Case Report:
Fifty years Nepalese farmer presented to our center with an alleged history of crushing and twisting injury of his left lower limb by his own tractor while he was working on his field. The patient was complaining of pain and was unable to bear weight. There was no history of loss of consciousness, headache, vomiting, and bleeding from the ear, nose, and throat. There was no history of comorbidities. He was a smoker but non-alcoholic.
The patient was presented to our center 14 hours after the incident after being managed in the local center where hemostasis was secured by compression bandages. At the time of presentation, his airway was intact, he was breathing spontaneously and was stable hemodynamically; his Glasgow coma scale(GCS) was E4V5M6. There were no visible external injuries in the head, neck, chest, back, abdomen, bilateral upper limbs, and right lower limb. There was no tenderness in the head, neck, chest compression, and pelvic compression. Cervical, thoracic, and lumbar spine tenderness were absent.
On examination of the left lower limb there was an open wound size of approximately 12cmx5 cm at the left ankle with grossly exposed, dislocated, and protruding both tibia and fibula over the lateral aspects of the ankle to the external environment with gross deformity as shown in figure 1 . The attitude of the left lower limb was shortened with hip and knee slightly flexed and his hip was tender with palpable femoral head anteriorly and superiorly. His left lower limb popliteal and posterior tibial artery were palpable with truncated visible pulsations likely of the anterior tibial artery without active bleeding. Capillary refill time was less than 3 seconds. Dorsalis pedis could not be palpated, and the sensation was intact but due to severe pain, his motor examination could not be performed. Vascular injury was ruled out after vascular consultation.
Non-contrast head computed tomography (NCCT), chest x-ray, x-ray cervical, dorsal and lumbosacral images were unremarkable. X-ray left ankle anteroposterior(AP) and lateral view images showed anterolateral dislocation of the ankle joint without any fracture as shown infigure 3 . X-ray left hip AP and lateral view showed superior type anterior dislocation which was not associated with fracture as shown in CT scan images figure 2A,2B . Arterial Doppler ultrasonography of the lower limb showed normal flow in the tibialis anterior and dorsalis pedis arteries and he was planned for emergency surgery.
Intraoperatively under general anesthesia close reduction of the anterior dislocation of the hip was done by axial traction and internal rotation. Open dislocation of the ankle was managed based on the principle of management of open fractures. Extensive debridement and washing with 15L of normal saline were done. Reduction of the dislocated joint was done by delta frame external fixator as shown infigure 4A along with that torn ligament were not repaired. Skin closure was possible and postoperative skin necrosis did not occur. Postoperatively he was admitted to the orthopedic high dependency unit for monitoring and was transfused with two units of packed RBCs to correct low hematocrit. Postoperatively he was managed with broad spectrum antibiotics, analgesics, alternate day dressing, and skin traction left lower limb. His postoperative period was uneventful.
Limb knee range of motion and crutch mobilization was started on the 12th postoperative day. He was discharged on the 12th postoperative day after suture removal with an external fixator in situ and advised to follow up after 6 weeks. The external fixator was removed at 6 weeks and ankle range of motion and physiotherapy were increased. Physiotherapy was continued and the patient had a good functional recovery in 3 months and started working in the field. He could do squat and his knee, hip, along with ankle range of motion were full with restricted dorsiflexion of the ankle. There was no evidence of avascular necrosis in the x-ray of the hip and had no complaints of pain. Ankle joint alignment was normal as shown in figure 5A .