Orthopaedics in internal medicine

Neck of femur fractures

Elderly patients presenting with a miscellany of different conditions may have a background event which has been missed. Urinary tract infections, pneumonia, deep vein thrombosis, or even constipation, may all be reasons why patients are brought to medical attention. However there may be a background of a fall or slip or trip, followed by an activity change – typically resting in bed with some pain, and then the rest period becomes drawn out, sometimes for weeks, before attention is sought. Apart from cerebrovascular accidents, femur fractures are another often missed cause.

Diagnosis:

• Take a decent history
• Look at the patient in general – an elderly patient with spinal curvature is likely to have osteoporosis and hence be at increased risk of a fracture.
• Look at the heels: the heel of the fractured leg will not be level with the normal leg
• Palpate: their may be considerable (or no) tenderness over the hip, depending on the age and stability of the fracture
• Do an XRay

Management

Patients with hip fractured who are not operated on have an approximately 60% one year mortality¹ Another systematic review² found a 50% mortality at one year in those treated conservatively, versus 20% in those who were managed with surgery.Delays of even 24 hours in surgery have been associated with worse 30 day mortality (6.5 vs 5.8%)³.

Spinal tuberculosis

Tuberculosis of the spine involves the disc with spread to the anterior aspects of the vertebral bodies above and below, resulting in vertebral erosions with loss of disc height. (The reason for preference for the anterior part of the disc is purported to be because of increased vascularity, which is also given as the reason for the lack of this finding in children, where vascular supply is apparently more even.)

There is usually localised tenderness. Look carefully for the double shadow of a paraspinal abscess. (Metastatic malignancy tends to spare the disc, so one sees vertebral destruction with a preserved intervertebral disc height, and sometimes also loss of the pedicles.) The thoracic and lumbar spine are most frequently involved in tuberculosis, although cervical spine disease is described. Patients without neurological signs may respond nicely just to medication, but once there is any evidence to suggest cord compression, surgical intervention should be considered promptly, as progression to complete (and irreversible) paraplegia can be very rapid. A rather dated systematic review⁴ did not find evidence that surgical intervention improved outcomes over medical management of the condition.

1. Loggers SAI, Van Lieshout EMM, Joosse P, Verhofstad MHJ, Willems HC. Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis. Injury. 2020 Nov;51(11):2407-2413. doi: 10.1016/j.injury.2020.08.027. Epub 2020 Aug 23. PMID: 32907702. ↩

2. Kim SJ, Park HS, Lee DW. Outcome of nonoperative treatment for hip fractures in elderly patients: A systematic review of recent literature. J Orthop Surg (Hong Kong). 2020 Jan-Apr;28(2):2309499020936848. doi: 10.1177/2309499020936848. PMID: 32638635. ↩

3. Pincus D, Ravi B, Wasserstein D, et al. Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery. JAMA. 2017;318(20):1994–2003. doi:10.1001/jama.2017.17606  ↩

4. Zhang X, Ji J, Liu B. Management of spinal tuberculosis: a systematic review and meta-analysis. Journal of International Medical Research. October 2013:1395-1407. doi:10.1177/0300060513498023 ↩