Hip fixation, foot fracture: An iatrogenic complication of DHS

Background

Dynamic Hip Screw (DHS) fixation is a standard surgical intervention for the treatment of intertrochanteric and certain subtrochanteric femoral fractures. The procedure often necessitates the use of a traction table equipped with a specialized traction boot to maintain limb alignment, provide controlled traction, and facilitate optimal fracture reduction . The traction boot applies axial force to the foot and lower limb, allowing the surgeon to manipulate the fracture site. Despite its widespread use and generally favorable outcomes, this method is not without complications. One underreported but clinically significant complication is the occurrence of iatrogenic foot fractures attributed to the traction forces exerted by the boot during surgery .

Foot fractures in the context of DHS operations are thought to arise from excessive or prolonged traction, improper positioning within the traction boot, or insufficient cushioning, which collectively can lead to focal pressure points on the foot . These mechanical stresses may induce stress fractures of the metatarsals and tarsal bones, such as the calcaneus. The precise incidence of such injuries remains unclear, largely due to the lack of dedicated studies and case reports focusing on this complication.

In addition to mechanical factors, patient-related variables such as bone quality, peripheral vascular disease, and pre-existing neuropathies may predispose individuals to traction-related foot injuries . Pathophysiology involves not only direct compressive forces but also ischaemic insult and nerve compression secondary to traction-induced soft tissue swelling. Given the subtlety of early clinical signs and the rarity of reported cases, vigilance is essential during DHS procedures to mitigate this risk. Surgeons are advised to minimise traction time, ensure proper boot fitting with adequate padding, and frequently reassess the limb’s neurovascular status intraoperatively . As the volume of DHS surgeries continues to rise globally, further research and documentation of these complications will be critical for improving patient safety and surgical outcomes.

Case presentation

A 60-year-old female presented with an extra capsular neck of femur fracture following a fall, while walking her dog. She immediately felt pain and was unable to weight-bear on her right lower limb. Apart from the right hip pain, right leg shortening and external rotation, no further injuries were noted. The patient underwent a right Dynamic Hip screw insertion for an extracapsular neck of femur fracture on a traction table. No complications or issues were noted intra-operatively. Post-operatively the patient remained uneventful but started to complain of new foot pain, swelling and struggling to weight-bear. Post-operatively tenderness was noted in the plantar aspect of the 2nd and 3rd tarsal bones of the right foot along with tenderness at the lateral malleolus and swelling around the right ankle was noted along with bruising at the right fore-midfoot plantar aspect. The patient was also struggling with range of motion within the ankle during physiotherapy. An X-Ray scan of the right foot revealed a suspicion of subtle undisplaced fractures at the base of the second and third metatarsals and a subtle avulsion fracture at the anterolateral aspect of the medial cuneiform, which was later confirmed with a CT scan.

Investigations

A radiograph of the pelvis with both hips in the anteroposterior projection was obtained and confirmed the diagnosis of an intertrochanteric fracture. A radiograph of the anteroposterior projection of the right foot was obtained showing subtle undisplaced fractures at the base of the second and third metatarsals and a subtle avulsion fracture at the anterolateral aspect of the medial cuneiform [ Fig. 2 ]. Weight-bearing radiographs confirmed that these fractures were stable [ Fig. 4 ]. CT imaging later confirmed the subtle undisplaced fractures at the base of the second and third metatarsals and a subtle avulsion fracture at the anterolateral aspect of the medial cuneiform [ Fig. 5 and 6 ].

Treatment

Following the radiographs of the right foot an Aircast boot was applied, and the patient was encouraged to bear weight with the boot. Analgesia was optimised and the patient engaged well in physiotherapy. The patient will be followed up in outpatient clinic in eight to ten weeks with an X-ray on arrival.

Discussion

Iatrogenic foot fractures resulting from a traction boot use during Dynamic Hip Screw (DHS) fixation represent an uncommon but clinically significant complication. While the traction table achieves controlled reduction and stabilisation of intertrochanteric fractures, the interface between the boot and the patient’s foot introduces potential risks, particularly in individuals with predisposing anatomical characteristics . In our patient, a small foot size combined with the application of compression via a standard traction boot contributed to a triad of injuries—undisplaced fractures at the base of the second and third metatarsals, and an avulsion fracture at the medial cuneiform, an injury pattern not widely described in existing literature.

Current understanding of traction-related complications predominantly centers on neuropraxia, soft tissue pressure injuries, and vascular compromise . However, increasing attention has been drawn to bony stress injuries occurring remote from the surgical site, especially in lower limb surgeries requiring prolonged traction. In our case the patient’s relatively narrow foot likely resulted in uneven force distribution across the foot. This is supported by the post-operative findings of plantar tenderness, midfoot swelling, and limited ankle range of motion.

These injuries can be attributed to a combination of axial loading and circumferential compression transmitted through the rigid boot construct during surgery , [ Fig. 1 ]. The application of traction across a small surface area may generate concentrated pressure points, particularly at the tarsometatarsal junction, where the second metatarsal is recessed and vulnerable .

Fig. 1

A photograph of the boot at the end of the traction table, marked with an arrow highlighting where the white clicking device can compress the foot during the procedure, depending upon the size of the foot, this will lie distal in smaller sized feet.

Sep 5, 2026 | Posted by in ORTHOPEDIC | Comments Off on Hip fixation, foot fracture: An iatrogenic complication of DHS

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