case_images: PMC11736768_01
case_images: Initial plain radiographs showing injury pattern.
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case_images: He had a displaced triplane fracture (Figure 1).
case_images: Post reduction plain radiographs demonstrating worsening in anterior displacement of the distal fracture segment.
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case_images: Attempted closed reduction led to further fracture displacement (Figure 2).
case_images: (A) Selected sagittal and coronal cuts showing the fracture line propagating in the coronal, axial, and sagittal planes. (B) Three-dimensional (3-D) volume rendering computed tomographic (CT) scan cuts showing the fracture geometry. Selected cuts are anterior, posterolateral, and anteromedial. (C) Postreduction CT scan showing tibialis posterior (TP) and flexor digitorum longus (FDL) tendons in the fracture site. The neurovascular (NV) bundle is stretched at the periphery of the fracture site.
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case_images: A preoperative computed tomography (CT) scan was obtained (Figure 3, A-C). Further consultation with the orthopaedic trauma foot-and-ankle service was obtained and based on a retrospective review of the scans, it was believed that the medial tendinous/neurovascular structures (PT vessels, tibial nerve, and tibialis posterior [TP] and flexor digitorum longus [FDL] tendons) were entrapped in the fracture site (Figure 3, C).
case_images: Plain radiographs after the first open reduction internal fixation.
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case_images: A lateral incision was used to perform ORIF of the fibula fracture (Figure 4).
case_images: Postoperative computed tomographic angiogram. Red arrows showing the tortuous course of the posterior tibial (PT) artery.
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case_images: An urgent postoperative CT angiogram (CTA) showed a filling defect of the PT, with a sharp tortuous course at the fracture site (Figure 5).
case_images: Clinical image showing the medial, and to a lesser extent, the anterior wounds at the time of initial presentation to the trauma center. Medial-sided ankle and hindfoot swelling and blistering can be appreciated. This image was before the foot fasciotomy procedure.
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case_images: At the accepting center, the foot was tensely swollen with blisters (Figure 6).
case_images: Clinical images of the medial wound from the revision surgery after hardware removal. In all 3 images, north is anterior, south is posterior, right is cranial, and left is caudal. In image A, the Adson forceps point to a "bare area" posterior to the medial malleolus that is void of the medial structures. In image B, the Steven scissors point at the medial neurovascular bundle, which is heading distally. In image C, the arrow shows the medial tendons (tibialis posterior and flexor digitorum longus) after being reduced to their anatomic location posterior to the medial malleolus in the tarsal tunnel.
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case_images: The posteromedial structures were absent from the area posterior to the tibia just above the ankle joint and replaced with blood clot (Figure 7, A). These structures were identified at the distal aspect of the tarsal tunnel with release of the flexor retinaculum and were traced proximal to the fracture (Figure 7, B). The posteromedial structures were then reduced to the tarsal tunnel (Figure 7, C).
case_images: Plain radiographs showing the revision open reduction and internal fixation.
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case_images: The fracture was then reduced and fixed with 2.7-mm lag screws (Figure 8).
case_images: Plain radiographs showing union of the tibia fracture at 6 months postoperatively.
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case_images: His fracture is healed (Figure 9).