Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is a 65-year-old woman, Marie Bobbins, presenting following a fall. Please take a history and perform an appropriate examination.
Patient History:
Your name is Marie Bobbins. You are 65 years old woman – retired.
While walking down the stairs 2 hours ago, you slipped accidentally and fell down the stairs, and suddenly, you heard a crack at your left hip. Since then, you have had this sudden, ongoing severe pain and your husband called the ambulance. You can't remember how long you have been lying on the ground. You are not sure if you have hit your head during the fall. No dizziness/vertigo. No palpitation. No loss of consciousness. No chest pain/ palpitation. No shortness of breath. No neurological symptoms. No fits/ incontinence/ tongue biting. No weakness/ slurred speech/ vision change. No warning signs. Waterworks/bowel normal.
You note you have pain in the groin and hip, which radiates to the knee. The pain is excruciating 10/10 – worsening by any movement, especially rotation. You have been given some morphine in the ambulance which helped. You are unable to stand or bear weight on the left side. You have some swelling in your left hip.
Ideas, Concerns, Expectations:
You think you have cracked a bone or something as your GP previously said you have brittle bones! You are concerned that you may need an operation! You want to avoid surgery as much as possible and get your pain under control.
Past Medical History:
Osteoporosis, Parkinson's disease. Diabetes type 2, paroxysmal atrial fibrillation, heart failure
Drug History:
Levodopa, alendronic acid weekly, metformin, furosemide, apixaban, omeprazole, vitamin D supplement
Family History:
Atrial fibrillation
Social History:
Drink 2-3 glasses of wine every other night
Ex-smoker – used to smoke around 5-10cigarettes a day for 10 years
Examination Findings:
Left leg shortened, abducted, and externally rotated. Pain palpating the greater trochanter.
Differentials:
Neck of femur fracture
Acetabular fracture
Pubic rami fracture
Femoral shaft or subtrochanteric femur fracture
Femoral head fracture
To rule out causes for falls e.g. Parkinson's, anaemia, electrolyte imbalance, arrhythmias, heart failure, MI, stroke, UTI, chest infection, dehydration, incorrect eyewear, poor footwear, obstacles at home…etc.
Investigations:
Bedside:
Primary Survey (ABCDE)
Observation including lying and standing BP
ECG / 24-48h Holter monitor (arrhythmias e.g. AF)
Consider Echo (aortic stenosis? fall)
Assess fluid status
Urine dip (rule out infection, +++blood in rhabdomyolysis)
Dix-Hallpike test if suspecting BPPV for cause of fall
Bloods:
Bloods (FBC, CRP, anticoagulation screen, electrolytes, bone profile, LFTs – rule out potential causes for fall/ fracture e.g. anaemia, electrolyte imbalance, underlying infection, plan for surgery…etc.) + group and save/ cross-match for surgery + CK (potential long lie/rhabdomyolysis) + glucose (hypoglycaemia is a cause of falls)
Imaging:
XR hip (AP + Lateral) – look for fractures, disruption of Shenton's line/ trabeculae, inferior/superior cortices…etc
MRI/ CT may be indicated if XR is negative, but fracture is suspected
Consider CT head for head injuries if indicated e.g. on anticoagulants
Consider XR Chest if suspecting pneumonia contributing to fall
Management: