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Abstract
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Introduction: Intramedullary nailing (IM) of proximal femoral fractures (PFF) is among the most common surgical procedures that are performed on geriatric traumatology patients. Vascular injuries can be caused by the accident itself, iatrogenic or, as in our case, by secondary displaced bony fragments. When it affects the profunda femoris artery (PFA), this vascular injury can be potentially life-threatening.
Material and Methods: We report the case of a 95-year-old patient who sustained a non-displaced intertrochanteric femoral fracture after a fall without any other injuries. Surgery was performed the following day with closed reduction and internal fixation (CRIF) using a trochanteric nailing system (TFNA®). The procedure was uneventful, and the patient was allowed to full weight bearing postoperatively. On day two after surgery the hemoglobin level dropped, and postoperative radiographs showed a secondary displaced lesser trochanter fragment. A CT-angiography revealed active bleeding from a perforated branch of the PFA caused by the secondary displaced lesser trochanter. The affected branch was urgently coiled by an interventional radiologist.
Results: A total of five red blood cell counts were transfused. The patient was discharged 13 days after initial surgery. At 6 weeks follow-up appointment the patient was in a good health condition and pain free while full weight-bearing.
Conclusion: PFF are common with approximately 100.000 cases in Germany in 2018. Inpatient mortality rate is 2.9 % raising to 15.1% after 90 days and up to 37% after one year. Preferred treatment is CRIF. Most commonly used implants are sliding hip screws or intramedullary nails. The incidence of vascular injuries is 0.5%, mostly due to iatrogenic lesions related to the surgical procedures. While venous bleedings of the perforating veins require open surgical revision, lesion of the PFA can be treated with percutaneous embolization.
Ongoing decrease of hemoglobin levels after surgery, distinct swelling of the thigh and increasing pain are indicators for persistent bleeding. Secondary dislocation of the lesser trochanter with injury of the PFA is a rare but potentially life-threatening complication after PFF. The combination of dislocated lesser trochanter fragments and persistent blood loss should make the treating physician think of this rare complication. Exact localization of the source of bleeding with CT-angiography is crucial to determine the appropriate treatment.
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