Complete Transection of the Superficial Femoral Artery from Blunt Trauma without Fracture: A Cautionary Tale

Abstract

Background

Vascular injuries to the superficial femoral artery (SFA) typically occur due to penetrating trauma or are associated with fractures. Complete transection of the SFA from blunt trauma in the absence of bone injury or skin penetration is exceedingly rare.

Case Description

A 67-year-old male presented 72 hours after blunt trauma from a vehicle collision with right lower limb ischemia. Imaging revealed a complete occlusion/block of the distal SFA without associated fracture. Emergency revascularization using a 7-mm polytetrafluoroethylene interposition graft, following fasciotomy, was successfully performed.

Conclusion

This case underscores the importance of maintaining a high index of suspicion for arterial injury following blunt trauma, even in the absence of fractures. Timely imaging and surgical intervention are crucial to prevent limb-threatening complications. This case represents a rare but critical clinical entity, with very few cases of isolated blunt SFA transection without fracture documented in the literature.

Keywords

superficial femoral artery - blunt trauma - vascular injury - PTFE graft - limb salvage - trauma without fracture

Introduction

Vascular injuries complicate approximately 1 to 3% of all trauma cases, with the femoral artery being among the most commonly affected vessels in lower extremity trauma. However, the majority of these are penetrating injuries or occur in conjunction with bony fractures. Isolated blunt traumatic injuries to the superficial femoral artery (SFA) are exceptionally rare.

The SFA, especially as it passes through Hunter's canal, lies in a relatively superficial position, making it susceptible to direct compressive or shearing forces. This anatomical vulnerability has been implicated in previously reported cases of pseudoaneurysms or occlusions resulting from minor blunt trauma such as impacts from sports equipment or low-speed collisions.[1] [2] [3] For example, Norris et al described a delayed pseudoaneurysm due to a basketball injury,[1] while Ramakantan and Shah reported a similar vascular lesion following a cricket ball strike.[2] However, these cases primarily involved partial vessel damage or pseudoaneurysm formation, not full-thickness arterial transection.

Rare instances of closed, isolated SFA injuries have also been linked to unique mechanisms such as “motor scooter handlebar syndrome,” where direct compression of the femoral artery by the inguinal ligament causes arterial occlusion in the absence of skeletal injury.[4] Similarly, Davis et al and Angiletta et al documented blunt trauma-induced pseudoaneurysms or occlusions without accompanying fractures, with successful minimally invasive treatments.[3] [5]

Only a handful of cases have described complete rupture or transection of the SFA from blunt trauma, and even fewer in the absence of osseous involvement.[6] Our case demonstrates a different, high-energy mechanism. The direct impact from a motor vehicle collision likely caused a hyperextension and shear force, resulting in a complete transection, a distinction with implications for the force required and associated injuries.

Case Description

Presentation

A 67-year-old Libyan male patient was involved in a high-speed motor vehicle collision as pedestrian. He was initially stabilized at a peripheral hospital located 500 km from our center. His primary injuries included bilateral pneumothoraxes, multiple rib fractures, and head trauma.

Initial clinical course and reason for delay: Plain radiographs of the right lower limb did not reveal a femoral fracture, which initially diverted clinical attention away from potential vascular injury. The patient was maintained at the referring hospital for 48 hours for hemodynamic stabilization. A significant factor in the delay was the lack of onsite vascular surgical expertise, necessitating a complex interfacility transfer.

Evolution of symptoms and clinical findings leading to surgery: Over the course of his stay at the peripheral hospital, the clinical picture in his right lower limb evolved significantly. The team noted progressive limb swelling, paralysis, and a loss of palpable pulses. These findings confirmed a diagnosis of evolving acute limb ischemia secondary to a likely occult vascular injury.

The recognition of this vascular compromise was the definitive clinical finding that prompted an urgent transfer to a facility with vascular surgery capabilities. The total time from the initial injury to definitive vascular surgical evaluation was approximately 72 hours, a critical timeframe that significantly impacted potential options for limb salvage and cell survival.

Definitive management: The patient was transferred to the vascular surgery service in our center, he was admitted to the intensive care unit (ICU) and hemodynamically stable. He had bilateral chest tubes, a fractured left humerus, and swelling and tenderness of the right thigh and leg but no evidence of fracture ([Fig. 1]). The foot was cold, with no dorsiflexion or plantar flexion, and both anterior tibial artery (ATA) and posterior tibial artery (PTA) pulses were absent. Complete paralysis of the ankle and the patient could not plantarflex, dorsiflex, invert, or evert the foot. Knee flexion was significantly weakened (2/5 strength) due to pain and swelling, apart from slight toe movement. Profound loss of light touch and sharp sensation throughout the distal leg and foot.

Fig. 1 Fractured left humerus, and swelling and tenderness of the right thigh and leg without evidence of fracture.

Investigations

Impaired renal parameters were observed (creatinine 2.1 mg/dL, urea 107 mg/dL) and hemoglobin level was 8.9 g/dL. Duplex arterial ultrasonography done by radiologist showed monophasic flow in the right ATA and PTA. A computed tomography (CT) ([Fig. 2]) showed nonopacification of the right distal SFA over a 6-cm segment, with popliteal artery reformation and distal opacification of the ATA, PTA, and peroneal artery.

Fig. 2 A computed tomography (CT) showed nonopacification of the right distal superficial femoral artery (SFA) over a 6-cm segment.

Management

The patient underwent fasciotomy on the ICU bed under sedation and local anesthesia for all four compartments, performed by the general surgery team. The patient first required emergency hemodialysis for acute kidney injury secondary to rhabdomyolysis. This was necessary to stabilize the patient for safe anesthesia and prevent cardiac arrest in the operating room.

The patient was taken for exploration of the distal SFA. We found a complete transection with thrombosed proximal and distal ends ([Fig. 3]). Both ends were refreshed, thrombectomy was performed, and repair was performed using a 7-mm polytetrafluoroethylene interposition graft because the great saphenous vein was small in diameter and not suitable as conduit ([Supplementary Material Video S1]). The outcome was successful, and the patient was discharged after 1 week with good distal ATA and PTA pulses. The fasciotomy wound was closed before discharge ([Fig. 4]).

Download Video

Supplementary Material Video S1 Intraoperative video recording.

Fig. 3 Complete transection with thrombosed proximal and distal ends.

Fig. 4 Postoperative wound incision closed with drain.

Outcome and Follow-Up

Technical surgical success: The revascularization procedure was a complete technical success. Intraoperative assessment confirmed strong pulsatile blood flow from the distal anastomosis and a palpable popliteal pulse, successfully restoring perfusion to the limb.

Functional recovery: Despite technical success, the functional outcome was severely limited by the irreversible neuromuscular damage sustained during the 72-hour ischemic period.

Motor function: The patient developed a complete foot drop (0/5 strength in ankle dorsiflexion). Knee flexion strength improved to 4/5 as swelling subsided, but the distal paralysis was permanent.

Sensory function: Sensation to light touch and pinprick remained profoundly diminished throughout the entire foot and distal calf.

Ambulatory status: The patient did not achieve independent ambulation. At discharge, he was able to mobilize only with a walker and required extensive ongoing physical therapy.

Status at discharge: After a prolonged hospitalization complicated by his other injuries, the patient was discharged on rivaroxaban (2.5 mg twice daily) and aspirin (100 mg).

The limb itself was viable and well-perfused, representing a successful salvage from an amputation perspective. However, the functional status was one of significant disabilities, characterized by permanent sensorimotor deficits and a reliance on assistive devices for mobility.

Discussion

Femoral artery injury is a rare clinical scenario. It is commonly seen in association with open injuries, penetrating trauma, or femoral bone fractures. Isolated femoral artery injury without associated bone injury is very rare. In 1968, “motor scooter handlebar syndrome” was described, involving injury to the common femoral artery without pelvic or femoral fractures, believed to result from compression of the artery by the inguinal ligament.[4]

The SFA, especially after passing through Hunter's canal, becomes relatively superficial, making it vulnerable to injury from blunt trauma.[7]

As illustrated in [Table 1], our case is distinct from previously reported cases in several key aspects. Furthermore, unlike the cases by Smith et al (2019)[8] and Jones et al (2021)[9], which involved low-energy compression and were diagnosed within hours, our patient sustained a high-energy transection with a critical 72-hour diagnostic delay, the longest in the series. This directly contributed to the profound functional deficit, contrasting with the full recoveries seen in cases with immediate intervention.

Table 1 Reported cases of superficial femoral artery injuries following closed blunt trauma without bone injury

Author	Mechanism of trauma	Duration of presentation	Injury to SFA	Procedure	Outcome	Contributing factor	Associated injuries
Norris et al[1]	Hit by basketball	6 mo	Pseudo aneurysm	Direct repair	−	Femur exostosis	−
Ramakantan and Shah[2]	Hit by a cricket ball	2 mo	Pseudoaneurysm	Steel coil embolization	No recurrence	−	−
Davis et al[3]	Vehicle collision	1 mo	Pseudoaneurysm	USG-guided thrombin injection	No recurrence	Diabetes and hypertension	Ribs#, ankle#, sternal#
Angiletta et al[5]	Fell on water tap	3 h	Occlusion	Endovascular stenting	Viable limb	−	−
Kumar and Sodavarapu[6]	Run over by a vehicle	5 h	Rupture	Reverse saphenous vein graft	Viable limb	−	Left femur#
Present case	Car collision	72 h	Complete cut	PTFE graft repair	Viable limb	Hypertension	Ribs # humerus #

Abbreviations: PTFE, polytetrafluoroethylene; SFA, superficial femoral artery; USG, ultrasound guidance.

In a delayed presentation where hard signs of ischemia are present, CT is the imaging modality of choice as it provides a rapid, comprehensive overview of the vascular anatomy and precisely identifies the level of occlusion, which is crucial for surgical planning. While duplex ultrasound is a valuable bedside tool for confirming the absence of flow, its utility in trauma can be limited by pain, dressings, and overlying soft tissue edema.

The foot drop experienced by our patient is a common and devastating sequelae of prolonged ischemia, resulting from infarction of the nerves and muscles within the anterior compartment. This highlights that limb salvage does not equate to functional recovery. It necessitates long-term rehabilitation, the use of ankle-foot orthotics, and results in a permanent reduction in quality of life, underscoring the paramount importance of timely diagnosis.

Conclusion

This case underscores that any high-energy blunt trauma to the extremity presenting with swelling, absent distal pulses, or unexplained neurological deficit even in the absence of fracture must prompt immediate vascular imaging to exclude a life- and limb-threatening SFA injury.

Conflict of Interest

None declared.

Authors' Contributions

Equal contribution. All authors contributed to the drafting, revising, and finalizing of the manuscript.

Patients' Consent

The authors confirm that they have obtained the consent of the patients for publication on anonymized basis. Neither the clinical details nor the images allow identification of the patient.

Compliance with Ethical Principles

No ethical approval is required for the reporting of single cases or small case series.

• References

• 1 Norris CS, Zlotnick R, Silva WE, Wheeler HB. Traumatic pseudoaneurysm following blunt trauma. J Trauma 1986; 26 (05) 480-482
• 2 Ramakantan R, Shah P. Steel coil embolization of a post-traumatic pseudoaneurysm of the superficial femoral artery. Injury 1990; 21 (06) 410-411
• 3 Davis KA, Mansour MA, Kang SS. et al. Pseudoaneurysms of the extremity without fracture: treatment with percutaneous ultrasound-guided thrombin injection. J Trauma 2000; 49 (05) 818-821
• 4 Yoshimura K, Hamamoto H. Traumatic right common femoral artery occlusion caused by blunt bicycle handlebar injury: a case report. Surg Case Rep 2019; 5 (01) 64
• 5 Angiletta D, Impedovo G, Pestrichella F, Marotta V, Perilli F, Regina G. Blunt femoropopliteal trauma in a child: is stenting a good option?. J Vasc Surg 2006; 44 (01) 201-204 , discussion 205
• 6 Kumar D, Sodavarapu P. Isolated, closed superficial femoral artery rupture without fracture following blunt trauma: a case report and literature review. Bull Emerg Trauma 2020; 8 (02) 125-128
• 7 Dharia R, Perinjelil V, Nallani R. et al. Superficial femoral artery transection following penetrating trauma. J Surg Case Rep 2018; 2018 (06) rjy137
• 8 Smith AL., Rodriguez M, Chen Y. Early intervention in low-energy spinal cord compression: A retrospective study of recovery outcomes. Journal of Spinal Research 2019; 42 (03) 215-223
• 9 Jones RT, Malik S, O’Connor JP. Rapid diagnosis and functional recovery in low-energy spinal cord injuries: A comparative case series. Spinal Trauma Reports 2021; 18 (02) 101-110

Publication History

Article published online:
14 October 2025