Limb Salvage for Extensive Muscle Necrosis due to Neglected Blunt Traumatic Popliteal Artery Injury-A Case Report

被忽視的鈍性膕動脈受傷後導致肢體廣泛性肌肉壞死的肢體挽救—病例報告

洪敏翔(Min-Hsiang Hung) ； 羅際衛(Chi-Wei Lo) ； 黃國峯(Kuo-Feng Huang) ； 陳俊嘉(Chun-Chia Chen)

《臺灣整形外科醫學會雜誌》 22卷1期 (2013/03) Pp. 47-54

摘要

背景：鈍性下肢受傷偶爾會伴隨血管的損傷。由於膕動脈特殊的解剖位置，在膝蓋附近的高能量傷害,往往容易造成膕動脈的損傷。然而臨床症狀卻有可能從無症狀的下肢血流量降低到下肢缺血壞死，因此容易造成診斷上的延遲。膕動脈受傷一旦延遲診斷，可能會造成很高的截肢率且肢體的搶救會變得更加困難。目的及目標：我們提出此病例來提醒臨床醫師在膝蓋附近的高能量創傷，即使是鈍性的，也有可能造成膕動脈受傷而引發很高的肢體截肢率。材料及方法：63歲的女性由於右股骨髁上骨折經由骨科醫師施打復位內固定術。病人在術後一個月後因為右下肢嚴重疼痛及皮膚壞死返回急診，清創後發現廣泛性的肌肉壞死，血管攝影檢查顯現膕動脈阻塞導致以下的動脈血流量降低，因此，立即為病人安排了血管整形手術並置放支架。由於廣泛的肌肉壞死及骨頭露出，我們進行多次的清創手術並使用負壓傷口治療以幫助肉芽的生長。雖然感染逐漸控制，但是仍然有骨頭露出的問題，因此我們使用右側自由闊背肌皮瓣來覆蓋露出的骨頭及傷口。結果：六個月後，病人在門診追蹤，闊背肌皮瓣稍微過大，但病人拒絕進一步的減積手術。在功能上，病人可以依靠枴杖行走。膝蓋功能正常但是腳踝僵硬，在足部感覺部分僅存保護感覺。結論：鈍性膕動脈受傷並不常見，延遲診斷後，肢體挽救更具挑戰性。外科醫師對於膝部附近的高能量創傷可能導致血管損傷造成後續的肢體壞死需要謹存於心。對於這樣的病例，如果能夠有效地的恢復下肢血液循環，搭配重複謹慎的清創手術，感染控制及重建計畫，受傷的肢體仍有機會挽留住。

並列摘要

Background:Blunt extremity trauma may bring about vascular injury. Specially, the popliteal artery is assailable due to its proximity to the distal femur and knee joint. Clinical symptoms of the injury can vary from waxing and waning pulses to a completely insensate limb, causing misdiagnosis easily. Delay diagnosis results in a high amputation rate; limb salvage after delayed diagnosis is rarer.Aim and Objectives:We present this case to remind clinicians that high energy trauma around the knee may have already generated popliteal artery injury leading to high amputation rate.Materials and Methods:A 63-year-old female underwent an open reduction with a buttress plate for the right femoral supracondylar fracture (Gustillo type I) as administered by orthopedists. Skin necrosis over her right leg was found about one month later. We performed radical debridement of devitalized skin and noticed extensive ischemic muscle necrosis. An angiography ascertained a segmentally occluded popliteal artery that leads to the small-caliber anterior tibial artery, tibioperoneal trunk and posterior tibial artery. An angioplasty with a stent placement achieved success. Because of massive muscle necrosis with infection and bone exposure evolved, serial debridements with negative-pressure wound therapy were carried out. The infection was controlled gradually. Bone exposure stayed, though. Therefore, she received a free latissimus dorsi (LD) musculocutaneous flap to cover the defect.Results:After our 6-month out-patient follow up, the LD flap was mildly bulky but she refused more debulking surgery. The salvage of a lower limb was achieved and she could stand steadily with a walker. The knee function well recovered but ankle stiffness was found with only protective sensation preserved.Conclusion:Blunt popliteal artery injury is uncommon and limb salvage for extensive muscle necrosis due to neglected blunt popliteal artery injury is even rarer. Limb salvage remains possible, however, if sufficient revascularization is performed in combination with repeated, meticulous wound debridements, infection control, and reconstructive plans.

並列關鍵字

popliteal artery injury ； limb salvage ； latissimus dorsi flap