Foot and Ankle Surgery
Volume 14, Issue 1 , Pages 40-42, 2008

Pseudoaneurysm of the anterior tibial artery following an ankle sprain: A case report of an uncommon ankle trauma with review of the literature

  • Panayiotis Christofilopoulos, MD

      Affiliations

    • Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland
    • Corresponding Author InformationCorresponding author.
    • ,
  • Aristotelis Panos, MD

      Affiliations

    • Clinic of Cardiovascular Surgery, University Hospital of Geneva, Switzerland
    • ,
  • Karen Masterson, MD

      Affiliations

    • Department of Radiology, University Hospital of Geneva, Switzerland
    • ,
  • Sophie Abrassart, MD

      Affiliations

    • Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland
    • ,
  • Mathieu Assal, MD

      Affiliations

    • Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland

Received 9 January 2007; received in revised form 14 August 2007; accepted 21 August 2007.

Article Outline

Keywords: Ankle sprain, Pseudoaneurysm, Pseudo-aneurysm, Ligament injury, Digital subtraction angiography, Percutaneous coiling

 

Back to Article Outline

1. Introduction 

Ankle sprains are common injuries and often result from inversion of the foot due to a low energy accident. In most cases the lateral collateral ligaments are injured. However, in addition to injury to the musculoskeletal system the sprain may also involve the surrounding neurovascular structures. This report concerns an uncommon associated lesion, a pseudoaneurysm of the anterior tibial artery following an ankle sprain. Review of the literature reveals few cases of vascular injury around the ankle joint due to low energy trauma without a specific consensus for their treatment.

Back to Article Outline

2. Case 

A 20-year-old male with a previous history of an ankle sprain was seen in the emergency department of a local hospital after having suffered a skateboard accident which resulted in a forced flexion-inversion movement to his right foot and ankle. The examining physician noted swelling over the dorsolateral aspect of the ankle, tenderness upon palpation of the anterior talofibular ligament (ATFL), and mild laxity of the ankle joint on inversion of the foot and ankle. Anterior–posterior and lateral radiographs revealed evidence of arthritic changes of the tibiotalar joint with osteophytes on the dorsal neck of the talus and anterior tibia (Fig. 1). A moderate ankle sprain was diagnosed and the patient was advised rest, elevation, ice, use of an ankle brace, and non-steroidal anti-inflammatory medication. The patient was referred to our institution two weeks after the injury with complaints of persistent swelling over the dorsum of his foot. Examination revealed tenderness over the ATFL and a pulsatile mass, 5cm in diameter, at the dorsal aspect of the tibiotalar junction. Palpation did not reveal pulsation of the dorsalis pedis artery distal to the mass. The neurological status of the foot was intact. An echo-doppler examination showed a voluminous aneurysm of the anterior tibial artery, 3.5cm in diameter, with partial thrombosis of its lumen. Arterial flow was diminished but present. To accurately determine the exact nature of the lesion and also to obtain a view of the remaining vascular supply to the foot an arteriogram of the right leg was performed. Digital subtraction arteriography confirmed the diagnosis of a false aneurysm of the anterior tibial artery. The vascular supply distal to the level of the aneurysm was adequate from collateral circulation (Fig. 2). The patient was admitted for surgical treatment.

  • View full-size image.
  • Fig. 1. 

    Anterior–posterior and lateral radiographs showing evidence of arthritic changes of the tibiotalar joint with osteophytes on the dorsal neck of the talus and anterior tibia.

  • View full-size image.
  • Fig. 2. 

    Digital subtraction arteriography a false aneurysm of the anterior tibial artery with adequate vascular supply distal to the level of the aneurysm from collateral circulation.

Surgery was performed through an anterolateral exposure of the anterior tibial artery. The incision extended from 10cm proximal to the tibiotalar joint line to 5cm distal to the aneurysm. Careful dissection of the subcutaneous tissue led to identification of the artery, which was cross-clamped proximal and distal to the lesion. The pseudoaneurysm itself was then approached with a longitudinal arteriotomy. The surgeon was able to palpate the osteophytes on the tibia and talus that were situated along the course of the artery. The artery was then ligated proximal and distal to the lesion and the aneurysm removed. The patient had an uneventful postoperative course. He remained under treatment for his ligament injury. In view of the arthritic changes in the ankle we discussed with the patient the possibility of future surgery for the excision of the osteophytes and débridement of the ankle joint.

Back to Article Outline

3. Discussion 

Plantar flexion and inversion is considered the most common mechanism of low energy trauma to the ankle joint [1]. However, with the very frequent occurrence of such an ankle sprain it is uncommon to sustain a vascular injury. To the best of our knowledge, only fourteen cases of injury to the anterior, posterior tibial and peroneal arteries after low energy trauma of the ankle joint have been previously described (Table 1) [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Pseudoaneurysm formation involving the arteries about the ankle joint have been described for the anterior tibial, posterior tibial, as well as the peroneal artery and its branches [5], [7], [8], [9], [10], [13], [14]. In the case presented, we are of the opinion that the mechanism of trauma to the anterior tibial artery was a combination of stretching of the artery due to flexion and inversion of the ankle, along with compression of the vessel against an osteophyte located on the dorsal aspect of the distal tibia and neck of the talus. Our hypothesis is supported by the location of the arterial lesion in relation to the bone spur as seen on radiographic examinations, as well as the intraoperative findings. Our review of the literature revealed one case where the proposed mechanism of injury to the anterior tibial artery was compression against a talar osteophyte resulting from early arthritic changes of the talo-crural joint [3]. And in another report [15] the pseudoaneurysm was felt to be due to arthroscopic resection of osteophytes from the medial malleolus and anterosuperior surface of the talar neck, although the fact that the patient had been on anticoagulation therapy may have played a contributing role. The surgical treatment options presented by different authors include ligation [3], [6], [7], [9], [13] or reconstruction of the artery [12], [14], as well as non-surgical treatment by percutaneous coil embolisation [2], [4], [8], [10]. We elected surgical treatment due to the fact that the patient was symptomatic, and then decided to ligate the anterior tibial artery since the vascular supply to the foot was assured by collateral circulation.

Table 1. Review of previously reported cases
AuthorCasesMechanism of injuryDiagnosisVessel involvedTreatment
Bandy et al.1Ankle sprainArteriographyPeroneal arteryCoil embolisation
Billey et al.1No traumaSurgeryAnterior tibial arteryResection
Jain et al.1Skin lacerationArteriographyAnterior tibial artery (prox)Coil embolisation
Maguire et al.1Ankle sprainArteriographyPeroneal arteryResection anastomosis
Marks et al.1Ankle sprainUltrasoundPeroneal arteryLigation
Rians et al.1Ankle sprainArteriographyPeronealEmbolisation
Rooney et al.1Ankle sprainArteriographyAnterior tibial arteryResection
Sarungi et al.1Ankle sprainUltrasoundPeroneal arteryCoil embolisation
Marron et al.1Ankle sprainArteriographyAnterior tibial arteryThrombin embolisation, surgical resection
Skomorowska et al.1Skin lacerationArteriographyPosterior tibial arteryResection-anastomosis
Skudder et al.2Direct blow/ankle sprainArteriographyAnterior tibial arteryLigation
Stio et al.1Ankle sprainArteriographyAnterior tibial arteryResection-anastomosis

Back to Article Outline

4. Conclusion 

This report calls attention to the fact that associated injuries not involving the musculoskeletal system can occur with the typical ankle sprain, and one must always look carefully for vascular injury after such a relatively minor trauma. Although the mechanism of plantar flexion and inversion has been proposed to be responsible for injury to the anterior tibial artery [7], [9], [14], there is no definitive confirming evidence. In our review of the literature we found no consensus as to the best way to treat such injuries. While embolisation is a less invasive method of treatment there are only a few cases treated by this method and its long-term efficacy has yet to be proved.

Back to Article Outline

References 

  1. Wolfe MW, Uhl TL, Mattacola CG, et al. Management of ankle sprains. Am Fam Phys. 2001;63(1):93–104
  2. Bandy WD, Strong L, Roberts T, et al. False aneurysm—a complication following an inversion ankle sprain: a case report. J Orthop Sports Phys Ther. 1996;23(4):272–279
  3. Billey T, Marin F, Vidal H, et al. Hemarthrosis of the ankle revealing an aneurysm of the anterior tibial artery. Rev Rhum Engl Ed. 1999;66(5):297–298
  4. Jain M, Naregal A, Kasat L, et al. Anterior tibial artery pseudoaneurysm. Indian J Pediatr. 1999;66(2):298–300
  5. Maguire DW, Huffer JM, Ahlstrand RA, et al. Traumatic aneurysm of perforating peroneal artery. Arterial bleeding—cause of severe pain following inversion, plantar flexion, ankle sprains. J Bone Joint Surg Am. 1972;54(2):409–412
  6. Marks RM, Stroud CC, Walsh D. Pseudoaneurysm of the lateral malleolar artery after an ankle sprain: case report and review of the literature. Foot Ankle Int. 1999;20(11):741–743
  7. Marron C, McKay D, Johnston R, et al. Pseudo-aneurysm of the anterior tibial artery, a rare cause of ankle swelling following a sports injury. BMC Emerg Med. 2005;5:9
  8. Rians CB, Bishop AF, Montgomery CE, et al. False aneurysm of the perforating peroneal artery: a complication of lateral ankle sprain. A case report. J Bone Joint Surg Am. 1990;72(5):773–775
  9. Rooney RC, Rooney RC. Anterior tibial aneurysm following inversion injury to the ankle. J Orthop Trauma. 1999;13(7):511–513
  10. Sarungi M, Milassin P, Csaszar J, et al. Arterial pseudoaneurysm of the ankle after plantar flexion-inversion injury. A rare complication and its non-invasive diagnosis. Arch Orthop Trauma Surg. 1994;113(6):349–350
  11. Scott JH. Traumatic aneurysm of the peroneal artery. J Bone Joint Surg Br. 1955;37-B(3):438–439
  12. Skomorowska EI, Grossmann E, Baekgaard N, et al. Post-traumatic pseudoaneurysm of the posterior tibial artery. Ugeskr Laeger. 1995;157(49):6883–6884
  13. Skudder PA, Gelfand ML, Blumenberg RM, et al. Tibial artery false aneurysm: uncommon result of blunt injury occurring during athletics. Ann Vasc Surg. 1999;13(6):589–591
  14. Stio F, Ortensi A, Battisti G, et al. Posttraumatic pseudoaneurysms of the anterior tibial artery: a review of the literature and a clinical case report. G Chir. 1993;14(2):109–112
  15. O’Farrell D, Dudeney S, McNally S, et al. Pseudoaneurysm formation after ankle arthroscopy. Foot Ankle Int. 1997;18(9):578–579

PII: S1268-7731(07)00075-6

doi:10.1016/j.fas.2007.08.005

Foot and Ankle Surgery
Volume 14, Issue 1 , Pages 40-42, 2008

Article Tools

* Image Usage & Resolution