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Distal third left femoral shaft fracture with arterial injury
Distal third Left Femoral Shaft Fracture With Arterial Injury By Muhamad Na’im B. Ab Razak (MD USM)35 years old lady was a passenger of a palm oil lorry together with another 30 colleagueswhen the lorry lost control while moving down the hill and skidded into the river. Uponpresentation, she was diagnosed with closed fracture of distal third left femoral shaft fractureand was put on skin traction while waiting for definitive management. Vital signs are stablethroughout observation.However, close observation of circulation chart shows evidence of acute limb ischemia withcoldness of the feet, paraesthesia, prolong capillary refilling, severe pain and pulselessness upto popliteal artery. Hand held Doppler reveals loss of biphasic wave. Emergency woundexploration was done and reveals oblique fracture of distal part of left femoral shaft togetherwith arterial injury. Partial cut of femoral artery beneath the bone fragment was alsoassociated with arterial spasm and minimal thrombus formation.The bone was the fixed with Dynamic Compression plate and followed by removal of clot,trimming of the artery and end to end anastomosis with Dafilon 6-0 followed by fourcompartment fasciotomy of left leg. Post operatively, weak pulse was felt at Posterior TibialisArtery/ Dorsalis Pedis Artery and Hand Held Doppler ultrasounds reveals strong biphasic
wave. One day after operation, patients shows great improvement and on the road of excellentrecoveryDiscussionDistal femur fracture is not common as compared to proximal femur fracture and occurs as aresult of high velocity injury or low velocity injury due to pathological or osteoporotic bone.It is often due to injury that occurs with flexion of the knee. Distal femur fracture can eitheraffecting the condyles, metaphysis, diaphysis and with or without articular involvement.Common complication are similar to the proximal femoral shaft fracture which includeshypovolumic shock due to bleedings from perforators artery, mal union, delay union and fatembolism syndrome.In exception to fracture involving the popliteal region, neurovascular involvement are notcommon and seldomly encountered especially in close fracture. By taking a look at this case,it is unknown the exact mechanism of injury especially since it’s involve a mass number of
victims. Therefore, vascular injury should not be missed in treating patient with femurfracture even though it is uncommon.Another interesting points to be learned is that, arterial injury may also manifested with largehematoma formation or haemodynamically unstable due to hypovolumic shock. However it isnot present in this case as a result of arterial spasm.It is recommended that patient with femur fracture should be monitored with circulation chartwhich includes the color of the leg, the warmness, capillary refilling time, sensation andpulse. This clinical examination plays a very crucial rule in managing this kind of patient. Ifin doubt whether the pulse is present or not, hand held doppler can be used to aid in makingdiagnosis. Rarely, patient may also need further imaging studies including dupplex scan andCT angiogram.