The frequency of vascular injury resulting from extremity trauma varies depending on an individual’s social or natural environment [1-4]. Traffic accidents appear to be a major threat to public safety in South Korea, where war-related or gunshot injuries are rare. Here, we present a trauma case of combined vascular and orthopedic injuries. A 77-year-old woman was brought to our emergency room as a pedestrian, who had been trapped under the wheel of a limousine. The crushed bones were exposed in both ankles, and the left leg had simultaneous fractures of the distal tibia and midshaft fibula (Fig. 1). There was no arterial pulse at the level of the ankle wound. Initial computed tomography (CT) angiography revealed an occluded anterior tibial artery (ATA) and diminished flow from the tibioperoneal trunk (TPT) (Fig. 2). Given its ease and combined degloving injury, we decided to repair the posterior tibial artery (PTA) first without exploring the ATA, which might have required a vein bypass. Unlike the apparent severe damage, the surgically exposed PTA through the open wound appeared intact. Following transverse arteriotomy on the PTA, bidirectional thrombectomy was performed using a 2-F Fogarty catheter. Except for a small amount of intima, nothing was found. The procedure was then completed because ankle pulse was restored.

Figure 1. (A) The photograph showed a nearly amputated left leg at the ankle. (B) Computed tomography scan demonstrated fractures of the distal tibia (Gustilo–Anderson type IIIc) and mid-shaft fibula.

Figure 2. Preoperative computed tomography angiogram of the lower extremity. (A) Maximum intensity projection image showed that the arterial flow of the left leg becomes dim below the mid-calf. (B) On axial images, whereas no flow was seen on arterial phase, faint proximal and mid-posterior tibial artery flow was seen on delayed phase at the level of the fibular fracture. This appeared to be a spasm associated with indirect impact.

On postoperative day 8, a CT scan showed a 25-mm–sized pseudoaneurysm just below the TPT. An intraoperative angiogram confirmed that the pseudoaneurysm originated from the PTA (Fig. 3). The damaged PTA was reconstructed with a reversed great saphenous vein. A completion angiogram revealed a patent interposition graft without extravasation (Fig. 4).

Figure 3. (A) The axial image of computed tomography scan 8 days after the initial operation revealed an approximately 25 mm×20 mm sized-pseudoaneurysm adjacent to a posterior tibial artery or a peroneal artery, which was located 7.5 cm above the fibula fracture site. (B) Conventional angiography before arterial reconstruction showed that the pseudoaneurysm with quite a large neck originated from the posterior tibial artery (arrowhead).

Figure 4. Operation field and completion angiogram. (A) The damaged posterior tibial artery was reconstructed using an interposition graft with an above-knee great saphenous vein of ipsilateral leg in a reversed fashion. The combined circumferential degloving injury appeared to have caused extensive skin necrosis. (B) Completion angiogram following bypass showed no extravasation of contrast medium and a good arterial flow to the foot.

The management of traumatic vascular injury is substantially demanding, especially when combined with other injuries [1,5]. In high-energy trauma involving the bone, arterial injury can occur not only adjacent to the fracture but also some distance away from it. In such cases, thrombectomy should be performed cautiously, considering the possibility of intimal injury, and a completion angiography can be helpful. Moreover, follow-up imaging is essential when the dissected intima is retrieved.