History of admission

a. Patient biography

Name initials : Madam. HZ Age : 65 y/oSex : femaleReligion : IslamCivil status : WidowedRace : MalayOccupation : FarmerRN : 573505Admission : 15/6/2010Clerking : 14/7/2010

b. Chief complaintMadam H is a known case of cerebrovascular accident on March 2010, presented with pain of right thigh for a period of 3 months.

History of presenting illness

Madam H complains of having pain at right thigh for 3 months. She fell down in a kitchen when trying to walk by her own without anyone attending after the CVA on 25/4/2010. Since then she was unable to walk, feeling numbness of the right lower limb downward. The pain is described as pulsating, there was swelling with bluish colouration at the thigh.

The pain is associated with headache, nausea/vomiting, but no fever, no significant loss of weight and no night sweat.

Comprehensive health history

a. Past medical/ surgical historyMadam H was known case of diabetes mellitus for 22 years on insulin treatment. She was diagnosed for hypertension not in any medication after cerebrovascular accident on March 2010 and was brought to HUSM for treatment.She had no significant history of surgery.

b. Social historyMadam H was a farmer, living with her children at Pasir Putih. Her husband was passed away 1984. Since then she never remarried, not sexual promiscuous, and no drug abuse. However, she was an ex-smoker for 15 years with 2 boxes per day. Madam H had menopause at age of 47 years old

c. Family historyMadam H father was passed away at age of 70 years old for asthma. Her mother was passed away at age f 63 years old due to old age. According to her daughter, patient have strong trait of diabetes mellitus, and hypertension runs in the family.

d. Allergy and medication historyPatient had allergy to seafood.

Physical Examination and assessment

a. GeneralPatient appearance matches his description of age and race; 65 years old Malay lady. Conscious –time and place oriented, and comfortable. She was breathing normally and able to communicate with the examiner. she was well nourished and she’s lying flat on the bed with support of two pillows.

Inspection of the hand revealed no clubbing, peripheral cyanosis or nicotine stain. No swelling or tenderness of the wrist. No wasting of muscle or flapping tremor. The hand was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm and good volume. There was no radio-radial delay or radio-femoral delay and there was also no collapsing pulse.

Examination of the eye shows no sign of ptosis, constricted pupil and loss of sweating. She had dropping of left eyelid, with discharge draining from the eyelid –evidence of CVA. No jaundice noted on the sclera and the conjunctiva was not pale. The tongue was moist and no central cyanosis seen. Oral hygiene was good.

Hi vital signs were as recorded;

Blood pressure : 122/76 mmHgHeart rate : 86 beat per minuteRespiratory rate : 26 breaths per minuteTemperature : 37°C

Impression: no remarkable findings except hemiparesis at left side of the face. Otherwise patient was stable

b. Musculoskeletal examination

On inspection, the right thigh appears swollen and bluish. In comparison between two thighs, the right appears smaller than the left side –apparent muscle wasting. There is a skin traction applied to the right leg. The right lower limb appears shortened and externally rotated. Palpation reveals tenderness at the upper third of the thigh, with warmness at the affected area. The patient is unable to feel sensation at upper third of the thigh extending downwards. However, the left thigh is not affected; sensation was present and felt by the patient.

Patient was unable to move the right thigh actively. Passive movement cannot be accessed due to the pain by the patient. Patient’s right thigh can be move sideways and retractable. Range of movement is not completed. However, the left thigh is not affected and can move freely and normally.

Impression: tenderness and swelling of the right upper third of the thigh. The bony alignment was deviated with apparent shortening and externally rotated. Area of the swelling is warm and bluish. Sensation at right thigh downwards was compromised. Skin traction was applied. Left lower limb was not affected.

c. Other systemic examination

Examination of the chest reveals equal air entry of the lung. No crepitus heard. Expansion of the chest is symmetry. The heartbeat was dual rhythm with no murmur.

Examination of the abdomen reveals soft and non-tender abdomen at all quadrants. No organomegaly findings. Bowel sound is present –normal.

Impression: No remarkable finding

Summary

65 years old Malay lady with known case of CVA on March 2010 presented to HRPZ II with pain at the right thigh for 3 months. She had a history of fall on April 2010. She had history of diabetes mellitus on insulin for 20 years, recently diagnosed for hypertension and history of CVA on March 2010. Physical examination reveals tenderness and swelling of the right upper third of the thigh with sensation at right thigh downwards compromised.

Provisional diagnosis

Fracture at the femoral neck

Patient presented with acute pain after falling down on April 2010. The pain lasted for 3 months since then. The pain characterized as pulsating, with association of swelling and bluish coloration. She was unable to walk, unable to bear weight and felt numbness of the right thigh downwards.

Physical examination and assessment revealed tenderness and swelling of the right upper third of the thigh. Area of the swelling is warm and bluish. Sensation at right thigh downwards was compromised. Skin traction was applied. The right leg appears shortened and externally rotated. The movement of the right leg is limited by the fact that patient in pain.

Differential diagnosis

diagnosis Positive relevant Negative relevant

osteoarthritisPain at the thigh, limited movement, swelling of the area

Bluish discoloration at the affected area. Localised to one limb instead of both limb.

Septic arthritisAcute pain at the thigh, limited movement of thigh, swelling of the affected area

No fever, no history of surgery or implantation,

Fracture of the femoral shaft

Acute pain at the thigh, swelling of the affected area.

Swelling and pain at upper third of thigh

Investigation

Investigation Reason to support

Full blood countTotal white cell count is raised above normal if the patient had generalized infection.

Blood urea serum electrolyte

To prepare patient for surgery.

PT/APTTElevation of PT/PTT means prolonged bleeding, insufficient of coagulating agent –vitamin K, increase consumption, or hematological factors.

Skeletal X-Ray Gross skeletal changes at the lesion

Full blood count

Blood Count

Result Interpretation Normal range

WCC 10 normal 4.5-13.5 x 109 /L

RBC 4.0 Normal 4.0-5.4 x 1012 /L

Hb 11.0 Normal 11.5-14.5 g/dL

HCT 35.5 Normal 37.0-45.0 Ratio

MCV 82.7 Normal 76.0-92.0 fL

MCH 27.2 Normal 24.0-30.0 Pg

MCHC 32.8 Normal 28.0-33.0 g/dL

Platelet 244 Normal 150-400 109 /L

Neutrophil 60.06.0

Normal 40.0-75.02.9-7.9

%109/L

Lymphocyte 23.92.4

Normal 20.0-45.01.8-4.0

%109/L

Monocyte 6.30.6

Normal 2.0-10.00.2-0.8

%109/L

Eosinophil 0.40.9

Normal 0.0-5.00.04-0.44

%109/L

Basophil 0.4 Normal 0.0-2.00.0-0.2

%109/L

Impression: no significant findings

Blood Urea Serum Electrolyte

Element Result Interpretation Normal range

Urea 3.9 Normal 2.5-6.7 Mmol/L

Sodium 135 Normal 134-145 Mmol/L

Potassium 3.7 Normal 3.4-5.0 Mmol/L

Chloride 100 Normal 95-105 Mmol/L

Impression: no significant findings

PT/APTT

Element Result Interpretation Normal range

PT 12.1 Normal10-14

s

PT © 12.5 normal s

INR 0.96 Normal ~1 – 2.5

APT 32.0 Normal21-35

s

APT © 37.4 Normal s

INR 0.86 Normal ~1 – 2.5

Impression: no significant finding

Skeletal X-Ray

Hip X-Ray AP/lateral 12/7/2010

Close fracture of intertrochanteric of the right femur. The femur angle is disrupted with deviation of the shenton’s line

Impression: closed fracture at intertrochanteric of the right femur.

Final diagnosis

Fracture at intertrochanteric of right femoral bone

1) Based on history, madam H presented with acute pain after falling down on April 2010. The pain lasted for 3 months since then. The pain characterized as pulsating, with association of swelling and bluish coloration. She was unable to walk, unable to bear weight and felt numbness of the right thigh downwards.

2) Physical examination and assessment revealed tenderness and swelling of the right upper third of the thigh. Area of the swelling is warm and bluish. Sensation at right thigh downwards was compromised. Skin traction was applied. The right leg appears shortened and externally rotated. The movement of the right leg is limited by the fact that patient in pain.

3) Full blood count and other investigation show no remarkable finding. The skeletal X-ray finding reveals closed intertrochanteric fracture at the right femur.

Principal management

1) Admission into orthopaedic ward2) Continuous observation3) Lying flat4) IV cefuroxime 150g 3 doses5) Review X-Ray of hip AP/Lateral6) Keep in view blood pressure7) Keep in view blood glucose8) To inform OT for right hip hemiarthroplasty9) Pain killers

Discussion

Intertrochanteric fractures are considered 1 of 3 types of hip fractures. The anatomic site of this type of hip fracture is the proximal, upper part of the femur or thigh bone. The proximal femur consists of the femoral head, femoral neck, and the trochanteric region. An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches

The etiology of intertrochanteric fractures is the combination of increased bone fragility of the intertrochanteric area of the femur associated with decreased agility and decreased muscle tone of the muscles in the area secondary to the aging process. Cauley et al [1]

says that the increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes. Several recent studies have identified additional risk factors for hip fracture. Sennerby et al identified generalized cardiovascular disease as a significant risk factor for hip fracture. [2] while Carbone et al determined that heart failure is a specific risk for hip fracture.[3]

Madam H is 65 years old lady with history of cerebrovascular accident a month prior to the fall that believed to lead to the fracture. Furthermore, she had menopause at 47 years old, with history of diabetes mellitus of 20 years and hypertension –diagnosed with CVA. She was a heavy smoker with significant packyears -30 packyears; claimed that already quit smoking.

The current treatment of intertrochanteric fractures is surgical intervention. Surgical intervention is used to treat essentially all intertrochanteric fractures and is described as open reduction and internal fixation (ORIF). Various surgical fixation devices are now available for the treatment of essentially all intertrochanteric fractures.

Conclusion

Intertrochanteric fractures are considered 1 of 3 types of hip fractures. Intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches. Usually it affects in elderly patients and women secondary to osteoporosis. The current treatment of intertrochanteric fractures is surgical intervention.

References

1. Cauley JA, Lui LY, Genant HK, Salamone L, Browner W, Fink HA, et al. Risk factors for severity and type of the hip fracture. J Bone Miner Res. May 2009;24(5):943-55.

2. Sennerby U, Melhus H, Gedeborg R, Byberg L, Garmo H, Ahlbom A, et al. Cardiovascular diseases and risk of hip fracture. JAMA. Oct 21 2009;302(15):1666-73. 

3. Carbone L, Buzkova P, Fink HA, Lee JS, Chen Z, Ahmed A, et al. Hip fractures and heart failure: findings from the Cardiovascular Health Study. Eur Heart J. Jan 2010;31(1):77-84.