Management of Shaft of Femur Fracture in a Patient with Underlying AVM
Abstract
Proof-of-concept case involving the successful intramedullary nailing of a pathological femur fracture through a high-risk Arteriovenous Malformation (AVM). The protocol utilized preoperative stereotactic radiotherapy to mitigate catastrophic hemorrhage.
Navigating High-Risk Vascular Malformations
Key Finding
"Preoperative stereotactic radiotherapy enabled safe closed intramedullary nailing of an intraosseous AVM fracture with zero significant blood loss."
Background: Fractures through bone containing Arteriovenous Malformations (AVM) present a therapeutic nightmare due to the high risk of uncontrollable hemorrhage during invasive procedures. Open reduction is often contraindicated, and conservative management frequently leads to nonunion due to the stealing of blood flow by the malformation.
Methods: The authors managed an 18-year-old male with a pathological femoral shaft fracture secondary to a diffuse, low-flow intraosseous AVM. The protocol involved four sessions of preoperative stereotactic external beam radiotherapy to reduce vascularity. This was followed by closed reduction and internal fixation (CRIF) using a proximal femoral nail (PFN) without reaming, chosen based on CT canal width analysis.
Results: The procedure was executed with no significant intraoperative blood loss. Clinical follow-up showed regression of the vascular lesion (reduced pain and swelling). Radiographic union was confirmed at 4 months post-operatively. This outcome contrasts with historical reports of nonunion in conservatively managed cases.
Conclusion: Minimally invasive intramedullary nailing is a viable salvage for AVM-associated fractures when combined with multidisciplinary preoperative vascular control (radiotherapy or embolization). Open reduction should be strictly avoided in favor of closed, distractor-assisted nailing.