Dr Housameddin Ghazzawi, MBBCh. MSc. Diploma. SHO Trauma and Orthopaedics
Dr. Viswanatha M Ramaraju, MBBS. FY2, Trauma and Orthopaedics.
Dr Mohammed Ghallab, MBBCh, SHO orthopaedic and Trauma
Mr. Neal Chhaya MBBS MRCS. Registrar Trauma and Orthopaedics.
Dr Khan MRCP PhD Consultant Cardiologist
Mr. B Bradnock. BSc. MS. FRCSEd (Orth), Consultant, Trauma and Orthopaedics.
Hemel Hempstead General Hospital, Hertfordshire, HP2 4AD

(We the above authors have no conflict of interest )

An elderly frail gentleman presented to casualty after having a fall. Shortly after, he developed chest pain. He had fractured his proximal right femur. Also, ECG and biochemical markers suggested myocardial infarction.

He was assessed by the cardiology team, whom he was known to, stabilized and prepared him for operation. The following day he developed further chest pain and ECG changes, which resulted in postponing the surgery.

We had to choose one from the following options:

  1. Treat myocardial infarction (MI) by percutaneous intervention (PCI) and the hip operatively.
  2. Treat MI by PCI and the hip conservatively.
  3. Treat both MI and the hip conservatively.
  4. Treat MI conservatively and the hip operatively.

Proximal femur fracture carries high risk of mortality and morbidity. In patients over 65 years of age it is as high as 23% within the first 6 months (R P Pitto. The mortality and social prognosis of hip fractures. Springer Berlin/ Heidelberg. Vol 18 number 2 / April 1994). In patients with known coronary artery disease, the mortality rate following orthopaedic operations is < 1% (Kim A Eagle, MD; Charanjit S Rihal, MD. Cardiac risk of non-cardiac surgery. Circulation 1997; 96:1882-1887).  Clinicians find it difficult making decisions in these complex cases.

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 Figure 1. Preoperative lateral radiograph. Click for larger image.

In the case mentioned above, the patient presented with proximal femur fracture and myocardial infarction. The cardiologists treated him conservatively because the risk of intervention and surgery was higher than the surgery alone. The patient was well informed of the potential high risk of mortality in view of his underlying medical problems.

He disliked the conservative management of his fractured hip, by means of analgesia and physiotherapy. He was very keen to undergo the operation, as he wanted to get back on his feet and independent life. Hence he made his mind against all the odds.

Patient was prepared for the surgery and had a successful dynamic hip screw operation. Post operatively, there were no immediate complications and subsequently was transferred to a rehabilitation ward.

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