Delayed Deep Femoral Artery Injury Secondary to Migrated Lesser Trochanter Fragment After Intertrochanteric Fracture Fixation: A Case Report and Updated Literature Review

Abstract

Background: With the increasing elderly population and prevalence of osteoporosis, geriatric intertrochanteric fragility fractures pose a major challenge to orthopedic practice. These fractures have a significant impact on patient outcomes, with a reported mortality rate of 13.3% within 30 days and 24.5% within one year.

Case presentation: This report presents a rare case of delayed iatrogenic deep femoral artery (DFA) injury due to progressive displacement of the lesser trochanter following intertrochanteric fracture fixation. An 87-year-old female patient developed significant thigh swelling and pain 33 days postoperatively. Imaging confirmed migration of the lesser trochanter fragment, leading to DFA injury and active bleeding.

Discussion: Through a comprehensive literature review, we explore the incidence, diagnostic modalities, and management of vascular injuries associated with pertrochanteric fracture fixation. We emphasize the importance of identifying significantly displaced lesser trochanter fragments (>1 cm) preoperatively, as they markedly increase the risk of DFA injury. While debate continues over routine fragment fixation, our case suggests that surgical fixation may be beneficial in selected patients with large displacements to prevent vascular complications. Early CT angiography is highlighted as a crucial non-invasive diagnostic tool for timely detection and intervention in these high-risk cases.

Conclusion: This case underscores the need for careful postoperative monitoring and early intervention to optimize patient outcomes. As PFFs become more prevalent, further research is essential to improve geriatric orthopedic care.

Keywords: femoral artery injury; fracture fixation; hemorrhage; lesser trochanter migration; proximal femoral fractures; pseudoaneurysm.

Figure 1.

AP radiograph of the hip and pelvis on admission to the emergency department.

Figure 2.

Intraoperative C-arm radiographs of the left hip show good reduction of the fracture in both planes. The lesser trochanter is displaced.

Figure 3.

AP radiograph of pelvis on second admission to the emergency department.

Figure 4.

CT angiography 3D image shows DFA injury caused by sharp edge of displaced lesser trochanter. The greater trochanter was also displaced by the traction of the abductor muscle.

Figure 5.

3D CT image shows an unchanged position of the proximal femoral implant, the relationship to the lesser trochanter and the injured DFA.

Figure 6.

Intraoperative image showing the sharp-edged fragment of the lesser trochanter (LTF) in contact with the wall of the deep femoral artery (DFA). The image also shows the superficial femoral artery (SFA), the resected bone fragment and the area where the hematoma has been evacuated.