The Obvious versus not so Obvious

Special Article - Family Practice

J Fam Med. 2015; 2(5): 1038.

The Obvious versus not so Obvious

Adibi F¹* and Leung L1,2,3

¹Weeneebayko General Hospital, Moose Factory, Canada

²Department of Family Medicine, Queen’s University, Canada

³Centre of Studies in Primary Care, Queen’s University, Canada

*Corresponding author: Farnaz Adibi, Weeneebayko General Hospital, Moose Factory, Canada

Received: October 01, 2015; Accepted: November 04, 2015; Published: November 09, 2015

Case Presentation

Mrs. M is a 70 years old aboriginal lady who was admitted to a rural city hospital for long term care since December 2014. Her medical diagnoses include diabetes mellitus, hypertension, dyslipidemia, chronic renal failure, schizophrenia, osteoarthritis, obstructive sleep apnea and gastro-oesophageal reflux diseases (GERD). Her conditions have been stable until she tripped and fell on her left side whilst maneuvering her wheeled walker. She denied any dizziness, chest pain or unilateral weakness prior to her fall.

Upon direct questioning, patient complained of a dull, nonradiating pain over her left hip with a rating of 6/10 at rest and 10/10 with movements. She had stayed in bed since the fall and refused to mobilize. She denied pain in other parts of her body or her head.

On physical examination, her BP was 138/80, pulse was 89/ min, regularly regular. Her left leg was shorter than right, in fixed abduction and externally rotated. There was no ecchymosis or obvious laceration.

Palpation of the left thigh revealed no crepitation. Local tenderness was elicited over the trochanteric area, but none over the distal femoral shaft or pelvis. There was minimal active and passive range of motions at the femoral joint or the knee joint. Examination of the spine and contra lateral hip was unremarkable.

1. What immediate investigations would you consider?

a) CT pelvis

b) Full blood count

c) Anteroposterior (AP) views of the pelvis and hip

d) ESR

e) MRI of hip and pelvis

Answer: c)

X-Ray of the pelvis and hip (anteroposterior views) is the first investigation to be ordered as it has the highest sensitivity for diagnosing fracture or dislocation. Internal blood loss and sceptic focus is unlikely due to stable blood pressure and lack of fever in the patient.

2. X-Ray was performed which showed a not-so-obvious finding in the hip. What was it?

a) Inter-trochanteric femur fracture

b) Femoral neck fracture with impaction

c) Femoral shaft fracture

d) Posterior dislocation of hip

e) Anterior dislocation of hip

Answer: a)

X-Ray shows an intertrochanteric fracture. The fracture line was not obvious, but on closer inspection, is found to run between the trochanters with minimal angulation and displacement of bone. (See Figure 1 and Figure 2) This is consistent with the history of fall on the affected side with local tenderness, inability to mobilise and reduction in movement ranges and fixed abduction and external rotation. This is not a femoral neck fracture because it does not involve the femoral neck. There is no disruption of Shenton’s line, nor loss of bone contour along the margins of the femoral neck and inferior edge of the superior pubic ramus.