Unable to weight-bear: a common presentation in emergency department that always needs thorough assessment: a case report

Abstract

Femoral neck fracture in young individuals with an unusual mechanism of injury is uncommon. We report a case of grade 3 fracture in young adults without significant trauma. This case reinforces the need for a thorough assessment of the hip joint even after an apparently trivial mechanism of injury.

BACKGROUND

This case is an unusual presentation and association of a femoral neck fracture. The patient is young with no previous significant medical and metabolic problems or risk of osteoporosis. There is also an additional, distracting, factor of the patient being in police custody and forensic history. In busy A&E settings there is a temptation to think that might be an accuse to get way with the police arrest. In particular, a junior doctor with less experience may overlook the overt signs and miss the fracture on the x-rays. This can lead to long-term patient morbidity and a risk of litigation to both the Trust and physician. It does emphasise how important a thorough history and examination are in the A&E. We think it might be useful to share this experience with other colleagues.

CASE PRESENTATION

A 33-year-old young man was brought into A&E by the police who had been arrested the night before and since then had been complaining of a painful lower back and right leg. He also complained of pins and needles in the left arm and left leg. He was having difficulty in weight-bearing on his right leg. He was under police arrest because he had had an argument with his wife. The police had apparently brought him to the floor without much force during restraint and he had been symptomatic since the incident. He was fit and healthy with no regular medications or drug allergy.

INVESTIGATIONS

On examination, he was haemodynamically stable. He was clinically tender over his right groin. Neurological examination revealed impaired sensation over dermatomes C4–C8 and over L3–L5 in the right lower leg. He was unable to do straight leg raises in the right leg due to pain. He was non-tender over the cervical, thoracic and lumbosacral spine. Apart from a painful right groin and being unable/?reluctant to weight-bear, his other clinical findings were difficult to correlate with the mechanism of injury. Based upon suspicion of injury, an x-ray of the hip was obtained that showed the Gardner’s grade III fractured right neck of femur.

DIFFERENTIAL DIAGNOSIS

• Fractured neck of femur.

• Lumber disc prolapse/lumber vertebrae fracture.

• Musculoskeletal.

• Functional.

TREATMENT

He was admitted to orthopaedics. Analgesia, baseline bloods, investigations and an urgent right hemi-arthroplasty were done.

OUTCOME AND FOLLOW-UP

The procedure itself was uneventful and he made a good recovery and was followed up by rehabilitation and orthopaedics’ outpatients. There were no major postoperative concerns.

DISCUSSION

Fracture of the neck of the femur is uncommon in healthy young adults with no metabolic problems. In this case, the mechanism of injury was very non-specific. The clinical presentation and neurology was unusual and it did not correlate well with the mechanism of injury. A high index of suspicion often is required for prompt diagnosis and treatment of an occult hip fracture.^1,2

Hip fracture has numerous atypical presentations. Unable to stand or walk is a common presentation in A&E. After a careful history and examination, one can reach the closest possible conclusions. Patients with a hip fracture typically present to A&E after a fall. They are often unable to walk and may exhibit shortening and external rotation of the affected limb. Frequently, they have hip pain. In some instances, however, patients with a hip fracture may complain only of vague pain in their buttocks, knees, thighs, groin or back. Their ability to walk may be unaffected, and initial radiographic findings may be indeterminate. In these patients, additional studies, such as magnetic resonance imaging or bone scanning, may be necessary to confirm the presence of a hip fracture.^1,3,4

The distinction between intracapsular and extracapsular fracture has prognostic value. For example, early detection of intracapsular fractures is especially important, because these fractures are prone to complications for two primary reasons. First, disruption of the blood supply to the femoral head frequently occurs and can lead to avascular necrosis. Second, the head fragment of the fracture is often a shell containing fragile cancellous bone that provides poor anchorage for a fixation device; this is a situation that often increases the possibility of non-union or malunion.^5,6

LEARNING POINTS

• Hip fracture is one of the major public health problems in the UK.

• Delayed recognition of hip fracture can result in increased morbidity and mortality along with a rapid decline in quality of life.^5–7

• Approximately 50% of patients who have lived independently before sustaining a hip fracture are unable to regain their independent lifestyle—instead, they face ongoing disability and prolonged institutionalisation.

• Failure to perform radiographs is one of the major causes of diagnostic errors in A&E.

• Given these serious consequences, it is vital to detect and appropriately treat patients with hip fracture.

Figure 1.

Gardner’s grade III fractured right neck of femur is shown.