An Unexpected Intra-operative Encounter of Anterior Tibial Vessels Entrapment in the Fracture of Tibial Pilon: A Case Re
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CASE REPORT
An Unexpected Intra‑operative Encounter of Anterior Tibial Vessels Entrapment in the Fracture of Tibial Pilon: A Case Report and Literature Review Abhinav Mishra1 · Saubhik Das1 · Hariom Prasad1 · Arvind Kumar2 · Prabhat Agrawal3 Received: 2 September 2020 / Accepted: 26 October 2020 © Indian Orthopaedics Association 2020
Abstract We present a rare case of a comminuted tibial pilon fracture with entrapment of anterior tibial vessels in fracture site, which was unexpectedly discovered intra-operatively. Following safe extrication of vessels and fracture fixation through minimally invasive approach, the patient recovered uneventfully. Phenomenon of anterior neurovascular entrapment should be kept in mind while dealing with high-energy tibial pilon fractures. Astute clinical examination, judicious use of imaging modality, and strict intra-operative vigilance are key to successful outcome. Keywords Tibial pilon · Fracture · Vessels · Entrapment · Management
Introduction Entrapment of neurovascular structures in fractures is not uncommon, frequently observed in upper limb; sporadic cases have also been reported following tibial shaft fractures [1–3]. However, to the best of our knowledge, there is no such mention of neurovascular entrapment in tibial pilon fractures in literature. The anterior tibial vessels and the deep peroneal nerve are at such risk in cases of tibial pilon fractures due to its location in close proximity to distal tibia [4–6]. We report a case of highly comminuted fracture of the distal tibia (AO/OTA 43-C3) with entrapment of anterior tibial vessels with sparing of deep peroneal nerve, managed with a combination of the conventional technique and minimally invasive approach to preserve the soft-tissue envelope while carefully extracting the incarcerated vessel from the fracture site. The patient was informed that data concerning * Saubhik Das [email protected] 1
Orthopaedics, Rajendra Institute of Medical Sciences (RIMS), Bariatu, Ranchi 834009, India
2
Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
3
Orthopaedics, All India Institute of Medical Sciences (AIIMS), Patna, India
the case would be submitted for publication, and he gave consent for the same.
Case Report A 42-year-old-male patient, manual laborer, had sustained injury following fall from tree. He was initially taken to a nearby hospital; relevant radiographs and CT scan of the involved extremity suggested comminuted fracture of tibial pilon (43-C3) with spiral extension of fracture proximally in diaphysis, and concomitant fibular fracture. He was operated upon with external fixator application and open reduction and internal fixation (ORIF) of fibula fracture. Two days after operation, he was referred to our centre for further management. Clinically, there was swelling, no distal sensory-motor deficit; dorsalis pedis artery (DPA) and posterior tibial artery (PTA) pulsations and capillary refill were well appreciated. However, DPA pulsation was feeble which was attri
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