LETTER TO THE EDITOR A Case of undiagnosed Pseudoaneurysm caused by an open tibial fracture

We would like to share an uncommon problem of pesudoaneurysm associated with an open comminuted fracture that was complicated with bone defect and infection. A 49 years old gentleman presented to our hospital with purulent discharge from his left leg for two months duration after sustaining an open fracture grade IIIA of left tibia and fibula in January 2016. He had a fall from 20 feet height while working and was admitted to another medical facility on 12/1/16. There were no other injuries reported. He underwent wound debridement initially and was put on an external fixator on 16/2/16. There was substantial bone loss at the fracture site which was bridged using an external fixator. Subsequently, he developed purulent discharge from his wound and was admitted with a diagnosis of osteomyelitis of his left tibia. On admission to our facility, he was noted to have minimal pus discharge from his wound and there was a uniplanar external fixator on his left leg. There were no swelling around the wound and no pulsatile mass felt. He was comfortable and there was no fever. Vital signs on admission were stable. Neurovascular examination of his left leg was normal. Radiographs on admission of the left tibia and fibula did not show signs of osteomyelitis but there was a bone gap of 2cm at the fracture site. (Figure 1a) During his stay in the ward, he was noted to have persistent bleeding from wound side. His Haemoglobin (Hb) levels,dropped from 9.1g/dL to 8.4 g/dL. He required blood transfusions up to 4 pints to stabilize his Hb levels. We initially suspected a vascular injury around the fracture site, possibly caused by the sharp tips of the Schuntz pins of the external fixator. However, radiographs did not indicate this. The positions of the pins were adequate and would not have damaged the vessels. As we could not identify any reason for his persistent bleeding, we suspected a pseudoaneurysm.