INTRODUCTION

Iatrogenic vascular injury is a rare but serious complication in the surgical management of distal femur fractures, particularly with the increasing use of retrograde intramedullary nailing [1]. While this technique offers biomechanical advantages, proximal interlocking screws are inserted with limited direct visualization, creating an inherent risk to nearby neurovascular structures [2]. Diagnosis can be challenging, as these injuries may present acutely or manifest days to years later as a pseudoaneurysm [3]. In some instances, they may present within days of surgery with sudden and rapid deterioration of vital signs [4].

This case report aims to describe the characteristics and management of an iatrogenic vascular complication that occurred during nailing of a distal femur fracture in a 72-year-old patient following a slip-down injury. While several reports have documented iatrogenic injuries to the deep femoral (profunda femoris) artery during femoral nailing, an injury to the lateral circumflex femoral artery has not, to our knowledge, been previously reported. Thus, this case serves as a valuable teaching example for clinicians managing similar postoperative scenarios.

Therefore, we present the first reported case of an iatrogenic lateral circumflex femoral artery injury after retrograde distal femoral nailing. Additionally, we discuss methods to reduce iatrogenic vascular complications that can occur during femoral nailing. Through this case, we aim to share practical considerations for distal femoral nailing and the necessary precautions when a postoperative vascular problem is suspected.

CASE REPORT

A 72-year-old female patient was referred to our outpatient clinic with a closed distal femur fracture. The injury had occurred 4 days earlier after a slip-and-fall in the bathroom. The patient’s medical history included hypertension, diabetes mellitus, and fatty liver disease. She had no ambulation difficulties before the injury. The fracture was a long oblique pattern originating from the meta-diaphysis and extending into the articular surface with a nondisplaced crack (Fig. 1A). On hospital day 3, the patient underwent surgery under general anesthesia. With a bolster placed under the knee, gastrocnemius muscle contraction was neutralized. The fracture was then reduced using manual traction and a Weber clamp. With reduction maintained by a mini-plate and independent screw, the intercondylar notch was accessed via a patella-splitting incision. After reaming the femoral canal to 13 mm, a 12×320-mm retrograde femoral nail (DePuy Synthes) was placed and distally secured with one blade and one screw (Fig. 1B). Two proximal screws were then inserted using a freehand technique. No unusual events or abnormal bleeding occurred during the procedure, and the patient remained hemodynamically stable throughout surgery.

Although the operation was uneventful, the patient developed hypoxemia and hypotension immediately after extubation. Subsequent pulmonary embolism computed tomography (CT) revealed evidence of pulmonary embolism involving the bilateral lower lobe pulmonary arteries and their segmental branches, and the patient was admitted to the intensive care unit (Fig. 2A). In consultation with a cardiologist, her hemodynamic instability was managed with oxygen therapy and enoxaparin.

Despite improvement in the patient’s overall condition, swelling of the operated thigh progressively worsened, although she displayed no neurologic symptoms or signs of compartment syndrome (Fig. 2B). Given the postoperative pulmonary embolism, contrast-enhanced CT was performed to evaluate for deep vein thrombosis. The scan revealed swelling and a hematoma within the anterior compartment muscles; however, no aneurysmal sac or contrast extravasation was observed (Fig. 2C, D). During this period, the patient’s hemoglobin level steadily decreased, from 10.2 g/dL on postoperative day (POD) 1 to 6.2 g/dL by POD 9. After transfusion of 3 units of packed red blood cells, her hemoglobin level increased to 10.0 g/dL.

Due to progressively worsening thigh swelling, an anterior compartment fasciotomy with negative pressure wound therapy (NPWT) was performed. Following fasciotomy, release of the anterior compartment was observed. Although the quadriceps muscle appeared somewhat dusky, no signs of necrosis were noted, and no vascular injury was identified intraoperatively (Fig. 3). On POD 15, the patient reported pain and warmth at the surgical site, prompting a contrast-enhanced lower-extremity CT scan. Imaging revealed a 1.2-cm pseudoaneurysm arising from the left lateral circumflex femoral artery at the subtrochanteric region of the left femur (Fig. 4A). Notably, the pseudoaneurysm lay in proximity to the trajectory of the proximal anterior-to-posterior interlocking screw, strongly implicating it as the iatrogenic cause of injury (Fig. 4B). Angiographic embolization of the distal segment was successfully performed using microcoils. Post-embolization imaging confirmed no residual aneurysmal sac or further contrast extravasation (Fig. 5). NPWT dressing changes were continued thereafter, and the fasciotomy wound was closed. The patient was subsequently discharged without further complications. The patient underwent outpatient follow-up; at 6 months, bone union was confirmed, and she had returned to her preinjury functional status (Fig. 6).

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient.

DISCUSSION

While iatrogenic deep femoral artery injuries are a known complication of retrograde femoral nailing, iatrogenic injury to the lateral circumflex femoral artery has, to our knowledge, not been previously reported [1,4–6]. Yoon et al. [5] described four mechanisms by which iatrogenic arterial injuries may occur: (1) direct injury from fracture fragments; (2) drill bit overpenetration; (3) prolonged irritation of the vessel wall from protruding screws; and (4) injury caused by improperly positioned retractors. In the present case, we presume the injury occurred not via these mechanisms but during the skin incision and subsequent drilling for proximal interlocking screw insertion. For this incision, a scalpel was used only to the fascial level, followed by blunt dissection with a hemostat. Even with meticulous technique, iatrogenic arterial injury can still occur; the use of a small incision may result in intraoperative hemorrhage that is not immediately apparent. In addition, Coupe and Beaver [6] demonstrated that muscle fibers can become entangled around the drill bit, potentially causing avulsion injury to surrounding neurovascular structures several centimeters from the drill bit tip. Consequently, the use of a drill bit sleeve or an oscillating drill is recommended. Extreme caution is warranted even during seemingly minor steps of the procedure.

Based on a cadaveric study, Riina et al. [7] reported that the deep femoral artery lies closest to the medial femur approximately 4 cm distal to the lesser trochanter (LT) and recommended placing proximal locking screws above the LT with care to avoid medial soft tissue penetration. However, this guidance is intended to prevent deep femoral artery injury from screws inserted in a lateral-to-medial direction. In contrast, in the present case, the proximal interlocking screw that caused the lateral circumflex femoral artery injury was located 1 cm distal to the LT and was inserted anterior to posterior. Although branches of the deep femoral artery typically cross the anterior femur roughly 4 cm distal to the LT, the lateral circumflex femoral artery branches more proximally, forming three terminal branches that run along the intertrochanteric crest to the anterior aspect of the femur [8]. Aydin et al. [9] found that the safest level for proximal locking screws in retrograde femoral nailing is 1 cm superior to the LT based on preoperative radiologic measurements. Accordingly, during retrograde femoral nailing, the nail tip should be positioned at or above the LT level. To minimize the risk of arterial damage, screws inserted lateral to medial should be positioned within 4 cm of the LT to avoid deep femoral artery injury. Similarly, care should be taken to avoid injuring the lateral circumflex femoral artery when inserting screws in an anterior-to-posterior direction.

In addition to carefully considering nail length, screw position, and vascular anatomy, other strategies to reduce iatrogenic vascular injury during surgery have been investigated. Given the finding of Patterson et al. [10] that a single-handed drilling position results in significantly greater drill plunge depth, a two-handed drilling technique is recommended to mitigate the risk of arterial damage from drill bit overpenetration. Choi et al. [11] reported that using a drill stopper as a safeguard effectively controls drill bit penetration depth, minimizing the risk of iatrogenic injury.

In the present case, vascular injury was not identified on the initial contrast-enhanced CT scan but was subsequently detected on follow-up contrast-enhanced CT, after which embolization was performed. Prior reports have described similar cases in which occult vascular injuries not apparent on initial imaging were revealed on follow-up studies [12–14]. Even with contrast-enhanced CT, occult vascular injuries may be missed due to factors such as small intimal tears, the patient’s hemodynamic status, or washout phenomena related to the timing of image acquisition after contrast injection [15]. Therefore, when clinical signs suggest vascular injury, CT angiography with an optimized protocol may improve diagnostic accuracy; moreover, even if no lesion is detected, follow-up imaging should be considered.

In conclusion, during retrograde femoral nailing, meticulous surgical technique and thorough anatomical knowledge are crucial to prevent iatrogenic vascular injury, particularly during proximal interlocking screw insertion near the LT, where the lateral circumflex femoral artery is at risk. While careful drilling and awareness of vascular anatomy are the primary preventive measures, repeated or delayed CT angiography should be considered when clinical suspicion persists, even if the initial contrast-enhanced CT scan is negative.

ARTICLE INFORMATION

Author contributions

Conceptualization: JSC, JWC; Investigation: all authors; Project administration: JSC, JWC; Writing–original draft: JSC; Writing-review & editing: JKO, JWC. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Preoperative and postoperative radiograph scans. (A) Preoperative radiograph showing a distal one-third oblique femoral shaft fracture (AO/OTA classification, 33A2.2). (B) Postoperative radiograph.

Fig. 2.

Computed tomography (CT) and clinical images. (A) CT pulmonary angiography demonstrating pulmonary embolism involving the bilateral lower lobe pulmonary arteries and their segmental branches (arrows). (B) Clinical photograph showing thigh swelling. (C, D) Contrast-enhanced CT demonstrating swelling and hematoma (arrowheads) within the anterior compartment muscles; however, no aneurysmal sac or contrast extravasation was evident in either the arterial or venous phase.

Fig. 3.

Clinical images. (A) Clinical photograph showing the incision site prior to fasciotomy. (B) Intraoperative view of the quadriceps muscle, which appeared mildly dusky; no signs of necrosis or vascular injury were observed during the procedure.

Fig. 4.

Contrast-enhanced computed tomography images demonstrating (A) a pseudoaneurysm (asterisk) measuring approximately 1.2 cm, arising from the left lateral circumflex femoral artery at the subtrochanteric level of the left femur and (B) the proximity of the pseudoaneurysm (asterisk) to the proximal interlocking screw (arrow) inserted in an anterior-to-posterior direction.

Fig. 5.

Femoral angiography images. (A, B) The pseudoaneurysm (arrows) arose from a perforating branch of the lateral circumflex femoral artery. (C) Following coil embolization (arrowhead), post-embolization angiography demonstrates resolution of the aneurysmal sac without evidence of residual bleeding.

Fig. 6.

Postoperative 6 months images. (A–D) Plain radiographs demonstrating bone union, with obliteration of the fracture line and callus formation.

REFERENCES

• 1. Handolin L, Pajarinen J, Tulikoura I. Injury to the deep femoral artery during proximal locking of a distal femoral nail: a report of 2 cases. Acta Orthop Scand 2003;74:111–3.ArticlePubMed
• 2. Kim HS, Yoon YC, Lee SJ, Sim JA. Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies. Eur J Trauma Emerg Surg 2024;50:763–80.ArticlePubMedPDF
• 3. Bose D, Hauptfleisch J, McNally M. Delayed pseudoaneurysm caused by distal locking screw of a femoral intramedullary nail: a case report. J Orthop Trauma 2006;20:584–6.ArticlePubMed
• 4. Lee PY, Rao PV, Golding DM, Brock J. Delayed profunda femoris artery bleeding after intramedullary nailing of an unstable intertrochanteric fracture: a case report. JBJS Case Connect 2017;7:e60.ArticlePubMed
• 5. Yoon HK, Oh HC, Park J, Oyunbat C, Kim T. Rupture of the deep femoral artery during proximal femoral nailing following an intertrochanteric fracture: a case report. Hip Pelvis 2016;28:54–9.ArticlePubMedPMCLink
• 6. Coupe KJ, Beaver RL. Arterial injury during retrograde femoral nailing: a case report of injury to a branch of the profunda femoris artery. J Orthop Trauma 2001;15:140–3.ArticlePubMed
• 7. Riina J, Tornetta P, Ritter C, Geller J. Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma 1998;12:379–81.ArticlePubMed
• 8. Hartog C, Metzler C, Meier C, Kalberer F, Wahl P. Anatomy of the lateral circumflex femoral artery: does the direct anterior approach to the hip jeopardize vascularization of the proximal femur? Orthop Traumatol Surg Res 2019;105:1257–64.ArticlePubMed
• 9. Aydin M, Surucu S, Ersin M, Ekinci M, Yilmaz M. Determination of the safest level and screw length for the proximal locking screw in retrograde femoral nailing. Jt Dis Relat Surg 2023;34:69–74.ArticlePubMedPMCLink
• 10. Patterson JT, Becerra JA, Duong A, Reddy A, Oakes DA. Drill bone with both hands: plunge depth and accuracy with 4 bracing positions. JB JS Open Access 2023;8:e22.00124.ArticlePubMedPMC
• 11. Choi JH, Lee YS, Hwang KT, et al. Usefulness of a drill stopper to prevent iatrogenic soft tissue injury in orthopedic surgery. Heliyon 2023;9:e20772.ArticlePubMedPMC
• 12. Yu MH, Kang NG, Jung JH. Delayed diagnosis and successful glue embolization of a post-traumatic bronchial artery pseudoaneurysm: a case report. Mil Med 2025;190:e1306–8.ArticlePubMedPDF
• 13. Koskinen SK, Alagic Z, Enocson A, Kistner A. The prevalence of early contained vascular injury of spleen. Sci Rep 2024;14:7917.ArticlePubMedPMCPDF
• 14. Lee CE, Jang IS, Song SY, Lim JW, Kim KT. Delayed diagnosis of popliteal artery injury after traumatic knee dislocation in Korea: a case report. J Trauma Inj 2023;36:142–6.ArticlePubMedPMCPDF
• 15. Boscak AR, Shanmuganathan K, Mirvis SE, et al. Optimizing trauma multidetector CT protocol for blunt splenic injury: need for arterial and portal venous phase scans. Radiology 2013;268:79–88.ArticlePubMed

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