British Journal of Radiology (2007) 80, e78-e80
© 2007 British Institute of Radiology
doi: 10.1259/bjr/44678280
Lower limb ischaemia caused by fractured osteochondroma of the femur
N Tanigawa
S Kariya
H Kojima
A Komemushi
H Fujii
and
S Sawada
Department of Radiology, Kansai Medical University, 10–15 Fumizono, Moriguchi, Osaka 570-8507, Japan
Correspondence: N Tanigawa, Dept of Radiology, Kansai Medical University, 10–15 Fumizono, Osaka 570–8507, Japan. E-mail: tanigano{at}takii.kmu.ac.jp
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Abstract
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Osteochondroma is the most common benign bone tumour and can arise in any bone. They frequently develop around the knee in the distal femur and the proximal tibia. These are usually asymptomatic, but can occasionally impinge on the surrounding vessels and cause various clinical manifestations. We have encountered a patient with multiple hereditary exostoses, in whom the osteochondroma located in the distal portion of the femur fractured as a result of an injury from a traffic accident. The migrated osteochondroma compressed the femoral artery and led to an acute onset of lower extremity ischaemia. Although trauma or vigorous exercise can cause vascular complications caused by osteochondroma, vascular insufficiency due to fracture of osteochondroma after a traumatic injury is extremely rare.
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Case report
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A 19-year-old male was brought to our emergency room because of an injury due to a traffic accident. Fractures of the skull, face and the left femur were observed. In addition, plain films taken at admission showed the presence of multiple exostoses. It was also noted that the right lower leg to the toe was pale in colour and pedal pulses was weak, indicating vascular insufficiency of the right lower extremity. Thus, emergency angiography was performed. The severity of the vascular impairment varied with the different positioning of the right lower extremity.
The angiography of the right lower extremity was performed from the left femoral artery by inserting a 5 Fr Cobra-type catheter (Cook, Bloomington, IN, USA) into the right external iliac artery. The frontal view of the angiogram of the right thigh showed short segment stenosis of the femoral artery (Figure 1a
) with decreased blood flow distal to the stenotic lesion. Oblique angiography (LAO 45°) of this area showed arterial stenosis at the same site as the front view, and a bone fragment resulting from a fractured osteochondroma was seen at this location (Figure 1b).
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Figure 1. 19-year-old male with fractured osteochondroma of the right femur. (a) Digital subtraction angiography of the right lower extremity: limited segmental stenosis is seen at the distal end of the femoral artery, with decreased blood flow distal to the lesion. (b) Angiography at oblique view (LAO 45°) of the right lower extremity. The fractured osteochondroma can be seen in contact with the stenosis. A fracture line can be seen clearly at the base of the osteochondroma. (c) Osteochondroma fragment. (d) Angiography at oblique view (LAO 45°) of the right lower extremity after surgery. Good run-off is seen.
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The fragment of osteochondroma impinging on the right femoral artery was surgically removed 2 days after angiography (Figure 1c
). After surgical removal of the migrated osteochondroma, angiography of the right lower extremity showed disappearance of the femoral artery stenosis seen prior to surgery, and the blood flow to the lower extremity also improved (Figure 1d).
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Discussion
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Osteochondromas are osteocartilaginous exostoses that develop in bones that form endochondral ossification. Osteochondromas are the most common tumours of bone with an incidence of about 1–3%. The femur and tibia are commonly involved but these may arise in many other sites. About 90% of these occur sporadically and are usually solitary. There is an autodominant form of this disease, which may be associated with multiple osteochondromas.
Osteochondromas can occasionally impinge on the adjacent vessels and cause various types of vascular injury [1–8]. The affected vessel is commonly the popliteal artery, which is involved in about 60% of the cases [1].
Clinically, these lesions can lead to pseudoaneurysms, and the pseudoaneurysms can also cause impingement, resulting in arterial occlusion or arterial thrombosis by the compression of pseudoaneurysm [1, 2]. Venous injury is less frequent than arterial injury, but venous impingement and deep venous thrombosis can occur [3, 4].
One of the causes of vascular injury due to osteochondromas is trauma. In many cases the clinical manifestations appear after exercise, such as excessive physical activity from sports etc. [4]. Among trauma-related vascular disorders, it is rare to see cases attributable to a fracture of an osteochondroma. There are only four case reports of a fracture directly causing a vascular injury [5–8]. Among these four cases, fracture was diagnosed after surgery in three cases, and only in the case reported by Lesser and Greeley was the vascular injury preoperatively diagnosed as being due to a fracture of an osteochondroma [8].
In our patient, a 6 cm long osteochondroma, which had developed at the femoral metaphysis in a posterior medial direction, had fractured at the base. The surface of the migrated osteochondroma in contact with the artery was flat, so there was no injury to the artery itself. In this case the non-subtracted images were very useful to correct diagnosis as well as the digital subtraction angiography (DSA) images. Treatment involved simply removing the fractured osteochondroma. In this patient, the degree of ischaemia varied depending on limb position due to the proximal migration of the osteochondral fragment juxtapositioned adjacent to the femoral artery.
Received for publication March 2, 2005.
Revision received August 31, 2005.
Accepted for publication October 11, 2005.
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References
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Abstract
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