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ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 266-268

Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka


Department of Vascular and Transplant Surgery, Anuradhapura Teaching Hospital, Anuradhapura, Sri Lanka

Date of Submission12-Aug-2019
Date of Decision05-Sep-2019
Date of Acceptance05-Sep-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Joel D Arudchelvam
Department of Vascular and Transplant Surgery, Anuradhapura Teaching Hospital, Anuradhapura
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_49_19

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  Abstract 


Introduction: Anuradhapura is located in the North Central province of Sri Lanka which is about 200 kilometres away from Colombo which is the commercial capital of Sri Lanka. About 22 to 25 arterial repairs are done for major limb vessel injuries (popliteal, femoral, iliac, brachial, axillary and subclavian arteries) for 1 year at The Anuradhapura Teaching Hospital. Common causes for major lower Limb arterial injuries include Road Traffic Accidents (RTA) and Trap Guns. Trap Gun is an improvised illegal device used to protect crops from animals in Sri Lanka. This is very prevalent in North Central province of Sri Lanka where the Teaching Hospital Anuradhapura is located. Materials and Methods: This study is a retrospective case note based study reporting the outcome of patients presenting with major lower Limb arterial injuries to the Teaching Hospital Anuradhapura including the injuries caused by the trap gun. Results: 24 patients were included with major lower limb arterial injury following trauma. 8 (33.3%) injuries were following trap gun. Two patients following trap gun injury underwent amputation whereas no one underwent amputation when the cause of injury was other than trap gun. This difference in outcome was significant (P 0.0277). Conclusions: Therefore trap gun injury results in poor outcome probably due to associated severe soft issue injury and contamination.

Keywords: Anuradhapura Sri Lanka, ischemic time, lower-limb arterial injuries, trap gun, vascular trauma


How to cite this article:
Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8

How to cite this URL:
Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Sep 27];6:266-8. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/266/273597




  Introduction Top


Anuradhapura is located in the North Central Province of Sri Lanka, which is about 200 km away from Colombo, the commercial capital of Sri Lanka. About 22–25 arterial repairs are done for major limb vessel injuries (popliteal, femoral, iliac, brachial, axillary, and subclavian arteries) for 1 year at the Anuradhapura Teaching Hospital. Common causes for major lower limb arterial injuries include road traffic accidents (RTAs) and trap guns. Trap gun [Figure 1] and [Figure 2] is an improvised, illegal device used to protect the crops from wild animals in Sri Lanka.[1] It is made up of a metal pipe which is loaded with gun powder (used to make firecrackers) and various small metal pieces (pellets). The barrel of the gun is placed horizontally stabilized with sticks. The gun is activated by a trigger which is attached to a trigger code. This trigger code runs across the animal path and is activated by the animal. Humans activate the gun accidentally. When it is activated by humans, the injury is generally at the knee joint level. The pellets cause multiple penetrating injuries [Figure 3]. These multiple penetrating injuries result in severe soft-tissue injuries, comminuted fractures of the bone, and vascular injuries. Vascular injuries are often lower superficial femoral artery (SFA) or popliteal arterial (PA) injuries. This is a unique form of arterial injury which is found in Sri Lanka, especially in areas where the trap gun use is prevalent. This study reports the outcome of major lower limb arterial injuries admitted to the Anuradhapura Teaching Hospital including injuries caused by the trap guns. Anuradhapura Teaching Hospital (THA) is located in Anuradhapura district in North Central Province of Sri Lanka where the trap gun injuries are frequent.[2]
Figure 1: Trap gun after its setup

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Figure 2: Diagrammatic representation of trap gun with its parts

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Figure 3: Leg showing multiple penetrating injuries by trap gun

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  Methods Top


This is a single-center, retrospective, case note-based study done at the Anuradhapura Teaching Hospital. Case notes of patients who were admitted to the emergency department with major lower limb arterial injuries from January 2017 to June 2019 were assessed. Incomplete records were excluded. Data on the patient demography, cause of the injury, the mechanism of injury, time of injury, viability of the limb, vascular intervention, ischemic time, and outcome were collected. Ischemic time was calculated beginning from the time of injury to the time of reperfusion. All the surgeries were done by the two vascular surgeons at the Anuradhapura Teaching Hospital.


  Results Top


Twenty-four patients were included [Table 1]. Twenty-two (87.5%) patients were male. The mean age was 36.9 years (17–69). There were 20 (83.3%) PA and 4 (16.7%) SFA injuries. Cause of injury was trap gun in 8 (33.3%) and RTAs in 13 (54.2%) patients. Overall 20 (83.3%) patients had associated fractures or dislocation. However, in patients with trap gun injuries, only 4/8 (50%) had fractures, and in patients with arterial injury due to other causes, all patients had either a fracture or dislocation. Laceration of the artery was found in 40% and contusion was found in 40% of patients. Following trap gun injuries, more lacerations of the arteries were found (6/8; 75% of patients). However, this observation is not statistically significant (P = 0.1043) probably due to small sample size.
Table 1: Patient characteristics, cause, intervention done, and outcome

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Twelve (50%) patients underwent reversed saphenous vein graft (RSVG) repair and 3 (12.5%) underwent end-to-end anastomosis, 3 (12.5%) had thrombectomy, 1 (4.2%) had venous patch repair, and the artery was ligated in 2 (8.3%) patients who were found to have all compartments nonviable on fasciotomy. Both of these patients also had venous injury, and the vein was ligated as well. The other two patients who had venous injury had sidewall laceration of the venous wall and thrombosis. They underwent thrombectomy and direct repair of the side wall injury. Out of 20 (83.3%) patients who had associated bone injuries, 15 (75%) had external fixator stabilization before revascularization and 3 (15%) patients had head stabilization with plaster of Paris backslabs. One patient who had fibular head fracture had common peroneal nerve injury. This was repaired at a later date by the plastic surgical team.

The mean and median ischemic times in all patients were (n = 24) 10.5 and 10.0 h, respectively (3–29). The mean and median ischemic times in patients with trap gun injury (8/24) were 7.8 and 8.0 h and the mean and median ischemic times in rest of the patients (16/24) were 11.9 and 11.5, respectively, and this difference was statistically significant (P = 0.042), i.e., patients with trap gun injuries had lower ischemic times. Of 8 patients, 2 (25%) after injury due to trap gun underwent amputation. This difference in amputation rate following trap gun injury was significantly higher (P = 0.0277). In patients with arterial injury due to other causes (16/24), 8 (50%) patients underwent RSVG repair, 3 (18.8%) underwent end-to-end repair, and 2 (12.5%) underwent thrombectomy. All these patients had a viable limb at the time of discharge from the hospital.


  Outcome and Conclusions Top


Trap gun and RTAs are the main causes for major lower limb arterial injuries (RTA and trap gun causing 54.2% and 33.3% of injuries in this study) in the North Central Province of Sri Lanka. Trap gun injuries result in more lacerations of the arteries (75%). However, because of low velocity of pellets, trap gun causes fewer fractures compared to other mode of injuries. However, multiple metal pellets released from the trap gun result in multilevel injury to skin and soft tissues with contamination. This results in poor outcome following trap gun injury (significantly high amputation rate, i.e., 25%, P = 0.0277), even though they had significantly lower ischemic time (7.8/8.0 vs. 11.9/11.5 h, P = 0.042) as in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kodikara S, Kudagama M. Trap gun: An unusual firearm, aimed at wild animals but causing a silent epidemic of human fatalities. Am J Forensic Med Pathol 2014;35:1-3.  Back to cited text no. 1
    
2.
Handagala DM, Gunasekara WD, Arulkumaran R. Trap-gun injuries – A menace in rural agricultural areas. Ceylon Med J 2006;51:152.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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