Trevor Silver Memorial Essay Prize 2014 First Prize

Case Study

September 2014

Dr Caroline Barclay

 

A 75 year old lady with left sided hip pain

 

Presenting Complaint

A 75 year old lady with Parkinson’s Disease presented to me with a 6 week history of left sided hip pain following a fall in the garden. She had tripped and fallen down 2 steps on to her left side. She was unable to weight bear following the fall. Her husband called an ambulance and she was taken to accident and emergency (A&E). A hip x-ray performed in A&E showed no fracture and she was discharged home with analgesia and crutches.

Over the next few weeks her pain did not improve and she was still using her crutches as she was unable to weight bear. Her husband was inevitably worried and booked an appointment to see the GP. She presented to me on crutches and in a lot of pain. She described pain aggravated by movement in any direction and pain keeping her awake at night time. She denied any weight loss or night sweats. She was taking paracetamol and codeine which was easing her pain slightly.

Past medical history

The patient had been diagnosed with Parkinson’s disease several years earlier and was taking Ropinirole and Co-beneldopa. Her Parkinson’s was relatively well controlled and her mobility prior to the fall had been reasonable. She had not been a frequent faller. She also had osteoporosis and was on Alendronic acid and Adcal – D3. A recent DEXA scan had shown an old vertebral L2 fracture and osteoporosis. She was awaiting a bone clinic appointment for IV Zolendronate. She also had hypertension and had been treated in the past for hyperthyroidism. She had no known drug allergies.

Social History

The patient lived with her elderly husband. They managed all of their activities of daily living and had no carers. She did not smoke or drink alcohol.

Examination

On examination she had an antalgic gait. There was no deformity or leg length discrepancy but she had a large old bruise over her left iliac crest. Her left groin was tender and she had severe pain on external rotation. Internal rotation, flexion and abduction were also limited due to pain. She had no pain over the greater trochanter or femur. Lumbar spine examination was normal and there was no neurology. Clinically I felt that the patient had a hip fracture which had been missed on initial x-ray so I asked her to have the hip x-ray repeated that day with a pelvic x-ray and booked her in to see me again two days later. I also asked her to have bloods done to check her inflammatory markers, bone profile, FBC and a myeloma screen and made sure to increase her analgesia. The couple declined any input from carers.

Review

I reviewed the patient two days later with her x-rays which again showed no fracture. Her blood results showed no evidence of myeloma or inflammation and she was not anaemic. I examined her hip again and the pain was no better. Examination findings were similar to the previous consultation. She actually felt the pain was getting worse and she wasn’t sleeping at all. Clinically this was a fracture and I felt she needed further imaging urgently. I requested an urgent MRI hip and pelvis and booked a review with her the next week. I increased her analgesia further to oral morphine as the pain was so poorly controlled. Again she declined any additional help from carers.

MRI

The MRI hip and pelvis showed an undisplaced fracture of the left iliac blade which extended down to the lateral wall of the pelvis above the acetabulum. There was some callus formation.

Management

I spoke to the Orthopaedic team about the MRI findings and they felt that as the fracture was undisplaced and healing it was appropriate to continue to treat her conservatively. They advised to refer her for urgent physiotherapy and were happy to follow her up in clinic. Her pain was much better controlled on morphine. Both her and her husband were happy to have finally got a diagnosis and were more than relieved not to require any intervention. She was seen by the physiotherapist four days later and rehabilitated well.

Follow Up

I reviewed the patient one month later and she was walking without crutches and not taking any analgesia. A repeat x-ray of her pelvis taken at her orthopaedic appointment showed a well healed fracture.

Fractures of the Hip and Pelvis

Elderly patients commonly present to the GP and A&E with hip pain and the majority of these patients present following a fall. Undisplaced fractures of the hip and pelvis can occasionally be difficult to diagnose on plain x-ray. A patient with a non displaced fracture can present with subtle clinical and x-ray findings and the diagnosis can be missed on initial evaluation (1). In some instances, the x-rays are entirely negative for a fracture (an "occult fracture"). Previous studies have shown that the incidence of delayed diagnosis of hip fractures ranges from 2% to 9% (1). There can be significant morbidity in discharging a patient with an undiagnosed undisplaced hip or pelvic fracture as was shown in this case study.

MRI is the current imaging method of choice for soft tissue and bone and more accurate than CT at identifying occult hip and pelvic fractures (2). MRI is well tolerated by elderly patients in pain, does not involve ionizing radiation and provides early and accurate diagnosis in patients with x-ray negative post-traumatic hip pain (3).

Karen M. Verbeeten et al.,(4) retrospectively examined the medical records of all patients who had visited A&E in Copenhagen University Hospital from June 2002 until May 2003 with a clinically suspected hip fracture, a negative x-ray and subsequent MRI examination. Four radiologists independently evaluated both the MR images and x-rays of all 33 patients in a blinded study. MRI proved to be far more sensitive and specific in the detection of occult hip fractures than x-ray. Using the MR images, the radiologists identified the occult hip fracture patients with 100% accuracy. A protocol implemented by the Emergency Department involving MR scanning patients with hip pain was estimated to save the hospital from 242 to 627 Euro’s per patient. The authors concluded that by shortening the time to diagnosis and permitting a superior visualization of both bone and soft tissue injuries, MRI prevented unnecessary hospitalization and delays in definitive treatment.

Several Emergency Departments throughout the U.K. have specific protocols for the management of patients with hip pain but no fracture. East Cheshire A&E state that if the patient is unable to weight bear and walk four steps following analgesia, an MRI must be requested followed by subsequent referral to Orthopaedics. If the patient is able to mobilize four steps then discharge is appropriate.

Wexham Hospital, Slough conducted a prospective study of 30 consecutive patients admitted with hip pain following a fall after normal x-ray of the hip. All 30 patients were examined and then underwent an MRI scan. The examination findings were analyzed. The authors found that patients with fractures seen on MRI were unable to straight leg raise, had limitation of rotation due to pain and groin tenderness to deep palpation on clinical examination. The authors concluded when all three signs are positive there is a definite fracture and an MRI scan is not actually necessary. When two signs are positive, possible diagnosis of neck of femur can be made. This can be confirmed with MRI scan. The authors concluded that astute clinical examination can minimize inaccurate diagnosis, unnecessary investigations and even inappropriate surgical intervention (5).

Whilst working as an F2 in A&E in 2009 I performed an audit on a random sample of seventy six patients aged 60 and over who presented with hip pain following a fall. Seventy three percent of the fractures reported on x-ray by a radiologist were actually missed on initial review of the x-ray by the A&E doctor. All of the fractures were small and undisplaced. Two patients went on to have MRI scans which picked up occult fractures. Several of the patients with fractures re-presented to A&E and were subsequently admitted. The remainder did not re-present and their fractures had healed with conservative management.

Discussion

Hip pain is an extremely common presenting complaint in General Practice. We ordinarily look at and trust x-ray reports from A&E and treat ongoing pain as soft tissue injuries with analgesia and physiotherapy. This case presentation and review of the literature has shown that many undisplaced fractures of the hip and pelvis are actually missed and subsequently managed inappropriately causing significant morbidity. When a patient presents with ongoing hip pain following a fall and is unable to weight bear and there is clinical suspicion of a fracture, should we be repeating the x-ray or requesting an MRI straight away?

Interestingly, another elderly patient presented to the surgery last week with ongoing left sided hip pain following a fall with a normal x-ray performed in A&E two weeks earlier. She was unable to weight bear and was using two sticks to mobilise. The examination findings correlated with a fractured hip. I requested an urgent MRI which showed a small undisplaced fracture of her neck of femur. Management in this case again was conservative but the patient was happy to find out why she was in so much pain and tailor her rehabilitation with the physiotherapist accordingly.

Summary

The management of an undisplaced fracture of the hip or pelvis is generally conservative but it is important we have the correct diagnosis so we are able to treat the patient appropriately, effectively and as quickly as possible. There is definitely a role for MRI scanning where we have diagnostic uncertainty, especially when access to MRI is now cheaper and widely available to GP’s.

 

 

 

 

References

  1. Pathak G, Parker MJ, Pryor GA. Delayed diagnosis of femoral neck fractures. Injury. 1997 May;28(4):299-301

 

  1. Lubovsky, M. Liebergall, Y. Mattan. Early diagnosis of occult hip fractures. MRI versus CT Scan. Injury. 2005 June;36(6):788-792

 

  1. Pandey R, McNally E. The role of MRI in the diagnosis of occult hip fractures. Injury 1998 Jan;29(1):61-3

 

  1. Verbeetan et al., The advantages of MRI in the detection of occult hip fractures.  European Radiology 2005 Feb; 15(1):165-9

 

  1. Rajkumar S, Tay S. Clinical Triad For Diagnosing Occult Hip Fractures With Normal Radiographs. The Internet Journal of Orthopedic Surgery. 2006. 3(1)