A Femoral Bone Fragment Penetrated the Peritoneal Cavity Following a Subtrochanteric Fracture

Case Description: Thirty-three years old male, no past medical history, was admitted to the emergency room (ER) after being injured as a pedestrian in a motor vehicle accident. The patient was complaining of left hip and pelvic pain. On physical examination, the left hip was externally rotated with some deformity. Diffuse pain to palpation over the pubic area was also noted. Intact peripheral neurologic and vascular exam. X-ray imaging preformed in the ER revealed a sub-trochanteric fracture with comminution. Total body computed tomography (TBCT) indicated no additional injuries other than a pelvic hematoma and a calcified structure in the left abdomen at the height of L2 vertebra, which was presumed to be an "artifact". He was cleared by the general surgeons` trauma team and was admitted to the orthopedic ward for further treatment. Several hours later, the patient complained of abdominal pain, exhibiting clinical signs of peritoneal irritation. Repeat complete blood count showed a decrease of 3 gram in Hemoglobin levels. A second TBCT indicated an increase in size of the previously described hematoma in the pelvis. The patient was then transferred to the intensive care unit for further evaluation. The morning after, the patient underwent an exploratory laparoscopy which demonstrated a small abdominal bleeding and an unexplained inguinal injury. While screening through the intestine a bone fragment was visualized around the mesentery. Retrieving the bone fragment was technically challenging and a conversion to a laparotomy ensued. Finally, a 4.5 cm bone fragment was removed. On a secondary survey, a mesenteric tear was identified and sutured. Thereafter, the patient underwent an open reduction of the fracture and internal fixation with a cephallo-medullary femoral nail.

Conclusion: Although rare, peritoneal signs following a comminuted proximal femur fracture associated with hemodynamic instability should prompt the surgeon’s suspicion and mandate immediate further investigation.