Rupture of the Deep Femoral Artery during Proximal Femoral Nailing Following an Intertrochanteric Fracture: A Case Report

Abstract

Recently, we experienced a case where the diagnosis and management of a deep femoral artery rupture was delayed. This vascular complication occurred during the insertion of a distal interlocking screw of a proximal femoral nail for the fixation of an intertrochanteric femur fracture. A 79-year-old male patient was diagnosed with a right intertrochanteric fracture after a fall. We fixed the fracture with a proximal femoral nail (Zimmer® Natural Nail™ System). One day after the procedure, the patient complained of pain and swelling on the anteromedial side of his middle thigh followed by hypotension, anemia and prolonged thigh swelling. Computed tomography angiography was performed 7 days after the procedure. We found a pseudoaneurysm of the perforating artery caused by injury to the deep femoral artery and an intramuscular hematoma in the anterior thigh muscle. We successfully treated the pseudoaneurysm using coil embolization. Throughout the management of intertrochanteric femoral fractures, it is important to be aware and monitor signs and symptoms related to the possibility of blood vessel damage. When a patient presents with swelling and pain on the middle thigh and/or unexplained anemia postoperatively, the possibility that these symptoms are caused by an injury to the femoral artery must be considered.

Keywords: Femoral artery rupture; Femur; Hip fractures; Proximal femoral nail; Pseudoaneurysm.

Fig. 1. Preoperative and immediate postoperative radiographs show stable intertrochanteric fracture without communition, acceptable reduction and good position of the nail and screws respectively.

Fig. 2. Computed tomography angiographies with three-dimensional (3D) reconstruction view. (A) 3D view reveals pseudoaneurysm lateral to a branch of the deep femoral artery (arrow). (B) The pesudoaneurysmal sac arises from the branch at the distal interlocking screw penetration level (arrow). Three minutes delayed venous phase views (C, D) show another huge aneurysmal sac connecting to the original lesion (arrow).

Fig. 3. Femoral angiography and digital subtraction angiography demonstrate that the pseudoaneurysm originated from a perforation branch of the deep femoral artery. After coil embolization, radiograph does not reveal aneurysmal sac or further blood leakage.

Fig. 4. Follow-up computed tomography (CT) angiographs confirm the complete embolization, but large hematoma in the rectus femoris remained (arrow). POD: postoperative day.