History of admission

a. Patient biography

Name initials : Madam. HZ

Age : 65 y/o
Sex : female
Religion : Islam
Civil status : Widowed
Race : Malay
Occupation : Farmer
RN : 573505
Admission : 15/6/2010
Clerking : 14/7/2010

b. Chief complaint
Madam H is a known case of cerebrovascular accident on March 2010, presented with
pain of right thigh for a period of 3 months.

History of presenting illness

Madam H complains of having pain at right thigh for 3 months. She fell down in a
kitchen when trying to walk by her own without anyone attending after the CVA on
25/4/2010. Since then she was unable to walk, feeling numbness of the right lower limb
downward. The pain is described as pulsating, there was swelling with bluish colouration
at the thigh.

The pain is associated with headache, nausea/vomiting, but no fever, no significant loss
of weight and no night sweat.
Comprehensive health history

a. Past medical/ surgical history

Madam H was known case of diabetes mellitus for 22 years on insulin treatment. She was
diagnosed for hypertension not in any medication after cerebrovascular accident on
March 2010 and was brought to HUSM for treatment.
She had no significant history of surgery.

b. Social history
Madam H was a farmer, living with her children at Pasir Putih. Her husband was passed
away 1984. Since then she never remarried, not sexual promiscuous, and no drug abuse.
However, she was an ex-smoker for 15 years with 2 boxes per day. Madam H had
menopause at age of 47 years old

c. Family history
Madam H father was passed away at age of 70 years old for asthma. Her mother was
passed away at age f 63 years old due to old age. According to her daughter, patient have
strong trait of diabetes mellitus, and hypertension runs in the family.

d. Allergy and medication history

Patient had allergy to seafood.

Physical Examination and assessment

a. General
Patient appearance matches his description of age and race; 65 years old Malay lady.
Conscious –time and place oriented, and comfortable. She was breathing normally and
able to communicate with the examiner. she was well nourished and she’s lying flat on
the bed with support of two pillows.

Inspection of the hand revealed no clubbing, peripheral cyanosis or nicotine stain. No

swelling or tenderness of the wrist. No wasting of muscle or flapping tremor. The hand
was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm
and good volume. There was no radio-radial delay or radio-femoral delay and there was
also no collapsing pulse.
 Examination of the eye shows no sign of ptosis, constricted pupil and loss of sweating.
She had dropping of left eyelid, with discharge draining from the eyelid –evidence of
CVA. No jaundice noted on the sclera and the conjunctiva was not pale. The tongue was
moist and no central cyanosis seen. Oral hygiene was good.

Hi vital signs were as recorded;

Blood pressure : 122/76 mmHg

Heart rate : 86 beat per minute
Respiratory rate : 26 breaths per minute
Temperature : 37°C

Impression: no remarkable findings except hemiparesis at left side of the face. Otherwise
patient was stable

b. Musculoskeletal examination

On inspection, the right thigh appears swollen and bluish. In comparison between two
thighs, the right appears smaller than the left side –apparent muscle wasting. There is a
skin traction applied to the right leg. The right lower limb appears shortened and
externally rotated. Palpation reveals tenderness at the upper third of the thigh, with
warmness at the affected area. The patient is unable to feel sensation at upper third of the
thigh extending downwards. However, the left thigh is not affected; sensation was present
and felt by the patient.

Patient was unable to move the right thigh actively. Passive movement cannot be
accessed due to the pain by the patient. Patient’s right thigh can be move sideways and
retractable. Range of movement is not completed. However, the left thigh is not affected
and can move freely and normally.

Impression: tenderness and swelling of the right upper third of the thigh. The bony
alignment was deviated with apparent shortening and externally rotated. Area of the
swelling is warm and bluish. Sensation at right thigh downwards was compromised. Skin
traction was applied. Left lower limb was not affected.
 c. Other systemic examination

Examination of the chest reveals equal air entry of the lung. No crepitus heard. Expansion
of the chest is symmetry. The heartbeat was dual rhythm with no murmur.

Examination of the abdomen reveals soft and non-tender abdomen at all quadrants. No
organomegaly findings. Bowel sound is present –normal.

Impression: No remarkable finding

Summary

65 years old Malay lady with known case of CVA on March 2010 presented to HRPZ II
with pain at the right thigh for 3 months. She had a history of fall on April 2010. She had
history of diabetes mellitus on insulin for 20 years, recently diagnosed for hypertension
and history of CVA on March 2010. Physical examination reveals tenderness and
swelling of the right upper third of the thigh with sensation at right thigh downwards
compromised.

Provisional diagnosis

Fracture at the femoral neck

Patient presented with acute pain after falling down on April 2010. The pain lasted for 3
months since then. The pain characterized as pulsating, with association of swelling and
bluish coloration. She was unable to walk, unable to bear weight and felt numbness of the
right thigh downwards.

Physical examination and assessment revealed tenderness and swelling of the right upper
third of the thigh. Area of the swelling is warm and bluish. Sensation at right thigh
downwards was compromised. Skin traction was applied. The right leg appears shortened
and externally rotated. The movement of the right leg is limited by the fact that patient in
pain.
Differential diagnosis

diagnosis Positive relevant Negative relevant

Bluish discoloration at the

Pain at the thigh, limited
affected area. Localised to
osteoarthritis movement, swelling of the
one limb instead of both
area
limb.
Acute pain at the thigh,
No fever, no history of
Septic arthritis limited movement of thigh,
surgery or implantation,
swelling of the affected area
Acute pain at the thigh,
Fracture of the femoral Swelling and pain at upper
swelling of the affected
shaft third of thigh
area.

Investigation

Investigation Reason to support

Total white cell count is raised above normal if the patient

Full blood count
had generalized infection.
Blood urea serum To prepare patient for surgery.
electrolyte
Elevation of PT/PTT means prolonged bleeding,
PT/APTT insufficient of coagulating agent –vitamin K, increase
consumption, or hematological factors.
Skeletal X-Ray Gross skeletal changes at the lesion
Full blood count

Blood Result Interpretation Normal range

Count
WCC 10 normal 4.5-13.5 x 109 /L
RBC 4.0 Normal 4.0-5.4 x 1012 /L
Hb 11.0 Normal 11.5-14.5 g/dL
HCT 35.5 Normal 37.0-45.0 Ratio
MCV 82.7 Normal 76.0-92.0 fL
MCH 27.2 Normal 24.0-30.0 Pg
MCHC 32.8 Normal 28.0-33.0 g/dL
Platelet 244 Normal 150-400 109 /L
Neutrophil 60.0 Normal 40.0-75.0 %
6.0 2.9-7.9 109/L
Lymphocyte 23.9 Normal 20.0-45.0 %
2.4 1.8-4.0 109/L
Monocyte 6.3 Normal 2.0-10.0 %
0.6 0.2-0.8 109/L
Eosinophil 0.4 Normal 0.0-5.0 %
0.9 0.04-0.44 109/L
Basophil 0.4 Normal 0.0-2.0 %
0.0-0.2 109/L

Impression: no significant findings

Blood Urea Serum Electrolyte

Element Result Interpretation Normal range

Urea 3.9 Normal 2.5-6.7 Mmol/L
Sodium 135 Normal 134-145 Mmol/L
Potassium 3.7 Normal 3.4-5.0 Mmol/L
Chloride 100 Normal 95-105 Mmol/L

Impression: no significant findings

PT/APTT
 Element Result Interpretation Normal range
PT 12.1 Normal s
10-14
PT © 12.5 normal s
INR 0.96 Normal ~1 – 2.5
APT 32.0 Normal s
21-35
APT © 37.4 Normal s
INR 0.86 Normal ~1 – 2.5

Impression: no significant finding

Skeletal X-Ray

Hip X-Ray AP/lateral 12/7/2010

Close fracture of intertrochanteric of the right femur. The femur angle is disrupted with
deviation of the shenton’s line

Impression: closed fracture at intertrochanteric of the right femur.

Final diagnosis

Fracture at intertrochanteric of right femoral bone

1) Based on history, madam H presented with acute pain after falling down on April
2010. The pain lasted for 3 months since then. The pain characterized as pulsating,
with association of swelling and bluish coloration. She was unable to walk, unable to
bear weight and felt numbness of the right thigh downwards.

2) Physical examination and assessment revealed tenderness and swelling of the right
upper third of the thigh. Area of the swelling is warm and bluish. Sensation at right
thigh downwards was compromised. Skin traction was applied. The right leg appears
shortened and externally rotated. The movement of the right leg is limited by the fact
that patient in pain.

3) Full blood count and other investigation show no remarkable finding. The skeletal X-
ray finding reveals closed intertrochanteric fracture at the right femur.

Principal management

1) Admission into orthopaedic ward

2) Continuous observation
3) Lying flat
4) IV cefuroxime 150g 3 doses
5) Review X-Ray of hip AP/Lateral
6) Keep in view blood pressure
7) Keep in view blood glucose
8) To inform OT for right hip hemiarthroplasty
9) Pain killers
Discussion

Intertrochanteric fractures are considered 1 of 3 types of hip fractures. The anatomic site
of this type of hip fracture is the proximal, upper part of the femur or thigh bone. The
proximal femur consists of the femoral head, femoral neck, and the trochanteric region.
An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus
medius and minimus muscles (hip extensors and abductors) attach, and the lesser
trochanter, where the iliopsoas muscle (hip flexor) attaches

The etiology of intertrochanteric fractures is the combination of increased bone fragility

of the intertrochanteric area of the femur associated with decreased agility and decreased
muscle tone of the muscles in the area secondary to the aging process. Cauley et al [1]
says that the increasing bone fragility results from osteoporosis and osteomalacia
secondary to a lack of adequate ambulation or antigravity activities, as well as decreased
hormone levels, increased levels of demineralizing hormones, decreased intake of
calcium and/or vitamin D, and other aging processes. Several recent studies have
identified additional risk factors for hip fracture. Sennerby et al identified generalized
cardiovascular disease as a significant risk factor for hip fracture. [2] while Carbone et al
determined that heart failure is a specific risk for hip fracture.[3]

Madam H is 65 years old lady with history of cerebrovascular accident a month prior to
the fall that believed to lead to the fracture. Furthermore, she had menopause at 47 years
old, with history of diabetes mellitus of 20 years and hypertension –diagnosed with CVA.
She was a heavy smoker with significant packyears -30 packyears; claimed that already
quit smoking.

The current treatment of intertrochanteric fractures is surgical intervention. Surgical

intervention is used to treat essentially all intertrochanteric fractures and is described as
open reduction and internal fixation (ORIF). Various surgical fixation devices are now
available for the treatment of essentially all intertrochanteric fractures.
Conclusion

Intertrochanteric fractures are considered 1 of 3 types of hip fractures. Intertrochanteric

hip fracture occurs between the greater trochanter, where the gluteus medius and
minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where
the iliopsoas muscle (hip flexor) attaches. Usually it affects in elderly patients and
women secondary to osteoporosis. The current treatment of intertrochanteric fractures is
surgical intervention.

References

1. Cauley JA, Lui LY, Genant HK, Salamone L, Browner W, Fink HA, et al. Risk factors
for severity and type of the hip fracture. J Bone Miner Res. May 2009;24(5):943-55.

2. Sennerby U, Melhus H, Gedeborg R, Byberg L, Garmo H, Ahlbom A, et

al. Cardiovascular diseases and risk of hip fracture. JAMA. Oct 21 2009;302(15):1666-
73. 

3. Carbone L, Buzkova P, Fink HA, Lee JS, Chen Z, Ahmed A, et al. Hip fractures and
heart failure: findings from the Cardiovascular Health Study. Eur Heart
J. Jan 2010;31(1):77-84.