A 73-year-old man is brought to the emergency department after his daughter found him on the floor. The patient says that he fell and now his left hip "hurts a lot," but he does not recall any details of the fall. Over the past several days, he has felt short of breath with a cough and intermittent palpitations that he attributed to "coming down with the flu." His other medical problems include hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. His temperature is 37.3 C (99.2 F), blood pressure is 118/76 mm Hg, pulse is 116/min, and respirations are 24/min. Pulse oximetry shows 95% on 2 L/min of oxygen by nasal cannula. Breath sounds are decreased at the right lung base, and crackles are present at the left lung base. The left lower extremity is shortened and externally rotated. Initial laboratory studies, including complete blood count, glucose, and serum chemistries, are normal. The pain improves with a dose of hydromorphone. X-ray findings are shown below. Which of the following is the best next step in management of this patient?

Question

A 73-year-old man is brought to the emergency department after his daughter found him on the floor.  The patient says that he fell and now his left hip "hurts a lot," but he does not recall any details of the fall.  Over the past several days, he has felt short of breath with a cough and intermittent palpitations that he attributed to "coming down with the flu."  His other medical problems include hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia.  His temperature is 37.3 C (99.2 F), blood pressure is 118/76 mm Hg, pulse is 116/min, and respirations are 24/min.  Pulse oximetry shows 95% on 2 L/min of oxygen by nasal cannula.  Breath sounds are decreased at the right lung base, and crackles are present at the left lung base.  The left lower extremity is shortened and externally rotated.  Initial laboratory studies, including complete blood count, glucose, and serum chemistries, are normal.  The pain improves with a dose of hydromorphone.  X-ray findings are shown below.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d969_341c_bc81_09b6dc1536ac_MD0003_00 This patient presents after a fall with a left femoral neck fracture. Hip fractures are classified by anatomic location and fracture type into either intracapsular (eg, femoral neck and head) or extracapsular (eg, intertrochanteric, subtrochanteric). Intracapsular fractures have a higher chance of avascular necrosis; extracapsular fractures have a greater need for implant devices (eg, nails, rods). The specific surgical intervention required depends largely on the details of the individual case. In general, surgical repair should be done as soon as feasible to relieve pain, minimize complications, and reduce length of hospital stay. However, surgery may be delayed up to 72 hours if needed to address unstable medical comorbidity. This patient has a number of concerning features. The uncertain details surrounding his fall suggest a possible syncopal episode. His tachycardia and palpitations can be due to arrhythmia (atrial fibrillation); decreased breath sounds on the right side could be due to pleural effusion; cough, dyspnea, and left basilar crackles also suggest pulmonary edema or pneumonia. The patient should therefore be evaluated with chest x-ray, electrocardiogram, and cardiac markers to determine the etiology of his fall and assess preoperative risk prior to surgical correction of his fracture. If there is evidence of pulmonary edema and pleural effusion, an echocardiogram is needed. Once it is determined that he is otherwise medically stable, he may be cleared for surgical intervention (Choice B). (Choice C) Before starting intravenous fluids, pulmonary edema (heart failure) and pleural effusion should be ruled out with chest x-ray. This patient is not hypotensive and likely has an intracapsular fracture, which has a relatively low risk of acute blood loss and need for intravenous fluids. (Choice D) Skeletal traction has been advocated as an interim measure for patients with hip fracture who require delayed surgical repair. However, recent studies have found that traction does not relieve pain or improve surgical outcomes. (Choice E) Surgery may reasonably be delayed up to 72 hours to allow for stabilization of acute medical problems, but longer delays increase the risk of medical complications and prolong the return to premorbid functional status. Educational objective: Older patients with hip fracture should undergo definitive surgical correction as soon as reasonably possible. However, surgery may be delayed up to 72 hours to evaluate surgical risk and ensure medical stability. References: Screening for acute myocardial infarction in elderly patients with collapse, confusion and falls. (http://www.ncbi.nlm.nih.gov/pubmed/10344041) Hip fracture protocols: what have we changed? (http://www.ncbi.nlm.nih.gov/pubmed/23544822)

A 73-Year-Old Man Is Brought to the Emergency Department After