左股骨粗隆間骨折開放性復位後脫位小粗隆碎片造成遲發性股靜脈損傷 陳旻鈴, 林建兆, 黃耀廣, 呂明憲, 鄭元熙 Department of Cardiovascular Surgery Chang Gung Memorial Hospital, Chia-Yi branch

General Data Age/Sex: 88y/o/Male Chief complaint: Left inguinal pulsatile mass noted for 2 weeks Past history: Type 2 diabetes mellitus Hypertension Coronary artery disease post stenting

Present Illness Traffic accident: left intertrochanteric fracture 2016/06/16 Traffic accident: left intertrochanteric fracture ORIF with Compression Hip Screw plate Aug. 2016 A small bulging mass from left inguinal region enlarged gradually with pulsation Associated with left leg swelling Soft tissue echo: favor left medial upper thigh vessels located above bony structure Referred to CVS OPD  CT scan

X-ray (lesser trochanteric fragment) Pre-ORIF Post-ORIF

CT scan Displaced bony fragment of lesser trochanter causing injury of left femoral artery with adjacent hematoma

OP finding-2nd Sep. 2016 Femoral A Femoral V Left lesser trochanter fragment protrusion with left femoral vein pseudoaneurysm Femoral A Fragment Femoral V OP procedure : 1.Direct repair of left femoral vein pseudoaneurysm 2.Resection of protruded lesser trochanter bone

discussions

Rare but important events! The incidence of vascular injuries in proximal femoral fracture is rare : 0.21~0.49% Morbidity/Mortality are high : 11.41%/6.62% Injured vessels Extrapelvic vessels > Intrapelvic vessels Pseudoaneurysm formation

Delayed risk Time of onset Mechanism of vessel injury: Immediate ~ several years after orthopedic procedure Mechanism of vessel injury: Direct injuries due to fracture fragments Drill or screw penetration

Treatment options Coil embolization Thrombin injection Stent graft deployment Definite procedure Pseudoaneurysm repair Harmful bony fragment removal

Problem-oriented case discussion #1. Venous injury vs. Arterial injury?? More arterial injuries, but few venous injuries The presentation of venous injuries could be similar with arterial injuries, but less violent May mimic deep vein thrombosis

Problem-oriented case discussion #2. Open repair or vascular intervention?? In vessel injuries caused by dislocated bony fragment, open surgical repair of injured vessel and removal of fragment could be superior to vascular intervention therapy.

Take home message The onset of vessel injuries after proximal femoral fracture could months or even years after the surgery. Fixation of lesser trochanteric fragments in proximal femoral fracture could prevent the delayed jeopardous vessel injuries.

Thanks for your attention!!