CASE REPORTHip Pelvis 28(1): 54-59, 2016http://dx.doi.org/10.5371/hp.2016.28.1.54

Copyright ⓒ 2016 by Korean Hip Society54

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In recent years, proximal femoral nailing has become aprimary surgical method for the treatment of intertrochantericfemoral fractures based on its mechanical advantages.However, this treatment requires the adduction andinternal rotation of the injured limb of the patient for theinsertion of the guide pin and the femoral nail. Inaddition, the perineal post, installed for traction, putssignificant pressure on medial soft tissues furtherpressing toward the femur. Therefore, the blood vessels,traveling inside of the thigh, could be displaced andmoved adjacent to the femur. In this report, we present thecase of delayed diagnosis and management of a deep

Rupture of the Deep Femoral Artery duringProximal Femoral Nailing Following

an Intertrochanteric Fracture: A Case ReportHan Kook Yoon, MD, Hyun Cheol Oh, MD, MPH, Junyoung Park, MD,

Choidog Oyunbat, MD, Taehwan Kim, MD*Departments of Orthopedic Surgery and Diagnostic Radiology*,

National Health Insurance Service Ilsan Hospital, Goyang, Korea

Recently, we experienced a case where the diagnosis and management of a deep femoral artery rupture wasdelayed. This vascular complication occurred during the insertion of a distal interlocking screw of a proximalfemoral nail for the fixation of an intertrochanteric femur fracture. A 79-year-old male patient was diagnosedwith a right intertrochanteric fracture after a fall. We fixed the fracture with a proximal femoral nail (Zimmer�

Natural NailTM System). One day after the procedure, the patient complained of pain and swelling on theanteromedial side of his middle thigh followed by hypotension, anemia and prolonged thigh swelling. Computedtomography angiography was performed 7 days after the procedure. We found a pseudoaneurysm of theperforating artery caused by injury to the deep femoral artery and an intramuscular hematoma in the anteriorthigh muscle. We successfully treated the pseudoaneurysm using coil embolization. Throughout the managementof intertrochanteric femoral fractures, it is important to be aware and monitor signs and symptoms related to thepossibility of blood vessel damage. When a patient presents with swelling and pain on the middle thigh and/orunexplained anemia postoperatively, the possibility that these symptoms are caused by an injury to the femoralartery must be considered.

Key Words: Femur, Hip fractures, Femoral artery rupture, Pseudoaneurysm, Proximal femoral nail

Submitted: October 18, 2015 1st revision: December 29, 20152nd revision: January 7, 2016 Final acceptance: January 7, 2016Address reprint request toHyun Cheol Oh, MD, MPHDepartment of Orthopedic Surgery, National Health InsuranceService Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444,KoreaTEL: +82-31-900-0441 FAX: +82-31-900-0343E-mail: hyuncoh@hanmail.net

This is an Open Access article distributed under the terms of the CreativeCommons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use,distribution, and reproduction in any medium, provided the original work isproperly cited.

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femoral artery rupture. This rupture occurred during theinsertion of a distal interlocking screw with a proximalfemoral nail for the fixation of an intertrochanteric fracture.Through the review of this case and literature, we wouldlike to discuss the appropriate method for preventing thisvascular complication and provide a method for earlydetection and treatment of a femoral artery injury occurringduring the operation process mentioned above.

CASE REPORT

A 79-year-old male patient visited our hospital due toright hip pain and motion disturbance after a fall. Accordingto the radiographic images, he had an intertrochantericfracture without comminuted fracture fragments. Thepatient’s medical history showed that he had been previouslydiagnosed with a right brain infarction and vasculardementia. However, he did not show noticeable neurologicalsymptoms and was not taking any antithrombotic agents.The patient had also received a femoral nailing proceduredue to a left intertrochanteric fracture three years ago. Hewas able to walk after the operation without any complication.

Four days after the injury, the patient underwent a closed

reduction on a fracture table under C-arm image intensifiercontrol before the operational management. For theclosed reduction, we pulled the injured right limb asinternally rotating 15。. After confirming proper fracturereduction, we further adducted the limb 20。for insertionof a femoral nail. After the closed reduction, we appliedthe following surgical procedure to the patient. First, atransverse skin incision was made from the greatertrochanter tip proximally for 5 cm and the fascia of thegluteus maximus and the abductor muscle wassubsequently split in line with its fibers. After insertionof a guide pin into the tip of the greater trochanter, aproximal femoral nail (Zimmer� Natural NailTM System-Cephalomedullary Femoral Nail-Asia short; Zimmer,Warsaw, IN, USA), with a neck shaft angle of 130。wasimplanted over the guide pin. We used a lag screw (10.5mm diameter and 90.0 mm length) and a distalinterlocking screw (5.0 mm diameter and 27.5 mmlength). During the surgery, satisfactory reduction andfixation were achieved without any representingcomplication (Fig. 1). The drainage tube was not appliedbecause there was no sign of bleeding from theoperation site.

FFiigg.. 11.. Preoperative and immediate postoperative radiographs show stable intertrochanteric fracture without communition,acceptable reduction and good position of the nail and screws respectively.

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FFiigg.. 22.. Computed tomography angiographies with three-dimensional (3D) reconstruction view. (AA) 3D view reveals pseudoaneurysm lateral toa branch of the deep femoral artery (arrow). (BB) The pesudoaneurysmal sac arises from the branch at the distal interlocking screw penetrationlevel (arrow). Three minutes delayed venous phase views (CC, DD) show another huge aneurysmal sac connecting to the original lesion (arrow).

A B

C D

FFiigg.. 33.. Femoral angiography and digital subtraction angiography demonstrate that the pseudoaneurysm originated from a perforationbranch of the deep femoral artery. After coil embolization, radiograph does not reveal aneurysmal sac or further blood leakage.

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One day after the surgery, the patient complained ofpain and swelling on the injured thigh. On the secondday, hemoglobin levels (Hb) dropped from 9.6 to 7.7g/dL without any noticeable signs of bleeding. Wetransfused packed red blood cell (2 packs) to the patient.On the third day after the surgery, the patient experienceda temporary drop in blood pressure followed by rapidrecovery. The general condition of the patient was stable.Therefore, we decided to monitor the symptoms furtherwithout medical intervention. However, the pain anddiffuse swelling on the middle thigh were not alleviatedand the Hb level dropped to 8.3 g/dL on the 7th dayfollowing surgery. The patient was subjected tocomputed tomography (CT) angiography of the lowerlimb. Using the CT, we identified a pseudoaneurysmadjacent to the perforating artery branch at the level ofthe distal interlocking screw, potentially due to bloodvessel damage and intramuscular hematoma of anteriorthigh muscle (Fig. 2). In response to this finding, aradiologist performed an angiogram and observed thatthe psedoaneurysm originated from the perforatingbranch of the deep femoral artery. He applied coilembolization with four micro coils to the damaged vesselunder fluoroscopic angiogram control. After the coilembolization, radiographs confirmed the absence of an

aneurysmal sac and further blood leakage (Fig. 3). Onthe 7th day following the embolization, the patient’sthigh swelling remained and he was subjected to anotherCT angiography. The pseudoaneurysm was not visible,but a large hematoma in the rectus femoris was observed(Fig. 4). Additional aspiration using ultrasound guidewas attempted but was not successful. We decided tomonitor the patient closely. Fortunately, the patient didnot present pain and swelling any longer. The patientstarted training with a walker and discharged 4 weeksafter the initial operation.

DISCUSSION

It has been known that arterial damage occurringduring the treatment of intertrochanteric femoralfractures is very rare; a review of the literature supportsthis. In 1964, Dameron1) reported a case with a deepfemoral artery psudoaneurysm following the treatmentof an intertrochanteric fracture2); after, additional caseswere continuously reported. Major reasons for thesearterial damages include 1) direct injuries due to fracturefragments3), 2) damages due to over-penetration of adrill bit, 3) prolonged irritation on a blood vessel wallowing to the protruding screws, and 4) injuries caused

FFiigg.. 44.. Follow-up computed tomography (CT) angiographs confirm the complete embolization, but large hematoma in therectus femoris remained (arrow). POD: postoperative day.

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by improperly positioned retractors2,4). In addition, thesetypes of injuries could occur throughout the variousstages of the fracture episode including 1) direct damageby less trochanter fracture fragment when the injury isgiven3), 2) the surgical reduction process, 3) screwinsertion, and 4) longstanding irritation of the insertedscrew in the months and years following surgery5). Thediagnoses of these psudoaneurysms can be made atdifferent points as well. It has been frequently reportedthat diagnoses of the psudoaneurysms may be delayedfrom several hours to several months after the surgery6).

According to previous case reports, psudoaneurysmsof the deep femoral artery were mainly found whendynamic hip screws were utilized4-7). Recently, however,femoral arterial damages were reported throughout theliterature related to surgeries using proximal femoralnailing for the treatment of the intertrochanteric fracture.Yang et al.8) and Grimaldi et al.9) reported superficialfemoral arterial ruptures following the insertion of distalinterlocking screws with Asian-Pacific type Gamma nailand Gamma 3 nail respectively. To our knowledge,however, there has been no case report to address theformation of a psudoaneurysm caused by the rupture ofthe deep femoral artery when proximal femoral nailingwas used. These findings imply that the formation of apsudoaneurysm can occur both in superficial and deepfemoral artery regardless of the fixation devices used.When the proximal femoral nailing procedure is used,the possibility of an injury to the blood vessel couldincrease because it is usually performed followingadduction and internal rotation of the injured limb tomake the insertion of nails easier. Furthermore in theprocess of reduction, a perineal post is used to draw thelower limb in. This could lead to the displacement ofmedial soft tissues towards the lateral side, place bloodvessels closer to the femur and elevate the likelihood ofarterial damages. Yang et al.10) conducted a study toobserve changes in the superficial femoral artery withthe color-flow duplex scanning. They found that thedistance between the femur and the superficial femoralartery is significantly reduced when the patient’s femurwas in adduction and adduction-internal rotationpositions compared to the neutral position. They alsofound that in 60% of cases, the distance was less than 10mm when the lower limb was in the adduction-internalrotation position. In 8% of cases, the distance was evenless than 5 mm. Given the results of this study, theauthors recommend that interlocking screws should be

inserted when a patient’s femur is located in the neutralposition.

Han et al.11) investigated the relationship between theinsertion sites of interlocking screws and femoralarteries with CT angiography. Through their study, theauthors addressed that 1) superficial femoral arteries arelocated anterior while deep femoral arteries are posteriorand 2) average distances to the femur are 9.24-9.87 mmand 27.27-27.81 mm for deep femoral and superficialfemoral arteries, respectively. This result implies thatdeep femoral arteries are more likely to be damagedduring surgical procedures. The lag screw of a proximalfemoral nail, used in the current case, has 15。anteversionto the main body. So, the distal interlocking screw isrelatively inserted and located posterior. This featurecould increase the risk of rupture of the deep femoralarteries.

Many cases have reported delayed diagnosis of thesevascular complications. In the present case, we confirmedthe diagnosis 7 days after the surgery, mainly due to thelack of recognition regarding this complication. Chonget al.12) suggested that there is a triad of symptoms forpsudoaneurysm resulting from deep femoral arterialdamages: 1) thigh swelling, 2) continuous bleeding ofthe fasciotomy wound, and 3) anemia with falling Hblevels. In our case, we did not notice bleeding on thesurgical sites or subcutaneous hemorrhage. Rather, thepatient experienced middle thigh swelling with pain,unexplained anemia and an episode of drop in bloodpressure. Therefore, it is recommended that carefulexaminations should be performed when considering thepossibility of blood vessel damage as suggested above.

In order to make an accurate diagnosis, non-invasiveCT angiography could be a more appropriate choicerather than the ultrasonic Doppler. Ultrasonic Dopplermay be limited in providing clear images of deep femoralarterial damages due to the location of the arteries. If thepsudoaneurysm is confirmed by CT angiography, coilembolization would be the best alternative for treatmentas demonstrated in the current case4,6). It is also possibleto consider insertion of a stent-graft3,8) depending uponconditions of adjacent blood vessels. Recently, injectionof thrombin has been used for treatment13). In somecases, surgical procedures would be options, includingligation of the psudoaneurysm through the surgicalexploration to confirm arterial damages or direct removalof damaged blood vessels. Previous studies5,7), however,have addressed complications of these surgical methods,

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including postoperative infections and vast blood lossduring surgery. Therefore, surgical treatment should beminimized.

To prevent the formation of a psudoaneurysm, it isadvisable to release the traction and place the patient inthe neutral position when inserting distal interlockingscrews. Further, careful use of the drill bit is warranted.Excessive power should not be used when drilling topenetrate the medial cortical bone. Appropriate drill guidesmight be needed to avoid over-penetration of the femur.

In order to diagnose this type of vascular complicationearly, it is important to be aware and monitor signs andsymptoms related to the possibility of postoperativeblood vessel damage throughout intertrochanteric fracturesurgical procedures. Specifically, it is highly recommendedto consider the possibility of a psudoaneurysm when apatient presents with diffuse swelling and pain on thethigh in which surgery has been done, and unexplainedanemia following the surgery. We recommend a diagnosisvia CT angiography and coil embolization with angiographyas the best option for the treatment of a psudoaneurysmafter surgery for femur fracture fixation.

CONFLICT OF INTEREST

The authors declare that there is no potential conflictof interest relevant to this article.

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