When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities

Monazzam, Shafagh; Goodell, P. B.; Salcedo, Edgardo S.; Nelson, Sandahl H; Wolinsky, Philip R

doi:10.1097/ta.0000000000001258

Cited by 33 publications

(27 citation statements)

References 28 publications

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“…It is quick and readily available, with relatively few contraindications or complications. We had no adverse effects or extra morbidity from the additional angiography sequence in our series, and this correlates with other studies [ 16 ]. The vast majority of trauma patients have a CT head to pelvis, and therefore, angiography may be suitable with little extra ionising radiation or risk.…”

Section: Discussionsupporting

confidence: 90%

“…However, the presence of open fracture, distal or shaft tibial fractures increases the risk of having vascular injury on CTA. They also concluded that all their patients who had diminished or absent pulses required vascular treatment and therefore emphasise how important clinical examination is [ 16 ].…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown the specificity and sensitivity to be 98.7–100% and 90–95.2%, respectively, for CTA diagnosis of arterial damage in the extremities following trauma. Signs eliciting vascular injury include active extravasation of contrast material, incidence of pseudoaneurysm formation, abrupt narrowing of an artery, loss of opacification of a segment of an artery and arteriovenous fistula formation [ 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

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How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study

O'Malley

Trompeter

Krishnanandan

et al. 2019

Eur J Orthop Surg Traumatol

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Background Tibial fractures have an incidence of 15% of all adult fractures. They have been shown to have the highest incidence of non-union in long bone fractures and the highest incidence of vascular injury. Evidence from the literature suggests that a good vascular supply is important to ensure bone union. The aim of our study was to prospectively assess the incidence of vascular injuries in open tibial fractures and determine whether they were associated with an increased risk of non-union. Methods We performed a prospective study to investigate the incidence of arterial injuries with computed tomography angiography (CTA) in patients with Gustilo–Anderson grade I–III open tibial fractures between 2013 and 2015. CTA was performed with the trauma series at acute admission and reported by two independent musculoskeletal radiologists. Patients were followed up with clinical and radiographic assessment for 1 year. Results We recruited 77 patients into the study, and 56 patients (47 males, 9 females) were available for the final analysis, between 16 and 90 years of age. At the initial assessment, 29% had signs of arterial injury with active extravasation in 5%. The most common site of injury was in the diaphysis (87.5%), and the commonest mechanism was a road traffic accident. We found no significant relation between occult vascular injury and non-union (p > 0.05). Conclusion The incidence of vascular injury in open tibial fractures is 29%, and CTA is therefore a useful test in identifying vascular injuries that may require vascular intervention.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study

O'Malley

Trompeter

Krishnanandan

et al. 2019

Eur J Orthop Surg Traumatol

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“…However, it was rarely described in existing fracture models. CTA is a unique radiographic method that demonstrates the arterial vasculature structures through 3D volumetric reconstruction which could rapidly detect vascular injuries [24]. In our study, CTA results showed moderate and partial vascular injuries in group 3 (2/36) and obvious vascular injuries in group 4 (36/36) ( Fig.…”

Section: Discussionmentioning

confidence: 56%

A novel rat model of tibial fracture for trauma researches: a combination of different types of fractures and soft tissue injuries

et al. 2019

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BackgroundThe outcomes for open tibial fractures with severe soft tissue injury are still a great challenge for all the trauma surgeons in the treatment. However, most of the existing open tibial fracture models can only provide minimal soft tissue injury which cannot meet the requirement of severe trauma research. Our goal is to investigate a novel tibial fracture model providing different fractures combined with soft tissue injury for better application in trauma research.MethodsA total of 144 Sprague-Dawley rats were randomly divided into 4 groups. With group 1 as control, the other groups sustained different right tibial fractures by the apparatus with buffer disc settings either 3 mm, 10 mm, or 15 mm. X-ray and computed tomography angiography (CTA) were performed at 6 h to evaluate the fracture patterns and vascular injuries. Peripheral blood and tibialis anterior muscle were harvested at 6 h, 1 day, 3 days, 7 days, 14 days, and 28 days for ELISA and histological analysis.ResultsX-ray and μCT results indicated that different fractures combined with soft tissue injuries could be successfully provided in this model. According to OTA and Gustilo classification, the fractures and soft tissue injuries were evaluated and defined: 36 type I in group 2, 34 type II in group 3, and 36 type III in group 4. The CTA confirmed no arterial injuries in groups 1 and 2, 2 arterial injuries in group 3, and 35 in group 4. ELISA indicated that the levels of pro-inflammatory cytokines TNF-α and IL-1β were significantly higher in group 4 than in other groups, and the levels of anti-inflammatory cytokines TGF-β and IL-10 were significantly higher in surgery groups than in group 1 in later stage or throughout the entire process. HE, Masson, and caspase-3 stains confirmed the most severe inflammatory cell infiltration and apoptosis in group 4 which lasted longer than that in groups 2 and 3.ConclusionsThe novel apparatus was valuable in performing different fractures combined with soft tissue injuries in a rat tibial fracture model with high reproducibility and providing a new selection for trauma research in the future.

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“…Many of these patients are taken directly to theatre and therefore do not undergo radiological investigation. In a recently published study by Monazzam et al [24] on CT angiograms of fractured lower extremities, they found no evidence to support the routine use of CT angiograms to evaluate lower-extremity fractures unless at least one hard or soft vascular sign was present. The data of the current study do not describe the indication for scans outside of blunt trauma, penetrating trauma and non-trauma; therefore, the lower yield rates may be due to scans being done without specific indications, as mentioned above.…”

Section: Researchmentioning

confidence: 99%

High positive computed tomography yields in the emergency department might not be a positive finding

Swartzberg

Goldstein

2018

S Afr Med J

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Background. There is growing pressure to reduce unnecessary computed tomography (CT) imaging requests that the radiology department receives from the emergency department (ED); however, information on acceptable usage rates and diagnostic yields remains scanty. Objectives. To describe the indications, clinical categories and positive yield rates of patients receiving CT scans in the ED. Methods. A retrospective record review was done of all patients who received CT scans at an urban, adult academic ED during a 4-month period. Primary outcomes were to establish CT scan usage and positive yield rates. Other outcomes included analysis of indications, demographics and anatomical areas scanned. Results. Scans (n=1 010) were analysed. The median age of patients was 36 (range 4 -93) years. Male patients received 64.3% of all scans, as well as 75.7% of the scans performed for trauma. The majority of the scans were for trauma patients. However, non-trauma patients had a higher positive yield; the non-trauma positive yield rate was 61.8% compared with the trauma positive yield rate of 47.1% (p<0.001). The majority of scans performed were of the head (58%) and neck (20%), with lowest positive yield rates of 48.9% and 17%, respectively. The overall CT scan usage rate was 4.6% and overall positive rate 53.8%. Conclusion. A negative CT scan does not necessarily mean that the test was not indicated. Higher positive yield rates may reflect insufficient use of CT scanning by the ED. Local guidelines should be established to ensure judicious and effective clinical use of CT scans.

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When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities

Abstract: Diagnostic test, level III.

Cited by 33 publications

References 28 publications

How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study

How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study

A novel rat model of tibial fracture for trauma researches: a combination of different types of fractures and soft tissue injuries

High positive computed tomography yields in the emergency department might not be a positive finding

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