Traumatic Lower Extremity Arteriovenous Fistulae in Children

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abstractArteriovenous fistulae are rare but potentially disastrous complications in pediatric orthopedic patients. We present 3 cases of traumatic fistulae presenting without the classic signs of bruit, thrill, or compromised pulses. Patients were identified by retrospective chart review for their common complication.The first patient presented emergently after sustaining closed tibia and fibula fractures. An intraoperative angiogram revealed a traumatic arterial laceration with resultant pseudoaneurysm and arteriovenous fistula of anterior tibial vessels. The second patient returned for evaluation 5 days after an elective fasciotomy for exertional compartment syndrome. Ultrasound with duplex Doppler confirmed a hematoma with the classic “Yin-Yang” sign of bidirectional flow representing a 2.0 × 1.8 × 2.2-cm pseudoaneurysm. The third patient presented as a transfer 4 weeks after in-situ pinning of a slipped capital femoral epiphysis at an outside facility. Computed tomography angiography revealed an arteriovenous communication between the lateral branch of first deep femoral perforating artery and the superficial femoral vein.Despite varied diagnoses and temporal acuity, each patient shared the common complication of traumatic arteriovenous fistula that required urgent embolization by interventional radiology. All patients are now full weight bearing with no further sequelae at 9- to 20-month follow-up. Arteriovenous fistulae may have subtle presentations and occur in the absence of obvious signs of vascular compromise. Angiography remains the gold standard, and with coil embolization, can be both diagnostic and therapeutic. The physician must maintain a high index of clinical suspicion to identify and promptly treat such perilous complications.

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