A case of concealed extracapsular subtrochanteric hip fracture

Dr Colm Shahmohammadi (SHO Emergency Medicine), Dr Housameddin Ghazzawi (Emergency Medicine Consultant), Dr Alister McIlwee (Emergency Medicine Consultant, Clinical Director Ulster Hospital SEHSCT)

A 65 year old lady presented to the Emergency Department following a fall with right groin pain.  Initial X-rays were normal.  She represented four weeks later with ongoing pain.  On this occasion X-rays showed an extracapsular subtrochanteric hip fracture.

A case of concealed extracapsular subtrochanteric hip fracture.

Dr Colm Shahmohammadi (SHO Emergency Medicine), Dr Housameddin Ghazzawi (Emergency Medicine Consultant), Dr Alister McIlwee (Emergency Medicine Consultant, Clinical Director Ulster Hospital SEHSCT)

The above named are the sole authors of this case.  Consent was obtained from the patient to produce this case report.

A 65-year-old lady presented to the ED department following a mechanical fall onto her right-hand side.  She complained of pain in the right-hand side of her groin and experienced pain on weight bearing.  She also complained of long standing non-traumatic right knee pain.

Her past medical history included recurrent falls, osteoarthritis, chronic kidney disease and hyperthyroidism. 

On examination, there was no deformity of the leg and she was non-tender over the greater trochanter.  She had a good range of movement at the hip and knee and was neurovasculary intact.

X-ray of her pelvis showed no fracture of her femur [figures 1 and 2].  It did however show a possible un-displaced inferior pubic ramus fracture on the right side.  She was given analgesia and crutches and discharged home from the Emergency Department. 

She then represented four weeks later with ongoing right groin pain.  She denied any further trauma to her right leg.  Again, she was non-tender over her greater trochanter and had good range of hip and knee movement.  X-rays were repeated and on this occasion showed an extra capsular subtrochanteric fracture extending from the lateral cortex of the femur spiralling down the femoral shaft [figures 3 and 4].  Bloods including electrolytes were unremarkable. 

Following the first presentation the patient continued to weight bear without the fracture being immobilised which resulted in non-union of the fracture.  If the patient had been non-weight bearing at first presentation, a CT scan of the hip may have been indicated, which may have resulted in a diagnosis.

After review by the orthopaedic team, she underwent insertion of a right femoral gamma nail.  The procedure went well with no complications and she made a good recovery.  She was discharged home and continued to mobilise well.

frac 1

Figure 1 (Pelvic X-ray at initial presentation)

frac 2

Figure 2 (Hip X-Ray at initial presentation)

frac 3

Figure 3 (Pelvic X-Ray at representation)

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Figure 4 (Hip X-Ray at representation)

 

 

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