Paediatric extremity vascular injuries - experience from a large urban trauma centre in India

Abstract

Introduction: Paediatric extremity vascular injuries are infrequent, and management protocols draw significantly from adult vascular trauma experience necessitating a continuous review of evidence.

Materials and methods: A retrospective registry review of all consecutive patients younger than 18 years age treated for extremity vascular trauma from 2007 to 2012 was carried out. Diagnostic algorithm relied little on measurement of pressure indices. Data was collected about demographics, time since injury, pattern of injury, ISS, initial GCS and presence of shock, results of diagnostic modality and treatment given with associated complications. Patients completing 2 years follow up were assessed for functional disability and vascular patency. A multivariable regression model was used to evaluate effects of - ISS, presence of orthopaedic injury, soft tissue injury, neural injury and arterial patency at the end of 2 years - on outcome of functional disability.

Results: Paediatric extremity vascular injuries accounted for 0.68% hospital admissions with a median delay of 8h from injury. 82 patients were included with 50 cases examined for long term outcome. Patient cohort was overwhelmingly male, with 'fall', 'road traffic injury' and 'glass cut' being most common injury mechanisms. CT angiography and duplex scan based diagnostic algorithm performed satisfactorily further identifying missed injuries and aiding complex orthopaedic reconstruction. Brachial and femoral vessels were most commonly injured. Lower extremity vascular injury was found associated with significantly higher ISS and requirement for fasciotomy. Upper extremity vascular injury was associated with higher odds of neural injury. Younger children were at higher risk of combined radial and ulnar vessel injury. No patient satisfactorily complied with post-operative anticoagulant/antithrombotic prophylaxis. 28 patients had good functional outcome with unsatisfactory functional outcome found associated with significantly higher ISS, presence of orthopaedic and neural injury, along with absence of arterial patency.

Conclusion: The epidemiology of paediatric peripheral vascular injury differs in India compared to west. Certain traditional management principles of extremity vascular trauma may stand uniquely challenged in the paediatric population.

Keywords: Extremity; Morbidity; Mortality; Non-iatrogenic vascular injury; Paediatric trauma; Vascular repair.