Injury of the profunda femoris artery from a displaced lesser trochanter fragment in an intertrochanteric fracture: A case report

Background Vascular injuries associated with intertrochanteric femoral fractures are rare but potentially limb- and life-threatening. Most cases are iatrogenic and occur intraoperatively, whereas non-iatrogenic arterial injuries caused by displaced fracture fragments are uncommon and often present with delayed onset. Injury to the profunda femoris artery due to displacement of the lesser trochanter fragment is particularly rare. This report aims to highlight a case of delayed vascular injury secondary to a displaced lesser trochanter fragment and to emphasize the importance of early recognition. Case report We report the case of a 92-year-old woman who sustained an intertrochanteric fracture of the left femur with a displaced lesser trochanter fragment following a low-energy fall. The fracture was treated with closed reduction and internal fixation using a proximal femoral nail. Postoperative management included early mobilization with full weight bearing. Clinical and radiological evaluation was performed upon readmission due to new symptoms. Approximately 20 days after discharge, the patient presented with progressive hip pain, thigh swelling, and severe anemia, despite preserved peripheral pulses. CT angiography revealed a large thigh hematoma originating from a branch of the profunda femoris artery at the point of contact with the displaced lesser trochanter fragment. Selective endovascular embolization was successfully performed, followed by surgical excision of the lesser trochanter fragment to eliminate the mechanical source of vascular injury. The postoperative course was favorable, with resolution of symptoms and no recurrence of vascular complications. Discussion The profunda femoris artery is the vessel most commonly involved in vascular complications associated with proximal femoral fractures because of its close anatomical relationship with the lesser trochanter. Delayed presentations may occur weeks after injury as repeated mechanical irritation from a displaced bone fragment leads to pseudoaneurysm formation and subsequent rupture. Diagnosis may be challenging because peripheral pulses can remain intact. Persistent thigh pain, swelling, or unexplained anemia should raise suspicion and prompt vascular imaging. Endovascular embolization combined with removal of the offending bone fragment provides an effective treatment strategy. Conclusions This case underscores the importance of maintaining a high index of suspicion for delayed vascular injury in patients with displaced lesser trochanter fragments, particularly in elderly individuals. Prompt imaging in the presence of anemia, thigh swelling, or persistent pain is crucial for early diagnosis and appropriate management.