March 18, 2012

Distal third Left Femoral Shaft Fracture With Arterial Injury

35 years old lady was a passenger of a palm oil lorry together with another 30 colleagues when the lorry lost control while moving down the hill and skidded into the river. Upon presentation, she was diagnosed with closed fracture of distal third left femoral shaft fracture and was put on skin traction while waiting for definitive management. Vital signs are stable throughout observation. 

However, close observation of circulation chart shows evidence of acute limb ischemia with coldness of the feet, paraesthesia, prolong capillary refilling, severe pain and pulselessness up to popliteal artery. Hand held Doppler reveals loss of biphasic wave. Emergency wound exploration was done and reveals oblique fracture of distal part of left femoral shaft together with arterial injury. Partial cut of femoral artery beneath the bone fragment was also associated 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 four compartment fasciotomy of left leg. Post operatively, weak pulse was felt at Posterior Tibialis Artery/ 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 excellent recovery


Distal femur fracture is not common as compared to proximal femur fracture and occurs as a result 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 either affecting the condyles, metaphysis, diaphysis and with or without articular involvement.

Common complication are similar to the proximal femoral shaft fracture which includes hypovolumic shock due to bleedings from perforators artery, mal union, delay union and fat embolism syndrome.

In exception to fracture involving the popliteal region, neurovascular involvement are not common 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 femur fracture even though it is uncommon.

Another interesting points to be learned is that, arterial injury may also manifested with large hematoma formation or haemodynamically unstable due to hypovolumic shock. However it is not present in this case as a result of arterial spasm.

It is recommended that patient with femur fracture should be monitored with circulation chart which includes the color of the leg, the warmness, capillary refilling time, sensation and pulse. This clinical examination plays a very crucial rule in managing this kind of patient. If in doubt whether the pulse is present or not, hand held doppler can be used to aid in making diagnosis. Rarely, patient may also need further imaging studies including dupplex scan and CT angiogram.

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