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

Discussion

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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Monoclonal Gammopathy with Pathological fracture

 

Disclaimers: This is a real case reports encountered by the authors. However, the discussion in this entry was taken either edited or un edited from a textbook The Internal Medicine Casebook: Real Patients, Real Answers, 3rd edition by Robert W. Schrier, 2007 published by Lippincott Williams @ Wilkins

This 40 years old lady presented to casualty with complaint of right thigh pain, swollen and inability to move following a trivial fall at home due to slippery. Examination reveals right thigh tenderness, swollen, warmness and deformity. Right femur X ray shows subtrochanteric fracture with reduce bone density arounds the trochanter region. Apart from that she also complained of easily lethargy and occasionally back pain. Otherwise, other systems are unremarkable with no hepatosplenomegally, pink conjunctiva and spine examination was normal.

Laboratory findings was uneventful except hypercalcaemia and normal renal function test. Skeletal survey was nil of significant except for skull x ray which shows multiple rounded lytic lesion

 

 

Discussion

1) Monoclonal gammopathy

A monoclonal gammopathy is defined as the overproduction of a particular immunoglobulin protein by a single clone of overactive or malignant B cells. This clone can produce a whole immunoglobulin, composed of both heavy and light chains, or it can produce just heavy chains, just light chains, or a combination of whole immunoglobulin plus excess light chains. The monoclonal light chains are called Bence Jones protein. [Robert W. Schrier et al,]

2) Typical presentation

- Back pain, anemia, hypercalcemia and renal disease.

- Waldenstrom's macroglobulinemia resembles lymphoma symptoms which is fever, lymphadenopathy and hepatosplenomegally

- Hyperviscosity

- Amyloidosis due to light chain disease

3) Further investigations

- Liver function test (Elevated total protein but decrease albumin level which suggestive of increase in globulin fraction)

- Urine or serum electrophoresis for Bence Jones Protein

- Skeletal survey (Skull, Complete Spine, Pelvis and Chest)

- CT Abdomen in case of solitary extramedullary plasmacytoma

- Serum calcium level

- Bone marrow aspiration to demonstrate clumping and sheets of plasma cells

4) Immunologic capability in this patient

- High chance of compromised with susceptible to high grade bacterial pathogens.

- Do not provide adequate antibodies after prophylactic immunizations

5) Management

a) For multiple myeloma

- Melphalan and prednisone (chemo agents)

- Bone marrow transplant

- IV gamma globulin for prophylaxis against infection

- Thalidomide

b) For fracture

- Open reduction and Internal Fixation should be done in center with specialty of orthopaedic oncology unit and reconstructive surgery and may require specialized plating to prevent implant failure.

c) Hypercalcaemia

- Fluid rehydration with normal saline together with IV furosemide enhance excretion of calcium.

- IV hydrocortisone 200mg QID or prednisolone 30-60 mg daily works well in patient with myeloma.

- Calcitonin

- Biphosphonate

- Dialysis in severe hypercalcaemia.

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