Al Kuwait Hospital 16th of December 2019 U00037134

University of Sharjah

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College of Medicine

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Year 5
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Internal Medicine Rotation

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Case Write Up – Orthopedics (2)

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Rana Salah U00037134

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 Al Kuwait Hospital 16th of December 2019 U00037134

Demographics:
 Name: AA
 MRN#: 00377253
 Age: 68 years old
 Gender: Female
 Nationality: Syrian
 Occupation: housewife
 Marital status: Married
 Date of admission: 12/11/2019

History:

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 Chief Complaint: right hip pain after falling

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History of Present Illness:

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
o Characterization of symptoms: Mrs. A a 68 year old a known diabetic, hypertensive and

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osteoporosis presented to the emergency department on the 11 th after she slipped and
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fell while walking in the airport. She felt a sharp pain after falling and was not able to
walk afterwards. The pain was:
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 In the right hip

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 Happened immediately after falling

 Stabbing
 Radiating to upper thigh
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 9/10
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o Associated symptoms: inability to walk, swelling, no numbness, no fever, no nausea, no

vomiting, no weight change
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o Alleviating and exacerbating factors: moving her right lower limb makes the pain worse,
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taking pain killers reduces the pain.

 ROS:
o Nervous: no headache, no blurry vision, no double vision, no convulsions
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o CVS: no palpitations, no chest pain, no dyspnea, no orthopnea

o Respiratory: no shortness of breath, no cough, no wheezing, no hemoptysis
o GI: no abdominal pain, no diarrhea, no constipation
o Urogenital: no dysuria, no urgency, no frequency

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 Al Kuwait Hospital 16th of December 2019 U00037134

o ENT: no hyperemic throat or tonsillitis, no runny nose

 PMH:
o Hypertension for 10 years
o Diabetes for 20 years
o No history of stroke/TIA
o No high cholesterol
 Surgical history: surgical fixation of right knee 6 years ago
 FH: no family history of cardiovascular diseases, similar conditions or cancers
 SH: she lives with her daughter in Sharjah, does not smoke, does not exercise
 Allergies: none
 Meds:

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o Clopidogrel

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o Oral hypoglycemic agents

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Physical Examination rs e
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 General appearance: conscious, alert, oriented, she appears to be distressed and in pain
 Vital signs:
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o Blood Pressure  131/77mmHg

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o spO2: 99%
o Pulse Rate  76 bpm, regular, normal volume and character
o Respiratory  18 br/m
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o Temp  37.0C
 Hands:
o Warm, no clubbing, peripheral cyanosis, or tortuous veins, no palmar erythema, no
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pallor, muscle wasting or astrexis, no tar staining

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 H/E:
o No icterus, pallor, no double vision
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o Pupils: reactive to light and accommodation

o Mouth: moist, no central cyanosis
o Face is relaxed and not puffy or plethoric
o No loss of the outer thirds of eyebrows

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 Al Kuwait Hospital 16th of December 2019 U00037134

o No chemosis, corneal arcus or palor in sclera

o No xanthelasma
o Oral mucosa is well hydrated and teeth are healthy
o Tongue is not smooth or enlarged
o No fissuring at the angles of the mouth
 Neck:
o LN non-palpable
o No thyromegaly
o JVP not raised
o Carotid no bruits
Heart: normal S1 and S2, no murmurs, normal apex beat located at the 5th intercostals space

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mid clavicular line, no thrills or parasternal heaves

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 Lungs: equal air entry, breath sounds vesicular, no crepitations, rhonchi or rub heard

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 Abdomen: soft, no tenderness, no distension, no discoloration, no scars, no dilated veins, normal

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bowel sounds, no organomegaly
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 Ext:
o Upper limb: normal tone, pulses are present, normal range of movement
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o Lower limb:
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 Left: normal shape, normal range of motion, radial nerve is intact, distal pulses
are present
 Right: shortened, externally rotated, bruises, swelling, tenderness, restricted
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range of motion, painful range of motion, no nerve injury clinically, distal pulse is
present, all reflexes are present
 Neuro exam: no nystagmus, intact cranial nerves, no weakness, reflexes are present, intact
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sensation
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 Skin: warm, no erythema, no rash

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Investigations:
 CBC
o RBC’s = 4.67 cellsx10^6/ul

o Hb = 12.10 g/dL

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 Al Kuwait Hospital 16th of December 2019 U00037134

o Plt = 280 cellsx10^3/uL

o WBC = 12.72 cellsx10^3/uL

 Electrolytes & renal profile

o Sodium = 137 mEq/L

o Potassium = 4.70 mEq/L

o Chloride = 105 mmol/L

o Creatinine = 116 umol/L

o Uric acid = 379 umol/L

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o Glucose = 13.4 mmol/L

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o Urea = 9.3 mmol/L

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 Lipid profile
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o Cholesterol = 5.63

o Triglycerides = 2.09
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o HDL = 0.96
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o LDL = 3.70

 PT = 11.60
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 PTT = 30.70

 INR = 1.05
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Working Dx:
 Hip fracture
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Differential diagnosis:
 Hip dislocation
 Femur fracture

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 Al Kuwait Hospital 16th of December 2019 U00037134

Treatment plan
 Skin traction
 Tramadol stat
 Admit to female surgical ward
 Bilateral hip x-ray + pelvis
 Chest x-ray
 ECG
 Medical, anesthesia and cardiac consultation

Medication Route of administration Dose Frequency

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Omeprazole Oral 20mg q24h

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Tramadol IM 50mg PRN

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Acetaminophen rs e IV 1000mg q6h
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Meperidine IM 75mg PRN
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Metoclopramide IM 10mg q8h

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Midazolam Oral 7.5mg q24h

Mebeverine Oral 200mg q12h

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Ceftriaxone IV 2gm q24h

Bromhexine Oral 8mg q8h

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Lactulose Oral 30ml q8h

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Valsartan Oral 80mg q24h

Bisoprolol Oral 5mg q24h

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Insulin regular SC 6units q8h

Enoxaparin SC 40mg q24h

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 Al Kuwait Hospital 16th of December 2019 U00037134

Follow-up:
 X-ray findings:
o Displaced fracture of the right proximal femur
o Bilateral hip joints appear normal
o Osteopenic bone
 S: patient is comfortable, no new complain
 O: alert, oriented, not in distress
 A: vitally stable, afebrile, skin traction in situ, active toe movement is present
 P: plan for operation, anaesthesia and medical review, obtain consent, explain risks and
complications, closed pertrochanteric fracture of femur

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Learning Points

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Hip fracture

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Clinical features
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 Acute hip pain
 Inability to bear weight
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 Short externally rotated leg

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 Pain is worse with movement

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Classification:
 Subcapital: intracapsular, can cause AVN
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 Intratrochanteric: extracapsular, can lead to non-union

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 Subtrochantric: extracapsular, can lead to malalignment

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Literature review

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 Al Kuwait Hospital 16th of December 2019 U00037134

Title: common hip fractures in adults

Introduction
As the worldwide population of older adults is growing, the number of hip fractures is also increasing. Ol
der adults have weakened bones and are more likely to fall due to decreased balance, side effects of me
dication, and difficulties in handling environmental hazards.

Anatomical considerations
The hip joint is a "ball and socket" joint consisting of an acetabular (socket) and a femoral head (ball).
The femoral neck connects the femoral head to the proximal portion of the femoral shaft and attaches to
the intertrochanteric region. In any of these cases, the term "hip fracture" is applied to these fractures.

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Blood supply disruption to the femur's head and neck can hinder the healing of fractures in these

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structures. A vascular extracapsular ring circles the base of the femoral neck. This ring results in feeder

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vessels (ascending cervical arteries) running up to the femoral head parallel to the femoral neck.

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This ring results in feeder vessels (ascending cervical arteries) running up to the femoral head parallel to
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the femoral neck. Medial and lateral femoral circumflex arteries, which derive from the deep femoral
artery, provide the arteries of this chain. Additional blood flow to the femoral head is provided by the
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foveal artery (a branch of the obturator artery). This flows into the fovea through the ligament teres.
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Nevertheless, it is not thought that the foveal artery alone is sufficient to meet the needs of the femoral
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head.
The femoral head is a superiorly flattened disk. His cancellous bone's arrangement is aligned along the
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major stress axes. The primary medial trabeculae (resistant to compression) and the primary lateral
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trabeculae (resistant to tension) are the most important of these structures. These structures allow the
bone to withstand the strong forces of the proximal femur. For example, in a one-legged posture, a force
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of 2.6 times body weight is transmitted across the hip.

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References:
https://www.uptodate.com/contents/overview-of-common-hip-fractures-in-adults
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