Profuse Bleeding from Traumatic Lateral Plantar Artery Pseudoaneurysm After Glass Foot Injury Diagnosed by CT Angiography: A Case Report

SLR - April 2015 - Kayla O’Malley

Podiatric Relevance: Lacerations and retained foreign bodies are common plantar foot injuries in children. Complications such as infection and inflammation from these events can frequently occur, whereas vascular injury and formation of pseudoaneurysms are rare. There has been a total of three pediatric cases of lateral plantar artery pseudoaneurysms reported due to traumatic laceration from a piece of glass. This case report is an example of how pseudoaneurysms and vascular injury should be appropriately investigated and managed to prevent further complications.

Methods: Case report is a 6-year-old boy who presented to the Emergency Room with a laceration to his plantar right foot from stepping on broken glass. Plain film radiographs were taken, but did not show any foreign bodies. The wound was explored and then primarily repaired with sutures in the ER. The sutures were removed on the tenth day. The boy was then seen in the ER three days later for bleeding from the plantar right foot wound that was controlled with compression. The boy then presented back to the ER twenty days after the initial injury with bleeding again. The bleed was then controlled with compression and a CT angiogram was ordered. This showed a right foot lateral plantar artery pseudoaneurysm and a small opacity, which was the retained piece of glass. The boy was then put under general anesthesia with a tourniquet applied to the right lower extremity. The wound on the plantar aspect of the right foot was reopened and irrigated with saline.

Results: A pseudoaneurysm of the lateral plantar artery was discovered and associated with the retained piece of glass. The glass was removed and the pseudoaneurysm was ligated proximally and distally to its feeding vessels. The tourniquet was let down and circulation to the right foot was noted to be adequate. The boy was discharged home the following day and upon revisit in the clinic three months later he was doing well. He has remained asymptomatic for eight years now. In a pseudoaneurysm there is a tear of the intimal and medial layers of the artery. The adventitia layer remains intact resulting in the development of a local hematoma with direct communication with the lumen of the vessel. There is fibrosis in the surrounding tissue along with recanalization which creates a new lumen in the false sac. During these lacerations caused by glass, it is likely that vascular injury initially occurs, but is unrecognizable and therefore allows the pseudoaneurysm to form later. In all the case reports there was a significant amount of bleeding at the initial injury, and all patients had the wound primarily closed and then presented back with enlarging mass on the plantar aspect of the foot. All the cases also came back to the hospital with bleeding after suture removal. The imaging used to diagnose a pseudoaneurysm include duplex ultrasonography, CT angiography, magnetic resonance angiography, or conventional angiography. Duplex ultrasonography will differentiate a pseudoaneurysm from a hematoma and abscess. This image modality is noninvasive, inexpensive, and portable. It will provide information on feeding vessels, flow, and morphology. The down side to duplex ultrasonography is that it is user dependent and does not generate three-dimensional images. The CT angiography is the primary image modality in that it has good diagnostic accuracy with a sensitivity of 95-100 percent and specificity of 87-100 percent., however it does provide radiation exposure. MRA demonstrates sensitivities and specificities lower to that of CTA, and has limited access. Some pseudoaneurysms can spontaneously resolve, but because the lateral plantar artery is superficial constant trauma from ambulation does not allow it to heal and creates an increased risk for rupture and bleeding. Non-surgical treatments for pseudoaneurysm include external compression, Ultrasound guided thrombin, or ultrasound guided compression. These modalities in a lateral plantar artery case would only be successful if the child to stay non-weight bearing for some time to allow healing. Surgical correction should be reserved for prolonged bleeding and rupture. Ligation can be done to the lateral plantar artery due to collateral circulation and absence of vessel disease in these children. To avoid complications of foot ischemia a preoperative workup of collateral circulation should be performed.

Conclusion: Though traumatic pseudoaneurysms of the lateral plantar artery are rare, it should be appreciated that penetrating injuries to the plantar foot by glass can become complicated by vascular injury. This type of event should be kept in the clinician’s head for differential diagnosis of complications with problematic lacerations to the plantar foot especially in children.