Case of the Week #13: Distal tibia/fibula fracture with peroneal artery injury in a 13 year old boy
Master D is a 13 year old skeletally immature boy who fell a height of one metre while running at speed, landing directly on his right ankle. He presented to the local Emergency Department with severe lower leg pain and a 60 degree valgus deformity. He had a white, pulseless foot on arrival.
He was stabilised in the Emergency Department and managed as per Emergency Management of Severe Trauma (EMST) principles. An urgent x-ray demonstrated an extra-articular, comminuted distal tibia and fibula fracture with significant valgus deformity that did not involve the physes. The lower limb was reduced under sedation and he was placed in a temporary backslab. After reduction in the Emergency Department, perfusion to the foot returned and Master D had normal sensation to his foot.
A CT angiogram confirmed an occlusion of the peroneal artery, but good perfusion via the posterior tibial artery and dorsalis pedis artery.
The following day, Master D underwent urgent open reduction, internal fixation via an anterior approach to the distal tibia and percutaneous wire stabilisation of the distal fibula. Percutaneous fixation to the distal fibula was utilised to minimise further soft tissue trauma to the lower limb, as well as spare the fibula growth plate. The procedure was uncomplicated. Master D had extensive swelling and fracture blister development over the following four days. Although there was no evidence of infection such as cellulitis, exudate or fever, Master D's anterior wound took approximately four weeks to heal. He was non weight bearing in a CAM boot during this time to protect the soft tissues and minimise swelling.
His six week post-operative x-ray (above) demonstrated callous formation of the fibula fracture so the wire used to stabilise the fracture was removed due to potential irritation to the peroneal tendons. Master D was permitted to weight bear in a CAM boot after the fibula wire was removed, and was able to come out of the boot for non weight bearing range of motion exercises, showers and sleep.
A repeat x-ray three months after his index procedure (below) demonstrated union of the fracture. Master D commenced weight bearing out of the boot and started a strengthening and rehabilitation program. Five months later, he has now started surfing again and has some mild pain with high impact activity, most likely due to muscle wasting and inactivity. The tibial plate will be removed as a day case procedure approximately twelve months after surgery due to the risk of development of a stress reaction at the proximal plate/bone junction.
This case highlights a significant limb threatening injury and the importance of early closed reduction in the emergency department. This fracture was reduced and temporarily stabilised in the Emergency Department within two hours of the injury, and this prompt assessment and reduction resulted in immediate return of perfusion to the foot. Normally three blood vessels supply the foot (the peroneal artery, dorsalis pedis artery and posterior tibial artery). The injury to the peroneal artery, most likely caught up in the fibula fracture site, did not affect peripheral blood supply due to the foot. Early reduction of deformity secondary to trauma is vital to prevent permanent ischaemic injury and potential compartment syndrome to the limb.
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