Cath Lab Digest

Discussion

False aneurysms after trochanteric fractures are a rare complication with a reported incidence of 0.21 percent.⁶ Most of these injuries are due to iatrogenic trauma or the trauma itself and rarely by dislocated bone fragments.⁴ In this case the anteriorly displaced lesser trochanter caused the false aneurysm by perforating the deep femoral artery wall. Displacement of this fragment with subsequent vascular injury is caused by mobilization after surgery due to the insertion of the iliopsoas muscle (flexion of the hip) on the lesser trochanter. A false aneurysm is difficult to recognize after hip surgery because of non-specific symptoms such as pain, swelling, anemia and hematoma; all of these symptoms are usually present after hip surgery. In retrospect, considering the extreme anterior dislocation of the sharp lesser trochanter, the diagnosis of a pseudoaneurysm might have been considered earlier. There should be a high index of suspicion of a pseudoaneurysm if there is a progressive (pulsatile) swelling in the groin and a continuous need for blood transfusion. The investigations of choice are a duplex ultrasound followed by CT angiography. The treatment depends upon the anatomical features and findings. Treatment options for a pseudoaneurysm consist of thrombin injection, open or endovascular repair. Due to the specific character of the described injury we think that an open repair with resection of the bone fragment is the only definite treatment. Depending on the size of the aneurysm and hemodynamics of the patient either an urgent or elective repair should be performed.

Conclusion

A false aneurysm due to a dislocated lesser trochanter after pertrochanteric femur fracture is rare and difficult to diagnose due to the non-specific symptoms. CTA or duplex are the preferred diagnostic techniques and should be used for further operative planning. Open surgery with resection of the bone fragment and arterial reconstruction is the only definite treatment.

References

1. Gillespie WJ. Extracts from “clinical evidence”: Hip fracture. Brit Med J 2001 Apr 21;322:968­­–975.
2. Abraham E, Pankovich AM, Jansey F. False aneurysm of the profunda femoris artery resulting from intertrochanteric fracture. A case report. J Bone Joint Surg Am 1975;57:871.
3. Mauerhan DR, Maurer RC, Effeney D. Profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments: A case report. Clin Orthop Relat Res 1981;161:215–219. 
4. Murphy PG, Geoghegan JG, Austin O, et al. Pseudoaneurysm of the profunda femoris artery due to intertrochanteric fracture of the hip. Arch Ortho Trauma Surg 1999;117–118.
5. Kizilates U, Nagesser SK, Krebbers YMJ, et al. False aneurysm of the deep femoral artery as a complication of intertrochanteric fracture of the hip: Options of open and endovascular repair. Perspect Vasc Surg Endovasc Ther 2009;21:245–248.
6. Karanikas I, Lazarides M, Arvanitis D, et al. Iatrogenic arterial trauma associated with hip fracture surgery. Acta Chir Belg 1993;93:284–286.

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From Amphia Hospital, Breda, the Netherlands.
The author reports no conflicts of interest regarding the content herein.
Manuscript submitted December 20, 2010 and accepted January 5, 2011.
Address for correspondence: Jack N. Helleman, MD, Amphia Hospital Surgery, Molengracht 21 Breda, 4818 CK, The Netherlands. Email: jackhelleman@yahoo.com