1. 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

2. 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

3. 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

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

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

6. 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

7. discussions

8. 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

9. 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

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

11. 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

12. 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.

13. 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.

14. Thanks for your attention!!