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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 36  |  Issue : 1  |  Page : 31-34

Profunda femoris artery injury following internal fixation with cannulated hip screws for a femoral neck fracture


1 Department of Orthopaedic Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
2 Department of Orthopedics, Taipei Medical University Hospital; Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
3 Department of Radiology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan

Date of Submission01-Oct-2015
Date of Decision30-Nov-2015
Date of Acceptance22-Dec-2015
Date of Web Publication23-Feb-2016

Correspondence Address:
Chih-Chien Wang
Department of Orthopaedic Surgery, Tri-Service General Hospital, 325 Cheng-Kung Road, Section 2, Taipei 114
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.177176

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  Abstract 

Profunda femoris artery (PFA) injury is a rare complication following fracture of the femoral neck. Here, we present a case of a patient with an injured branch of the PFA following internal fixation with cannulated hip screws for a femoral neck fracture. Computed tomography angiography revealed active bleeding from the ascending and descending branches of lateral femoral circumflex artery. We suspected that the cause of the vessel laceration was the sharp tip of the guidewire used during surgery or the closed reduction performed during surgery. The patient was successfully treated with coil embolization. With early recognition and prompt radiological intervention, this rare complication following fracture fixation surgery can be treated without the need for additional surgery.

Keywords: Profunda femoris artery, femoral neck fracture, cannulated hip screw


How to cite this article:
Hung CC, Wang CC, Lin LC, Pan RY, Shen HC, Lee CH, Huang GS. Profunda femoris artery injury following internal fixation with cannulated hip screws for a femoral neck fracture. J Med Sci 2016;36:31-4

How to cite this URL:
Hung CC, Wang CC, Lin LC, Pan RY, Shen HC, Lee CH, Huang GS. Profunda femoris artery injury following internal fixation with cannulated hip screws for a femoral neck fracture. J Med Sci [serial online] 2016 [cited 2019 Oct 13];36:31-4. Available from: http://www.jmedscindmc.com/text.asp?2016/36/1/31/177176


  Introduction Top


Profunda femoris artery (PFA) injury is a rare complication following fracture of the femoral neck,[1],[2],[3] and it can be caused by the initial trauma or subsequent internal fixation.[4] Cases of pseudoaneurysms following arthroscopy, application of an external fixator, fracture, arthrodesis, and internal fixation have been previously reported. A pseudoaneurysm should be suspected if persistent pain, thigh swelling, and unexplained anemia are noted, and further investigations should be performed. The clinical diagnosis can be confirmed with angiography and computed tomography angiography (CTA), and transcatheter embolization can be used for the treatment. Here, we present a patient with an injured branch of the PFA following internal fixation with cannulated hip screws for a femoral neck fracture.


  Case Report Top


A 55-year-old man presented to our department with a displaced subcapital fracture of the right femoral neck [Figure 1]. He had a history of recurrent intracranial hemorrhage with right-side limb hemiplegia and epilepsy syndrome, and he was on piracetam (Nootropil 1200 mg once daily). We performed closed reduction and fixation with cannulated hip screws 7 days after admission [Figure 2]. One version wire was used during surgery, which proceeded unremarkably. There were no intra-operative or immediate postoperative complications. In addition, no vascular or neurological complications were noted on initial examination. However, the swelling was noted over the right proximal femur 4 days after surgery, and blood analysis revealed a hemoglobin level of 8.8 g/dl. Urgent ultrasonography and CTA were performed. CTA revealed active contrast extravasation from the ascending and descending branches of lateral femoral circumflex artery (LFCA), which arises from the PFA [Figure 3]. Based on the bleeding site, we suspected that the cause of vessel laceration was the sharp tip of the guidewire used during surgery or the closed reduction performed during surgery. The bleeding was successfully treated with transarterial embolization using a single vascular occlusion coil (3 mm × 4 cm) [Figure 4]. The patient recovered well and was discharged 19 days after the initial fixation. At the 12-month follow-up, no complications were noted, and plain radiography revealed bony union without osteonecrosis of the femoral head [Figure 5].
Figure 1: A preoperative plain radiograph of the right hip showing a displaced subcapital fracture of the femoral neck

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Figure 2: A postoperative plain radiograph of the right hip after closed reduction and internal fixation with three cannulated screws

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Figure 3: A computed tomography angiography image showing active contrast extravasation from the ascending and descending branches of the lateral femoral circumflex artery (red arrow), which arises from the profunda femoris artery

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Figure 4: Images showing transarterial embolization with a single vascular occlusion coil (3 mm × 4 cm) (red arrows) for the injury site of profunda femoris artery indicated in Figure 3

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Figure 5: A postoperative plain radiograph of the right hip obtained at the 12-month follow-up showing bony union without osteonecrosis or loss of reduction

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  Discussion Top


The common femoral artery usually bifurcates into the superficial femoral artery and PFA. The LFCA arises from the lateral side of the PFA, travels across the iliopsoas anterior to the femoral neck, runs beneath the sartorius, and lies deep in the rectus femoris. It divides into the ascending, transverse, and descending branches, and one of these branches was likely injured in our case.[5] The relative anterior position of the LFCA increases the risk of injury from a version wire passed along the femoral neck toward the head. Vascular complications after femoral neck fractures are rare. Damage to the vessel can result from the fracture itself (bone spike),[6] or iatrogenic postosteosynthesis (drills, screws, and displaced implants).[7] Femoral artery pseudoaneurysms have been reported to occur after surgical procedures, such as internal fixation for intertrochanteric, subtrochanteric, or intracapsular femoral neck fractures, intramedullary nailing of the femur, core decompression of the femoral head for osteonecrosis, and revision total hip arthroplasty.[8] Injury from a bone spike may occur at the time of initial trauma, during reduction or postoperatively during mobilization and may involve a lesser trochanter fragment, which can migrate with the movement of the hip owing to the function of the attached iliopsoas muscle.[9] A previous study identified technical risk factors specific to dynamic hip screw fixation.[10] The retraction of surrounding tissue that complicates thigh compartment syndrome has been considered in the progression of vessel injury.[11] Sclerotic vessels in the elderly have been reported to prone to injury during torsional manipulation at surgery.[12] In addition, internal rotation of the hip has been reported to move the PFA closer to the femur cortex, increasing the risk of arterial injury.[13]

Our patient was being administered piracetam (Nootropil), which is known to increase the risk of hemorrhage. Piracetam can affect platelets, red blood cells, and vessel walls by increasing erythrocyte deformability and decreasing platelet aggregation, erythrocyte adhesion to vessel walls and capillary vasospasm, resulting in a high risk of arterial injury and bleeding after trauma and surgical interventions.[14]

Acute symptoms onset occurs when the arterial injury is caused by fractured bone fragments at injury or manipulation, or by over-penetration of a drill bit, retractor, or screw. Delayed symptoms onset occurs secondary to prolonged impingement or erosion of the artery by a protruding fixation screw, particularly seen in arteries with atherosclerotic plaques.[13] The injury risk can be decreased by manually clearing the path of the guidewire and by using its blunt end. The diagnosis of arterial injury after fixation for hip fracture is difficult because the injury is usually masked by trauma or other complications, such as deep venous thrombosis. Clinical differentiation between these complications is difficult, and therefore, diagnosis is usually delayed.[13] Without timely management, a pseudoaneurysm may continue to enlarge and eventually rupture, which may result in severe hemorrhage.[15] Potential complications include infection, interference with fracture healing, and thigh compartment syndrome, [16] which can affect adjacent tissues and result in soft tissue destruction, neuropathy, venous obstruction, and thrombosis. In previously reported cases of iatrogenic false aneurysms of the profunda artery, surgical repair (ligation and excision, and suture of the arterial defect) was advocated. Interventional radiological procedures are preferred because most patients with hip fractures are elderly with multiple comorbidities and are poor candidates for a second surgery. Percutaneous transarterial embolization can be performed to avoid a second major surgery and general anesthesia. Embolization at diagnosis can save time and eliminate the risks associated with a second surgery. Limited time is required for coil embolization, and it can even be performed in patients who are on oral anticoagulation therapy. In addition, infection and wound healing problems associated with reintervention can be avoided.[12] With early recognition and prompt radiological intervention, vessel injury following fracture fixation surgery can be treated without the need for additional surgery.

We reported a case of an injured branch of the PFA following internal fixation, which was treated successfully with coil embolization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Barnes DI, Broude HB. False aneurysm of the profunda femoris artery complicating fracture of the femoral shaft and treated by transcatheter embolization. A case report. S Afr Med J 1985;67:824-6.  Back to cited text no. 1
[PUBMED]    
2.
Canbaz S, Acipayam M, Gürbüz H, Duran E. False aneurysm of perforating branch of the profunda femoris artery after external fixation for a complicated femur fracture. J Cardiovasc Surg (Torino) 2002;43:519-21.  Back to cited text no. 2
    
3.
Cowley A, Williams D, Butler M, Edwards A, Parsons S. Pseudo-aneurysm of the profunda femoris artery as a late complication of hip fracture in a patient with myelodysplasia. Ann R Coll Surg Engl 2007;89:W4-6.  Back to cited text no. 3
    
4.
Dameron TB Jr. False aneurysm of femoral profundus artery resulting from internal-fixation device (screw). J Bone Joint Surg Am 1964;46:577-80.  Back to cited text no. 4
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5.
Davda K, Pollard TC, Graham AJ. Delayed presentation of lateral femoral circumflex artery injury post cannulated hip screw surgery - A case report. Ann R Coll Surg Engl 2009;91:W3-5.  Back to cited text no. 5
    
6.
Ritchie ED, Haverkamp D, Schiphorst TJ, Bosscha K. False aneurysm of the profunda femoris artery, a rare complication of a proximal femoral fracture. Acta Orthop Belg 2007;73:530-2.  Back to cited text no. 6
    
7.
Tiwary SK, Kumar S, Khanna R, Khanna AK. Iatrogenic femoral artery aneurysms in orthopaedic practice. ANZ J Surg 2007;77:899-901.  Back to cited text no. 7
    
8.
Valli F, Teli MG, Innocenti M, Vercelli R, Prestamburgo D. Profunda femoris artery pseudoaneurysm following revision for femoral shaft fracture nonunion. World J Orthop 2013;4:154-6.  Back to cited text no. 8
    
9.
Maheshwari R, Pemmaraju K, Sloan R, Hamlet M. Pseudoaneurysm of profunda femoris artery following intertrochanteric fracture of the hip. Eur J Orthop Surg Traumatol 2004;14:192-4.  Back to cited text no. 9
    
10.
Laohapoonrungsee A, Sirirungruangsarn Y, Arpornchayanon O. Pseudoaneurysm of profunda femoris artery following internal fixation of intertrochanteric fracture: Two cases report. J Med Assoc Thai 2005;88:1703-6.  Back to cited text no. 10
    
11.
Chong KC, Yap EC, Lam KS, Low BY. Profunda femoris artery pseudoaneurysm presenting with triad of thigh swelling, bleeding and anaemia. Ann Acad Med Singapore 2004;33:267-9.  Back to cited text no. 11
    
12.
Jiya TU, Bruijninckx MM, Slis HW, de Rooij TP, de Ridder V. False aneurysm of the profunda artery complicating dynamic hip screw osteosynthesis. Eur J Trauma 2000;26:261-3.  Back to cited text no. 12
    
13.
Chan WS, Kong SW, Sun KW, Tsang PK, Chow HL. Pseudoaneurysm and intramuscular haematoma after dynamic hip screw fixation for intertrochanteric femoral fracture: A case report. J Orthop Surg (Hong Kong) 2010;18:244-7.  Back to cited text no. 13
    
14.
Evers S, Grotemeyer KH. Piracetam and platelets - A review of laboratory and clinical data. Pharmacopsychiatry 1999;32 Suppl 1:44-8.  Back to cited text no. 14
    
15.
Inamdar D, Alagappan M, Shyam L, Devadoss S, Devadoss A. Pseudoaneurysm of anterior tibial artery following tibial nailing: A case report. J Orthop Surg (Hong Kong) 2005;13:186-9.  Back to cited text no. 15
    
16.
Sarwar C, Riaz S, Lukhadwala R. Iatrogenic pseudoaneurysm of the superficial femoral artery in a pediatric patient: Case report. Internet J Orthop Surg 2003;2:1.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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