Iatrogenic Injury of Profunda Femoris Artery Branches after Intertrochanteric Hip Screw Fixation for Intertrochanteric Femoral Fracture: A Case Report and Literature Review

A case of arterial rupture of the profunda femoris arterial branches, following dynamic hip screw (DHS) fixation for an intertrochanteric femoral fracture, is presented. Bleeding is controlled by coil embolization, but, later on, the patient underwent orthopedic material removal due to an infection of a large femoral hematoma. 1. Introduction Pseudoaneurysms and hemorrhage of the profunda femoris artery (PFA) are rare injuries and have been reported following trauma or orthopedic procedures performed in the proximal femur [1–4]. Pseudoaneurysms or hemorrhage of the PFA following dynamic hip screw fixation (DHS) for an intertrochanteric femoral fracture constitutes 0.2% of all PFA injury cases [5]. Presentation may be acute or delayed [6]. If not diagnosed properly, this injury can be life- or limb-threatening. 2. Case Report A 92-years-old female was referred to the department of vascular surgery due to an enlarging hematoma of the left thigh. At the time of admission, the patient had fever (>38°C), anemia (Ht 32.9% and Hb 10.7？μg/dL), but she was hemodynamically stable and in good general condition. Both lower extremities had palpable peripheral pulses. Two months earlier, the patient underwent an intertrochanteric femur fracture repair using DHS fixation, a procedure that took place in another hospital. During the postoperative period, there has been a gradual but significant decrease in the hematocrit and hemoglobin levels to 22.5% and 7.1？μg/dL, respectively, despite repeated transfusions. Ultrasound scans performed postoperatively showed a hematoma gradually increasing in diameter, from 9？cm initially to >20？cm. At the 25th postoperative day, since the enlargement of the thigh hematoma was halted and there were no signs of lower extremity ischemia, the patient was considered stable enough to be discharged. In the day following her admission to our department, an angiography was performed, that showed hemorrhage by two perforating arteries at the tip of the first and fourth orthopedic screws (Figures 1 and 2). A patent superficial femoral and popliteal artery with a patent anterior tibial artery was also demonstrated. Percutaneous transarterial embolisation with coils was performed successfully (Figure 3). Figure 1: Hemorrhage fed by two perforating arteries, located at the tips of the first and fourth screws. Figure 2: Extravasation of the contrast agent in the deep intramuscular space of the thigh. Superficial femoral artery is visibly patent. Figure 3: Successful coil embolisation of the two feeding arteries. No extravasation of the contrast