Keywords
closed femur shaft fracture - vascular injury - superficial femoral artery - thrombectomy
- fasciotomy - intramedullary interlocking nail
Any blunt injury, if severe enough to cause a bony injury, has the potential to cause
concomitant arterial injury. Arterial injury can vary, from traumatic laceration to
thrombosis and, if not intervened upon early can lead to prolonged ischemia, leading
to potentially devastating complications including the need for an amputation.[1] Most of the encountered arterial injuries with fractures are due to penetrating,
crush injuries leading to a definitive compound/open fractures. As such, closed injuries
presenting with an arterial injury are rare and hence the primary surgeon may not
suspect it. In this report, we present two cases of superficial artery injuries associated
with closed femoral shaft fractures.
Case Report
Case 1
A 22-year-old male patient sustained an injury to his left thigh when he met with
a road traffic accident after being hit by a truck. The patient presented 6hours after
the injury. On examination, the patient was conscious and oriented, hemodynamically
stable. Clinical examination revealed swollen and tense left thigh with absent distal
pulses. Limb oxygen saturation was not recordable. The patient had toe and ankle movements
with no other signs of ischemia. Radiographs showed transverse left midshaft femur
fracture ([Fig. 1A, B]). Computed tomography angiography (CTA) revealed complete interruption of superficial
femoral artery (SFA) at the level of fracture secondary to an occluding thrombus ([Fig. 1C, D]).
Fig. 1 (A, B) Anteroposterior/lateral view radiographs of the left femur showing transverse midshaft
femur fracture. (C, D) Computerized tomography angiography image showing interruption of the superficial
femoral artery at the level of fracture site. (E) Intraoperative image of superficial femoral artery showing thrombus at the level
of fracture site. (F) Postoperative radiograph showing reduced femur shaft fracture with intramedullary
interlocking nail in situ.
The patient was taken for surgery on an emergent basis. First, the fracture was stabilized
with an intramedullary interlocking nail. No circulatory improvement noted after the
procedure. Vascular exploration was done on the medial side of the thigh at the level
of fracture between the adductor and extensor compartment of the thigh, which revealed
a thrombosed femoral artery segment of 5cm with surrounding hematoma and no transmitted
pulsations ([Fig. 1E]). A small arteriotomy of 5mm was done just proximal to the level of the thrombus
artery using a scalpel no. 11 and thrombectomy was done proximally and distally with
a Fogarty's catheter. Immediately after the thrombectomy, a sudden gush of fresh blood
was noted from the arteriotomy site. Vascular clamps were applied proximal and distal
to the arteriotomy site. Each clamp was released individually to check the anterograde
and reverse flow. The reason for the arterial thrombosis is attributed to a minor
tear in the artery due to the fracture fragments which lead to hematoma around the
artery and thrombosis of the vessel. The arteriotomy site and the tear on the vessel
were well irrigated with heparin saline and adventitia was debrided, and the opening
was repaired with Prolene 7–0. After the repair, the Acland clamp test was performed
to check the anterograde and reverse flow.[2]
Within a few minutes both distal pulses were well palpable and oxygen saturation was
restored. Intraoperatively patient was given heparin 5,000IU bolus dose and postoperatively
patient was put on low molecular weight heparin 60mg subcutaneously twice a day for
5 days and discharged with an advice of tablet aspirin 75mg once a day for 3 months.
Follow-up was uneventful and weight-bearing was started at 6 weeks and bone showed
good union with no long-term signs of ischemia. A repeat Doppler study done at 1 year
showed good triphasic flow of the femoral artery.
Case 2
A 21-year-old male patient was referred to our department with an alleged history
of a motor vehicle accident 4 days back due to falling from a bike. After the injury,
he was taken to the primary care center where he was diagnosed with diffuse axonal
brain injury along with left pulseless limb and associated femur shaft fracture. In
view of his brain condition, the fractured limb was immobilized with a Thomas splint
and not intervened early. However, he had already undergone a CTA of the left limb
and diagnosed with SFA injury. On presentation to our center, patient's Glasgow Coma
Scale was 5/15 but was hemodynamically stable. On local examination, there was a deformed
left thigh with absent peripheral pulses and unrecordable oxygen saturation on the
affected limb. Active foot movements could not be assessed because of poor GCS; however,
his limb was warm, in good color, and soft calf muscles with unlikely signs of ischemia.
Radiograph of left thigh revealed left comminuted midshaft femur fracture ([Fig. 2A, B]). CTA performed earlier showed complete interruption of SFA at the level of fracture
([Fig. 2C, D]).
Fig. 2 (A, B) Anterioposterior and lateral radiograph showing comminuted midshaft femur fracture.
(C, D) Computerized tomography angiography image showing interruption of superficial femoral
artery at the level of fracture site. (E) Intraoperative image of superficial femoral artery showing thrombus at the level
of fracture site. (F) intraoperative image showing fasciotomy over lateral aspect of leg. (G) Postoperative radiograph showing reduced femur shaft fracture with intramedullary
interlocking nail in situ.
Similar to the previous case the fracture was stabilized with an intramedullary interlocking
nail. As there was no circulatory improvement after closed reduction, femoral vessels
were explored, and the intraoperative finding was similar to the previous case ([Fig. 2E]). Unlike the first case, the arteriotomy was done distal to the thrombus and clots
were removed with Fogarty's catheter. Anterograde and reverse flow were confirmed
and arteriotomy site along with the tear on the vessel was closed with Prolene 7–0.
The peripheral pulses were restored immediately. Prophylactic fasciotomy of the left
leg was done through both medial and lateral incision decompressing all four compartments
keeping in view the delayed presentation and unreliability of assessing compartment
syndrome postoperatively considering poor GCS ([Fig. 2F]). Anticoagulation protocol similar to the previous case was followed. Successively
patient was intubated for airway protection. He underwent one stage of debridement
for the fasciotomy site on day 2 followed by split skin thickness graft cover on day
5. The patient stayed in the intensive care unit for more than 20 days due to the
head injury. After the recovery patient underwent rehabilitation and discharged with
oral anticoagulants for 3 months similar to the previous case. On subsequent follow-up,
he had persistent foot drop and decreased sensation of the foot over the supply of
deep peroneal and posterior tibial nerve areas but mobilized with a splint. At 1 year,
his fracture united well and arterial Doppler showed a triphasic flow of the femoral
artery; however, his limb weakness persisted because of ischemic insult to the muscles
due to delayed presentation. He is waited for further corrective surgeries of the
foot.
Discussion
Arterial ischemia in lower extremity injuries vary from intimal tear/contusion with
subsequent secondary thrombosis, to occlusion due to extrinsic compression, angulation,
dissection with an intact adventitia, spasm, or entrapment of the vessels within fracture
ends.[3] Of all the vessels, femoral arterial injuries constitute 70% of all vascular injuries,
and 90% of these is due to penetrating trauma.[4] Arterial injuries lead to thrombus within the vessel or rent in the vessel can cause
a false aneurysm. A false aneurysm is formed through a full-thickness defect in the
vessel leading to the escape of blood into periarterial tissue. This tissue along
with the thrombus form the wall of the aneurysm and the blood enters this cavity during
systole leading to an expanding pulsatile lesion with a systolic bruit.[5] There are few case reports describing femoral artery aneurysms associated with femoral
shaft fractures.[5]
[6] Blunt arterial injury is rare and reported in 0.3% of long bone fractures.[3]
[7]
[8] Blunt vascular injury prognosis is worse than penetrating injury and has a higher
risk of amputation because the blunt injury is associated with injury to surrounding
structures which include bone, soft tissue, and nerve complicating the management.[3]
[7]
[9]
[10]
[11] Arterial repair done in vascular injuries reduced the risk of amputation from 49.6
to 10.8%.[12]
[13]
In closed femoral fractures, arterial injures are overlooked, because it is uncommon
and in false aneurysms, the distal pulses being normal can be misleading, and when
in doubt further imaging is recommended.[5]
[8] Doppler is a good diagnostic tool and if doubt exists, arteriography (arterial angiogram)
is recommended. The strong indications for arteriography or surgical exploration include
excessive bleeding, expanding hematoma, bruit or thrill over injured vessels, and
absent pulses.[9]
[14] Digital subtraction angiography remains the gold standard. Arteriography can establish
the exact location, extent of arterial damage, or extrinsic cause for pulselessness,
on the contrary, it is time-consuming.[3]
Safe time for surgical intervention is considered between 6 and 8hours[13]; however, adequate collateral circulation provides a longer safe period.[15] In our second case though the presentation was late, considering the collaterals,
limb condition (soft and warm), and muscle texture during fasciotomy we proceeded
with revascularization. However, delayed repairs can end up with poor functional outcome
such as contracture or atrophy similar to our case.[15] Patients with prolonged ischemia have a risk of renal failure due to increased levels
of myoglobin and its products which can be avoided with good hydration and mannitol
preoperatively, intraoperatively, and postoperatively.[3] Due to delayed presentation in our second patient, to avoid renal complications,
we infused injection mannitol 100mL thrice a day for 5 days from the day of arrival
to our hospital and hydrated with fluids 100mL per hour for 7 days. Isolated vascular
injuries with good collaterals could have been ignored but it was intervened in our
case as it was performed in the same procedure along with femur fracture fixation
just to avoid further compromise with collaterals after fixation. Relative indication
is to avoid complications such as arteriovenous fistula/pseudoaneurysm and prevent
ischemic muscle pain in future.
For fractures with arterial injury, primary arterial repair should always be accompanied
by internal fixation for closed fractures or with clean wounds, and external fixator
or traction for contaminated or delayed presented injuries.[16]
[17]
Various treatment options include lateral repair, venous patch graft, resection of
injured vessel and primary repair, autogenous or synthetic vein graft interposition,
bypass graft, or thrombectomy by Fogarty's catheter.[3] Results with interposition veins graft have been good.[18] Synthetic arteries have a higher risk of false aneurysms.[19] Endovascular management in peripheral vascular injuries is limited.[20] In our series, we were able to get away with a simple thrombectomy using Fogarty's
catheter to establish the circulation accompanied by internal fixation using an intramedullary
interlocking nail. Vein graft was not considered in our cases since the injured vessel
had a good vessel wall with minimal intimal damage.
Compartment syndrome is a known complication associated with vascular injuries due
to reperfusion injury. In our second case, prophylactic four-compartment fasciotomy
was done keeping in view the delayed presentation in addition to the reperfusion.
Severely damaged or ischemic limb resulting in nonfunctional or useless limb should
undergo primary amputation.[3] Failure of prompt diagnosis of vascular injury and the severity of the soft tissue
damage are the potential reasons for the amputation. Closed fractures can be accompanied
by vascular injury where its early diagnosis with the help of a CTA and speedy surgical
intervention to restore the blood supply can attain an excellent functional limb.
It is recommended to follow strict immobilization of the injured limb for at least
6 weeks to prevent unnecessary insult to the artery at the fracture site.
