocations: is arteriography always necessary?.
J Trauma.
2005;
59
672-675
discussion 675-676
-
24
Klineberg E O, Crites B M, Flinn W R, Archibald J D, Moorman III C T.
The role of arteriography in assessing popliteal artery injury in knee dislocations.
J Trauma.
2004;
56
786-790
-
25
Levy B A, Zlowodzki M P, Graves M, Cole P A.
Screening for extremity arterial injury with the arterial pressure index.
Am J Emerg Med.
2005;
23
689-695
-
26
Martinez D, Sweatman K, Thompson E C.
Popliteal artery injury associated with knee dislocations.
Am Surg.
2001;
67
165-167
-
27
Miranda F E, Dennis J W, Veldenz H C, Dovgan P S, Frykberg E R.
Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.
J Trauma.
2002;
52
247-251
discussion 251-252
-
28
Atta H M, Tagoe A, Walker M L.
Delayed presentation of popliteal artery pseudoaneurysm following blunt trauma.
Am Surg.
1997;
63
496-499
-
29
Krige J E, Spence R A.
Popliteal artery trauma: a high risk injury.
Br J Surg.
1987;
74
91-94
-
30
Jones R E, Smith E C, Bone G E.
Vascular and orthopedic complications of knee dislocation.
Surg Gynecol Obstet.
1979;
149
554-558
-
31
Seroyer S T, Musahl V, Harner C D.
Management of the acute knee dislocation: the Pittsburgh experience.
Injury.
2008;
39
710-718
-
32
Johnson M E, Foster L, DeLee J C.
Neurologic and vascular injuries associated with knee ligament injuries.
Am J Sports Med.
2008;
36
2448-2462
-
33
Baum R A, Rutter C M, Sunshine J H American College of Radiology Rapid Technology Assessment Group et al.
Multicenter trial to evaluate vascular magnetic resonance angiography of the lower extremity.
JAMA.
1995;
274
875-880
-
34
Potter H G.
Imaging of the multiple-ligament-injured knee.
Clin Sports Med.
2000;
19
425-441
-
35
Potter H G, Weinstein M, Allen A A, Wickiewicz T L, Helfet D L.
Magnetic resonance imaging of the multiple-ligament injured knee.
J Orthop Trauma.
2002;
16
330-339
-
36
Bok A P, Peter J C.
Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis.
J Trauma.
1996;
40
968-972
-
37
Friedman D, Flanders A, Thomas C, Millar W.
Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences.
AJR Am J Roentgenol.
1995;
164
443-447
discussion 448-449
-
38
Klufas R A, Hsu L, Barnes P D, Patel M R, Schwartz R B.
Dissection of the carotid and vertebral arteries: imaging with MR angiography.
AJR Am J Roentgenol.
1995;
164
673-677
-
39
Kohler C, Weishaupt D, Guggenheim M, Künzi W, Wedler V.
Magnet resonance angiography versus conventional angiography for the planning of reconstructive surgeries.
Eur J Trauma Emerg Surg.
2007;
33
40-45
-
40
Egglin T K, O'Moore P V, Feinstein A R, Waltman A C.
Complications of peripheral arteriography: a new system to identify patients at increased risk.
J Vasc Surg.
1995;
22
787-794
-
41
Runge V M.
Safety of approved MR contrast media for intravenous injection.
J Magn Reson Imaging.
2000;
12
205-213
-
42
Waugh J R, Sacharias N.
Arteriographic complications in the DSA era.
Radiology.
1992;
182
243-246
-
43
Stain S C, Yellin A E, Weaver F A, Pentecost M J.
Selective management of nonocclusive arterial injuries.
Arch Surg.
1989;
124
1136-1140
discussion 1140-1141
-
44
Sawchuk A P, Eldrup-Jorgensen J, Tober C et al..
The natural history of intimal flaps in a canine model.
Arch Surg.
1990;
125
1614-1616
-
45
Chapman J A.
Popliteal artery damage in closed injuries of the knee.
J Bone Joint Surg Br.
1985;
67
420-423
-
46
Lohmann M, Lauridsen K, Vedel P.
Arterial lesions in major knee trauma: pedal pulse a false sign of security?.
Arch Orthop Trauma Surg.
1990;
109
238-239
-
47
Busch H P, Hoffmann H G, Metzner C, Oettinger W.
[MR angiography of the lower extremities with an automatic table translation (Mobitrak) compared to i.a. DSA].
Rofo.
1999;
170
275-283
Wendell M.R HeardM.D.
Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University
593 Eddy Street, Providence, RI 02905
Email: wmrheard@yahoo.com
