Post-traumatic posterior tibial artery pseudoaneurysm
Patient presented with swollen left leg 2 months after suffering a Grade IIIA open fracture of the shaft of left tibia.
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There is evidence of an encapsulated, predominantly hypoechoic collection with internal echoes measuring 3.3 cm x 2.3 cm x 3.0 cm in the middle of left calf in close proximity to the left posterior tibial artery. Doppler ultrasound shows the Yin-yang sign due to turbulent flow within the collection.
The findings are suggestive of pseudoaneurysm of the left posterior tibial artery following an open fracture of left tibia.
Posterior tibial artery pseudoaneurysm is a recognized, though uncommon, late manifestation of vascular injury associated with tibial fractures. Pseudoaneurysms are more common with penetrating injuries, e.g. bullet injury, than with blunt trauma. Patients usually present late with complications, e.g. rupture,thrombosis, hemorrhage, compression of surrounding soft tissues.
The pathogenesis of pseudoaneurysm formation is attributed to the initial trauma caused by bone fragments or edges which may transect the arterial wall leading to local hematoma formation with subsequent degradation of the enclosed vessel.
Pseudoaneurysms are potentially limb threatening complications of long bone fractures and a high index of suspicion is required for early diagnosis and repair. Presence of distal pulses can be misleading. Plain x-ray findings are unrelated to the possibility of vascular injury. Angiography, Doppler ultrasound and CT angiography can be useful in management of pseudoaneurysms, both for diagnosis and treatment.
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