Proximal femoral fractures and vascular injuries in adults: Incidence, aetiology and outcomes

Introduction: Vascular injuries (VI) presenting during internal fixation (IF) of proximal femoral fractures (PFF) are potentially limb- and life-threatening. The purpose of this systematic review of the literature is to report on their incidence, associated complications and to give special emphasis in their prevention. Materials and methods: A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of VIPFF-IF and series of PFF-IF with cases of VI published between inception of journals to March 2015 were eligible for inclusion. Relevant information was divided in two parts. Part I included the analysis of cases of VIPFF-IF, with the objective of establishing the frequency of injury of each vessel, the types and mechanisms of injury, the diagnostic and therapeutic modalities, and the outcomes. Part II analysed series of PFF-IF, which included case(s) of VI for assessing the incidence of VIPFF-IF. Results: Overall 160 articles with 182 cases of VIPFF-IF met the inclusion criteria. The injuries to extrapelvic vessels prevailed over those of intrapelvic vessels. There was a higher frequency of injury to the deep femoral artery and its branches in extrapelvic vessels and of external iliac artery and vein in intrapelvic vessels. The types of injury were: compression, intimal flap tear, disruption of the intimal layer with thrombosis, laceration with haemorrhage, and puncture or progressive erosion leading to a pseudoaneurysm (PSA) or arteriovenous fistula (AVF), with high prevalence for PSA, followed by lacerations. PSAs were more frequent in extrapelvic lesions and lacerations in the intrapelvic vessels. There were 7 non-iatrogenic injuries, produced by a displaced lesser trochanter fragment or other bone fragments, and 175 iatrogenic injuries (96.15%). The intrapelvic intraoperative protrusion of instruments or implants, or the post-operative migration of implants produced the injuries of intrapelvic vessels. For iatrogenic injuries of extrapelvic vessels the prevalent mechanism was a displaced lesser trochanter fragment, either intra- or postoperatively, followed by injuries by an overshot drill bit or a protruding screw; several other mechanisms completed the list. The clinical and radiological investigations were similar to those of VI elsewhere. VI occurred either at the time of fracture, during surgery or after it, early or late, weeks, months or even years after IF. The diagnostic and therapeutic modalities were most diverse, and the incidence of morbidity and mortality was 18.06%. The overall incidence of VIPFF-IF was 0.49%. Conclusion: The incidence of VIPFF-IF is low, though it will probably rise because of the increasing frequency of PFF. With few exceptions, these injuries, which are potentially limb and life-threatening, are iatrogenic, resulting of errors in IF, with different types of lesions to intra- and extrapelvic vessels running in close proximity to the bone. Although the surgeon should bear in mind this possibility and achieve early diagnosis and prompt accurate treatment, there is no consensus as to what is the best diagnostic or therapeutic modality. A precise diagnosis of the preoperative vascular status of the limb, monitoring of the displacement of the lesser trochanter fragment, careful and gentle reduction of the fracture, and precise handling of instruments and implant selection and placement during IF, are factors to consider in order to prevent this complication, which should never be underestimated.