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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 133-135

Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism


1 Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
2 Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission03-Sep-2020
Date of Decision06-Oct-2020
Date of Acceptance23-Oct-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Tungish Bansal
Department of Orthopedics, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_30_20

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  Abstract 


Proximal tibial physeal injuries with neurovascular injuries are rare. Here, we report the case of a 12-year-old boy with a rare fracture pattern that is segmental tibia fracture with physeal and diaphyseal fracture with popliteal artery and common peroneal nerve injury, which has never been reported earlier to the best of our knowledge. We also discuss the possible mechanism of injury and also describe the surgical decision-making and highlight the importance of prompt identification and early management of such patients for a good clinical outcome.

Keywords: Child, physeal injury, segmental, trauma, vascular injury


How to cite this article:
Bansal T, Patel S, Sudesh P, Kumar V. Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism. J Orthop Dis Traumatol 2020;3:133-5

How to cite this URL:
Bansal T, Patel S, Sudesh P, Kumar V. Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism. J Orthop Dis Traumatol [serial online] 2020 [cited 2021 Apr 16];3:133-5. Available from: https://www.jodt.org/text.asp?2020/3/3/133/305738




  Introduction Top


Physeal injuries are fairly common in children.[1] The injuries of the physis of the proximal tibia are quite rare.[2],[3] Proximal tibial physeal injuries have been associated with popliteal artery injury.[4],[5],[6] Here, we report the case of a segmental fracture tibia with an associated physeal and neurovascular injury in a 12-year-old boy. To the best of our knowledge, such an injury pattern has never been reported previously. The management and considerations for such a case have also been discussed.


  Case Report Top


A 12-year-old boy presented to our emergency 4 h after a road traffic accident. The patient had sustained injury to his right leg. The limb was cold to touch, and distal pulses (anterior tibial artery, posterior tibial artery, and dorsalis pedis artery) were not palpable. There were tenderness and crepitus along the middle of the leg, and the patient was unable to dorsiflex his ankle and toes. After initial resuscitation, he was sent for radiographs which showed a segmental fracture of the tibia with injury to the physis of the proximal tibia (Type-1), a fracture of the diaphysis of the tibia [Figure 1]. Subsequently, ultrasonography color Doppler and computed tomography (CT) angiography were done for the patient. The Doppler showed no flow in the distal vessels. This was further confirmed by CT angiography which showed a thrombus in the popliteal artery at the site of the proximal physis injury with some distal reformation [Figure 2]. The patient was urgently shifted to the operating theater and was operated on by orthopedic and vascular teams. A single-incision lateral fasciotomy was performed first to access the status of the muscles. This was followed by fixing the diaphyseal fracture with an external fixator and stabilizing the proximal tibial physis with 2 K wires after reduction. A trans-articular fixator was applied to offload the proximal tibial fixation and facilitate vascular intervention. The case was then handed over to the vascular team for their intervention. The vascular team performed thrombectomy and a vascular repair of the popliteal artery. The perioperative and postoperative periods were uneventful. The distal pulses were palpable post surgery. The fasciotomy wound required split-skin grafting (SSG) and was done on the postoperative day 5. The patient was given a foot drop splint for common peroneal nerve (CPN) palsy, and nonweight bearing mobilization with walker was started. The patient was discharged on the 10th postoperative day. The patient was followed up in the outpatient department after 2 weeks when sutures were removed. At 6-week follow-up, there were radiological signs of union at the proximal tibia [Figure 3] and hence trans-articular frame and two k-wires in physis were removed and knee range of motion had started. There was also partial recovery of the foot drop. The SSG uptake was excellent, and all wounds were healthy and healed. The patient was also started on partial weight-bearing with a fixator in situ. At 10 weeks postoperatively, the fixator for tibial shaft fracture was also removed and a PTB brace was applied. At 4-month follow-up, the fracture showed complete union. The patient had a complete recovery of CPN palsy with complete sensory and motor recovery at 6 months. The child was pain free, able to walk with full weight-bearing, and could carry out all activities of daily living at final follow-up at 1 year. He had a slight limb length discrepancy 1 cm compared to the opposite leg, which required no further intervention. The radiographs at final follow-up are presented in [Figure 4].
Figure 1: Anteroposterior and lateral views of the patient at the time of injury

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Figure 2: Three-dimensional reconstruction images from computed tomography angiography for the patient. The cutoff of the popliteal artery at the proximal tibial physis can be made out

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Figure 3: Anteroposterior and lateral views of the patient at 6-week follow-up

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Figure 4: Anteroposterior and lateral views of the patient at 1-year follow-up

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  Discussion Top


Physeal injuries are quite common and have been reported in up to 18% of all child fractures.[1] Proximal tibial physeal injuries make up for 0.6%–1.1% of all physeal injuries.[1],[2] These fractures are rare because powerful ligamentous attachments are absent in the periphery of the epiphysis.[3] Capsular and collateral ligaments are attached distal to the physis, thus protecting it. Popliteal artery injury is a known complication of proximal tibial physeal injury and has been reported by various authors.[4],[5],[6] The incidence of vascular injury has been estimated to be 7.1%–7.7% in few case series.[5],[6] Popliteal artery is prone to injury as it lies in proximity to the bone at the level of physis and is bound by fibrous septa close to the knee capsule. Vascular injury may also be rarely associated with CPN palsy.[4] The association of a segmental fracture with physeal injury and neurovascular compromise makes the present case rare and unique.

Tibial physeal injuries occur due to various mechanisms such as valgus, varus, hyperextension, and flexion avulsion type of fractures. The mechanism of injury in our case was hyperextension. Mubarak et al. in their study on tibial physeal fractures noted that in extension-type injuries, Type 1 and 2 injuries have been noted although tibial spine avulsion was the most common injury.[7] It is interesting to note that in our case the hyperextension not only resulted in a displaced Type 1 physeal fracture but also continued to act which resulted in a diaphyseal tibial fracture and a fracture of the proximal fibula. This also indicated a very high energy trauma. The distal fragment after the physeal injury hinged on the posterior soft tissue and with continued extension resulted in a diaphyseal fracture. To the best of our knowledge, this type of injury pattern has never been reported previously. Such an injury pattern when noticed should alert the surgeon of a high-energy trauma and raise suspicion of neurovascular injuries.

Early intervention is the key to a successful outcome. Various studies have shown that best results can be obtained in popliteal artery injuries if repair is undertaken within 6–8 h, but successful repairs have been undertaken up to 12 h.[4],[8],[9] Time though being an important factor is not the only consideration. Age, extent of occlusion, and presence of collaterals also play a role in the final outcome.[9] Patients should be diagnosed and treated at the earliest to avoid adverse consequences such as amputation and even death.[10],[11] In our case, we operated on the patient within 8 h of injury. A high index of suspicion should be kept for vascular injuries, compartment syndrome, and neurological complications in such cases. The injury to the popliteal artery may not be obvious at initial presentation and may develop slowly.[10] It is of utmost importance that serial examination for vascular status in such cases be deployed. At 6-month follow-up, our patient has made full functional recovery with no distal neurovascular deficit. The fracture shows radiological and clinical signs of union. There were some disturbances in the growth which resulted in a 1-cm limb length discrepancy, which required no active intervention at 1-year follow-up. The knee range of motion on both sides was comparable.


  Conclusion Top


Physeal injuries of proximal tibia are rare. A high index of suspicion should be kept for vascular and neurological injuries. Physeal injuries may be associated with diaphyseal fractures, creating difficulties in management. Early diagnosis and intervention is the key for a successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop 1986;7:518-23.  Back to cited text no. 1
    
2.
Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs. adult vascular trauma: A National Trauma Databank review. J Pediatr Surg 2010;45:1404-12.  Back to cited text no. 2
    
3.
AITKEN AP, INGERSOLL RE. Fractures of the proximal tibial epiphyseal cartilage. J Bone Joint Surg Am 1956;38-A: 787-96.  Back to cited text no. 3
    
4.
Guled U, Gopinathan NR, Goni VG, Rhh A, John R, Behera P. Proximal tibial and fibular physeal fracture causing popliteal artery injury and peroneal nerve injury: A case report and review of literature. Chin J Traumatol 2015;18:238-40.  Back to cited text no. 4
    
5.
Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. JBJS 1979;61:996-1002.  Back to cited text no. 5
    
6.
Shelton WR, Canale ST. Fractures of the tibia through the proximal tibial epiphyseal cartilage. Bone Joint Surg Am 1979;61:167e173.  Back to cited text no. 6
    
7.
Mubarak SJ, Kim JR, Edmonds EW, Pring ME, Bastrom TP. Classification of proximal tibial fractures in children. J Child Orthop 2009;3:191-7.  Back to cited text no. 7
    
8.
Reed MK, Lowry PA, Myers SI. Successful repair of pediatric popliteal artery trauma. Am J Surg 1990;160:287-90.  Back to cited text no. 8
    
9.
MacGowan W. Acute ischaemia complicating limb trauma. J Bone Joint Surg Br 1968;50:472-81.  Back to cited text no. 9
    
10.
Shinomiya R, Sunagawa T, Nakashima Y, Nakabayashi A, Makitsubo M, Adachi N. Slow progressive popliteal artery insufficiency after neglected proximal tibial physeal fracture: A case report. J Pediatr Orthop Part B 2016;27:35-9.  Back to cited text no. 10
    
11.
Reid JJ, Kremen TJ Jr., Oppenheim WL. Death after closed adolescent knee injury and popliteal artery occlusion: A case report and clinical review. Sports Health 2013;5:558-61.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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