Advice about possible hip fracture- management

[Karying14]

hi there,
There is a 90 year old female who fell and landed on her right hip 2 days ago, and the xray that was done yesterday shows a lucency in the area over the greater trochanter, suspicious for for fracture, but no definitely, as per the radiologist. I also saw the film, and it is small and suspiciious lucency. She is having pain, but it has only been 2 days since the fall. Would you get a CT scan to further assess the possible fracture, or would you just manage conservatively with pain control for now and see how she feels in a week? At her age, don't want to have her have needless radiation from CT if not needed, and the "possible" small fracture, if it is a fracture, is so small that surgery wouldd not be indicated anyways. Any input? Thanks

---

Members don't see this ad.

 

[deleted185747]

At her age, no point in worrying over radiation exposure. If it is obviously fractured on exam (shortened and externally rotated) then she may be a surgical candidate if she would be likely to survive the operation. If she is able to bear weight and walk then treat the pain. The lucency in the greater trochanter may be an avulsion fracture which would be non-operative if small. If a hairline fracture or non-displaced fracture then you would want her to be NWB for a few weeks. Small lucency could be a lot of things including multiple myeloma.

 

[MSKMed]

It is unlikely that any surgeon would view her as a surgical candidate given her age. I would agree with your conservative approach in lieu of exposing her to needless radiation, as your treatment approach will be probably be the same even if a fracture is identified on CT.

 

[bedrock]

It is unlikely that any surgeon would view her as a surgical candidate given her age. I would agree with your conservative approach in lieu of exposing her to needless radiation, as your treatment approach will be probably be the same even if a fracture is identified on CT.

As a med student, I don't think you've seen enough to know when someone will get operated on.

If you'd been in medicine longer, you'd know that seen plenty of 80 and 90 year olds get pinned for a hip fracture.

Why? because if you don't and they are permanent bed-ridden, they are much more likely to die of other medical issues within a year. That is a major consideration for their relative surgical risk.



Treat your lady conservatively for several weeks. If her pain persists and repeat X-rays aren't helpful, then its time for advanced imaging.

 

[MSKMed]

As a med student, I don't think you've seen enough to know when someone will get operated on.

If you'd been in medicine longer, you'd know that seen plenty of 80 and 90 year olds get pinned for a hip fracture.

Why? because if you don't and they are permanent bed-ridden, they are much more likely to die of other medical issues within a year. That is a major consideration for their relative surgical risk.



Treat your lady conservatively for several weeks. If her pain persists and repeat X-rays aren't helpful, then its time for advanced imaging.

You are correct in regard to my experience in this matter. However, from an outpatient PM&R perspective, would the treatment administered by a physiatrist be drastically different for this particular patient immaterial of whether she undergoes surgery or not?

If she does undergo surgery followed by a course inpatient rehabilitation and medical management, when she visits a physiatrist in an outpatient setting will her treatment be any different than if she did not undergo surgery? I am asking out of genuine interest.

 

[lobelsteve]

If she has a linear lucency extending across the femoral subtrochanteric region, then she is turf to Ortho. She gets nailed and does not go inpatient PMR, but either home or SNF.

PMR gets the call (or at least I do) when 1 week later she says her back is killing her and T12 collapsed. Brace, meds, kypho. Been there and done that (3 times).

 

[Louisville04]

If she has a linear lucency extending across the femoral subtrochanteric region, then she is turf to Ortho. She gets nailed and does not go inpatient PMR, but either home or SNF.

PMR gets the call (or at least I do) when 1 week later she says her back is killing her and T12 collapsed. Brace, meds, kypho. Been there and done that (3 times).

Do you still have them wear a brace after the kypho? Those braces are expensive, uncomfortable, and noncompliance is common.

 

[lobelsteve]

Do you still have them wear a brace after the kypho? Those braces are expensive, uncomfortable, and noncompliance is common.

Nope, bracing from Fx to fix. Once the cement "cast" is inside the bone, external bracing is not needed.

 

[RUOkie]

hi there,
There is a 90 year old female who fell and landed on her right hip 2 days ago, and the xray that was done yesterday shows a lucency in the area over the greater trochanter, suspicious for for fracture, but no definitely, as per the radiologist. I also saw the film, and it is small and suspiciious lucency. She is having pain, but it has only been 2 days since the fall. Would you get a CT scan to further assess the possible fracture, or would you just manage conservatively with pain control for now and see how she feels in a week? At her age, don't want to have her have needless radiation from CT if not needed, and the "possible" small fracture, if it is a fracture, is so small that surgery wouldd not be indicated anyways. Any input? Thanks

I would MRI if I could get it done same day. Otherwise CT scan. I'd be on the phone with ortho so that they know about her BEFORE the scan.

 

[Karying14]

Thanks for the input guys. Why would you get an MRI over CT?

 

[RUOkie]

Thanks for the input guys. Why would you get an MRI over CT?

slightly higher specificity for AVN. Also since this is a "small suspicious lucency", things like myeloma show up a little better on MR than CT.

 

[PMR 4 MSK]

4-5 years ago I had a pt with hip pain. No fall/trauama. Got an x-ray, it was negative for fx, but showed OA. We did a intra-articular steroid injection. It did not help, and she went to the ER a couple days later with severe pain. They x-rayed her again and it was read as negative for fx. I was consulted for pain control. I ordered an MRI, thiking she had to have a gluteal tear or similar.

It was a holiday weekend, so it was 3 days before we got the MRI. We got finally got the MRI and I get a call that the MRI shows a non-displaced femoral neck fx with early AVN. While I was calling one of my ortho partners to come fix her, one of her daughters, an RN at the hospital, comes screaming at me "How the hell did you miss a hip fracture for over a week?!!!? Are you even a real doctor? Do you know how to read a god-damned xray?!?!?!"

I explained that 2 xrays had been negative, and had even just gone back and re-read the last x-ray with a radiologist who confirmed no evidence of fx on the x-ray. The only thing that calmed her down was the arrival of the other daughter, another nurse, but one who did prn work at our ASC, who took our side in the fight.

The pt got her hip replaced, and she still see me periodically for her back pain.

X-rays miss stuff. Orthos generally prefer CT to MRI for occult fxs, unless you are looking for things like early AVN.