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 .