Kevin S. Barlotta, MD
Courtney Blayke Gibson, MD
University of Alabama at Birmingham (UAB)
Chief Complaint: Right thigh pain
HPI: 58-year-old female with a history of end-stage renal disease (ESRD) on intermittent hemodialysis presented to the emergency department with acute onset right lower extremity pain upon exiting her shower at home. The patient was post-operative day five following placement of a right femoral AV-graft. The patient reported sharp pain after her leg “bent backward” as her right foot failed to clear the top edge of the shower tub basin. The patient denied head injury or loss of consciousness.
Physical Exam: 160/90 102 98.9 20 96% RA
- General: Alert, moderate discomfort complaint of right leg pain and numbness.
- Extremity: Obvious deformity of the mid-thigh of right lower extremity with a 90-degree bend creating a crossed-leg appearance. No skin breakdown or defect noted. Mild soft tissue swelling. The right knee was stable. Pedal pulses were absent.
ED course 1:
- Longitudinal traction was applied to the right lower extremity re-establishing leg alignment with return of pedal pulses and distal perfusion.
- Acute onset right thigh swelling was observed (Figure 1).
Figure 1: Right thigh swelling
ED course 2:
- A bedside right femoral radiograph was obtained while vascular and orthopedic surgery were consulted. Preparation for transfusion was initiated.
- A comminuted, proximal right femur fracture was observed. Surgical clips from the recently placed AV-graft were noted (Figure 2).
Figure 2: Right femur (AP) radiograph
ED Course 3:
- The patient’s thigh swelling stabilized, and hemodynamics remained favorable without transfusion. The patient was sent for CT-angiography of the right lower extremity which demonstrated an intact AV-graft and a large thigh hematoma originating from the right femur fracture (Figure 3). The patient was admitted for operative intervention and hemodialysis following contrast administration.
Figure 3: CT-angiography of the right lower extremity
Discussion:
This is a rare case involving an ESRD patient with recent placement of an right femoral AV-graft and acute right femur fracture. Patients with a fractured femur can lose between 500 and 1,500 mLs of blood without an associated vascular injury which is typically present in 0.1-2% of femur fractures. Blood loss may be greater, and bleeding may remain active with associated vascular injury. More than 50% of patients with femur fractures require blood transfusions. Emergency providers should maintain a high index of suspicion for large volume blood loss with femur fractures with or without an associated vascular injury.
Reference:
- Zagorac S, Lesic A and Bumbasirevic M. A case of acute bilateral femur fracture with vascular injury. J Acute Disease, 5(1) 2016, 86-89.