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Traumatic Blue Toe Syndrome with Tibial Plateau Fracture: A Rare Case of Foot Ischemia and Toes Gangrene in Spite of Patent Arterial Injury

 Mehdinasab  Seyed Abdolhossein*  Alamshah, Seyed Mansour**

*Assistant professor of orthopaedic surgery
**Assistant professor of vascular surgery
Departments of Orthopaedic surgery and general – vascular surgery. Golestan and Imam Khomeini Hospital. Jundishapour University of Medical Sciences. Ahwaz – Iran.

Address for Correspondence:

Dr. Mehdinasab.
Orthopedic department,
Imam Khomeini Hospital, Ahwaz, Azadegan Street,Iran
Tel: 0916 111 1052
Fax: 0611 2216504 and 0611 222 5763
E mail:



Tibial plateau fractures involve the articular surface and condylar portion of the proximal tibia. These fractures occur as a result of severe trauma on the knee joint; therefore, the associated soft tissue injuries are frequently seen with these fractures in popliteal fossa. Neuro-vascular injury is one of the complicated damages that contain popliteal artery thrombosis in the form of direct intimal injury or arterial disruption. Possible plantar arc thrombosis as an embolic complication of popliteal artey intimal flap in the form of “traumatic blue toe syndrome” is a rare concomitant clinical entity with this fracture which has not been reported in our experience. This is a report of a minimal displaced fracture of the tibial plateau in a young patient who was admitted for driving injuries with cyanosis of four toes and severe plantar pain due to ischemic foot. He had normal symmetrical pedal pulses, but developed gangrene of toes leads to distal foot amputation.

Keywords: Tibial plateau fracture, popliteal artery, foot gangrene, blue toe  Syndrome.

J.Orthopaedics 2007;4(4)e17


Vascular injuries coexisting with fractures are detected in nearly 50% of traffic accidents (1) in about young age males (mean 23-33.2) (2, 3, 4, 5, 6). Lower extremity arteries are more affected and damaged due to knee dislocation, distal femoral or proximal tibial fractures (1, 2, 5, 6, and 7). Clinical signs have insidious presentation or may be overwhelmed by the severity and urgency of fracture types especially those needed emergency surgical intervention. In comparison, popliteal artery and branches in calves are the most common involved arteries in the lower limbs (4, 5, 6, 7) while brachial artery is the most prevalent in the upper extremities (8, 9, 10, 11). It is crucial that pedal pulses also to be considered in the first clinical impression of the surgeons as they reflect the main early signs of arterial insufficiencies to be confirmed following the ischemic symptoms. Arterial disruption(74%) then intimal laceration advocated for the main pathologic site of injury could be etiologic for micro embolization or total thrombosis of damaged artery(1,5,7,12). Fractures produced by direct high energy mechanism such as tibial plateau types, are responsible for concomitant neuro-vascular damages that endanger the limb and end to severe complications (13, 14, 15). Delay in surgery, blunt trauma, extensive soft tissue damages in combination with orthopedic and vascular injuries are associated with increased risk of amputation (4, 5, 7, 10, 16, and 17). Hereby, we describe a patient with this type of fracture in whom distal foot amputation was performed for his foot gangrene due to thrombosis of deep plantar arc and toe arteries

Case Report:

A 19-years old man was admitted to our emergency department after a vehicle road traffic accident.  He was an unrestrained driver who was ejected from his car during his crush accident. His general condition was stable on admission (GCS 15) and only complained of severe left thigh and right knee joint pain without any abrasion, laceration or obvious skin contusion except for his right hand hematoma and ecchymosis. Pedal pulses of the both foot were symmetrically normal and also had no any neurological deficit. Midshaft fracture of the left femur and a minimal displaced Schatzker type IV fracture of the right tibial plateau were seen by radiological assessment (fig.1). following a routine and through examination at emergency department, lower limbs were splinted; then, he transferred to the orthopedic department and Enoxaparin ( clexan ) 40 u/daily was injected subcutaneously. After 36 hours of injury, open reduction and internal fixation of the left femur and right tibial plateau fractures was performed (fig, 2). The knee joint was stable without any sign of instability or dislocation. The day after operation, we found his right toes pale and cyanotic because of distal plantar arc thrombosis with complaining of tingling and coolness. He developed gangrene in spite of prescribed heparin in 4th days of admission. (Fig, 3, 4). Doppler ultrasound study identified no abnormal signals in the vascular flow in popliteal artery and its branches in his calf and proximal foot; but, some endo-luminal irregularities in distal popliteal artery have been reported simultaneously. Amputation of three medial toes and debridement of the necrotic skin of distal planter foot was performed. The plantar aspect of the foot was repaired in the form of advanced skin graft two weeks later, because his foot gangrene was dry and mumificated. MESS (Mangled Extremity Severity Score) was not applicable.

 Fig 1.  Right tibial plateau fracture    

Fig 2. Fixation of plateau fracture              

Fig 3. Ischemia & Gangrene of the toes

Fig 4. demarcated level of foot gangrene 14 days after   injury

Fig 5. amputation of the toes


Tibial plateau fracture and its severity and complexity in young adults usually produced by high-energy trauma. This can lead to comminuted fractures with significant associated ligamentous and neuro-vascular injuries needed careful clinical assessment of knee-soft tissue envelope (13, 14, and 15). These fractures are resulted from a combination of axial loading of the femur on the tibil condyles with varus or valgus force (19). Thus, the capsular, ligamentous and meniscal injuries also coexist with this kind of fracture (20). One and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular compromise produced by injuries including knee dislocations, displaced medial tibial plateau fractures, displaced bicondylar fractures of the knee, and floating joints (21).These fractures are rare with low energy trauma, but existing high energy displaced fractures with Schatzker types “IV, V, VI” carry a high risk of injury to the popliteal artery and its branching (22).

     The most common site of injury is in popliteal/tibio-peroneal trunk and its variable causes of arterial injury can expectantly be entrapment, contusion or direct lacerations, internal traction leading to intimal damages and flapping or intramural hematoma (5, 6, 23). Mural intra luminal thrombosis which is unstable in the first hours of formation may become mobile in the result of fracture site movements persuading distal emboli to be fixed as an early or late manifestation of limb ischemia. Even, during elective orthopedic joint surgery and manipulation of the injured limb there is strong possibility of any unwanted new arterial damage with thrombosis and involvement of popliteal artery as the most common abnormality and site of arterial injury. This kind of associated problem may be represented clinically with at least more than 24 hours delay in diagnosis (25% of cases) and also is more common during redo procedures and in patients with preexisting atherosclerosis (24). Overall, early considered support consisting of the minimum delay for admission after injury(=/<3 hours)(1,8,10,18), golden timed autogenous  vein graft vascular repair following by fixation of fracture site simultaneously and prompt post operative handling are the best accepted treatment ways; though, the amputation rate with the about-knee popliteal artery injuries is too high (4,6,7,11,12,18).

In this patient, the fracture of tibial condyles was minimally displaced without knee dislocation. We suppose that our patient sustained a progressive trombosed intimal flap arterial injury in which there has been strong possibility of an unobstructed mural thrombosis of popliteal artery damage due to high energy trauma of the knee joint. It seems the intimal flap injury would be caused by direct blunt soft tissue trauma, because condylar fracture of tibia was minimally displaced. Under these circumstances, knee movement, or elective open reduction and fixation procedure could force the clot to lodge in deep arterial arc of right foot in a rare form of traumatic blue toe syndrome.    

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This is a peer reviewed paper 

Please cite as : Mehdinasab  Seyed Abdolhossein : Traumatic Blue Toe Syndrome with Tibial Plateau Fracture: A Rare Case of Foot Ischemia and Toes Gangrene in Spite of Patent Arterial Injury

J.Orthopaedics 2007;4(4)e17





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