Management of Shaft of Femur Fracture in a Patient with Underlying Arteriovenous Malformation with an Intramedullary Nail


Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India


Magnetic resonance imaging showed extensive intraosseous femoral involvement of the vascular malformation, and the canal was deemed to be wide enough for a nail based on the radiograph templates and computed tomography (CT) scan. The patient was given four sessions of stereotactic external beam radiotherapy preoperatively, and closed reduction and internal fixation was performed using a proximal femoral nail without any complications. Radiographic evidence of fracture union was observed at 4 months. Fracture fixation by closed reduction can be either intramedullary fixation or external fixation based on the adequacy of the canal as determined by radiograph and CT scan. Preoperative measures to decrease vascularity such as stereotactic radiotherapy and angiographic embolization can be undertaken to reduce bleeding. A multidisciplinary approach is essential to improve the management of fractures in a patient with AVM.


1. Jończyk J, Szubert W, Panasiuk M. Pathological subtrochanteric femoral fracture due to extensive arterio‑venous malformation. A case study. Ortop Traumatol Rehabil 2015;17:297‑303. 
2. Ohshika S, Yanagisawa M, Tsushima F, Ishibashi Y. Diagnosis and conservative treatment of a rare case of femoral intraosseous arteriovenous malformation in a patient with polyostotic fibrous dysplasia: A case report. Mol Clin Oncol 2019;10:587‑91. 
3. Stein M, Guilfoyle R, Courtemanche DJ, Moss W, Bucevska M, Arneja JS. The “little AVM”: A new entity in high‑flow versus low‑flow vascular malformations. Plast Reconstr Surg Glob Open 2014;2:e187. 
4. TakeuchiA, Matsubara H, Yamamoto N, Hayashi K, Miwa S, Igarashi K, et al. Successful treatment of pathologic femoral shaft fracture associated with large arteriovenous malformations using a 3‑dimensional external fixator and teriparatide: A case report. BMC Surg 2019;19:35. 
5. Gupta Y, Jha RK, Karn NK, Sah SK, Mishra BN, Bhattarai MK. Management of femoral shaft fracture in Klippel–Trenaunay syndrome with external fixator. Case Rep Orthop 2016;2016:8505038.
6. Nahas S, Wong F, Back D. A case of femoral fracture in Klippel– Trenaunay syndrome. Case Rep Orthop. 2014;2014:548161. 
7. Notarnicola A, Pesce V, Maccagnano G, Vicenti G, Moretti B. Klippel‑Trenaunay syndrome: A rare cause of disabling pain after a femoral fracture. Arch Orthop Trauma Surg 2012;132:993‑6. 
8. Tsaridis E, Papasoulis E, Manidakis N, Koutroumpas I, Lykoudis S, Banos A, et al. Management of a femoral diaphyseal fracture in a patient with Klippel‑Trenaunay‑Weber syndrome: A case report. Cases J 2009;2:8852. 
9. Gibbon WW, Pooley J. Pathological fracture of the femoral shaft in a case of Servelle‑Martorell syndrome (phleboeclatic osteohypoplastic angiodysplasia with associated arterio‑venous malformation). Br J Radiol 1990;63:574‑6. 
10. Lunsford LD, Kondziolka D, Flickinger JC, Bissonette DJ, Jungreis CA, Maitz AH, et al. Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 1991;75:512‑24.