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Zorluk: OrtaOrthopedic Surgery

A 78-year-old woman is brought to the emergency department after slipping and falling in her kitchen. She complains of severe left groin pain and is unable to bear weight on her left leg. She has a medical history of hypertension, type 2 diabetes mellitus, and osteoporosis. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 138/86 mm Hg, and respiratory rate 16/min. Physical examination reveals normal alignment of the left lower extremity with no shortening or external rotation. However, severe pain is elicited with active straight leg raise and gentle internal rotation of the left hip. The dorsalis pedis and posterior tibial pulses are 2+ and symmetric. Sensation is intact to light touch in all distal dermatomes. Anteroposterior and cross-table lateral radiographs of the left hip and pelvis show severe osteopenia and degenerative joint disease but no cortical step-off or radiolucent fracture lines. Which of the following is the most appropriate next step in management?

  1. Magnetic resonance imaging of the left hipCevap
  2. B
    Discharge with partial weight-bearing instructions and repeat radiographs in 14 days
  3. C
    Computed tomography angiography of the lower extremities
  4. D
    Reassurance and initiation of physical therapy for early mobilization
  5. E
    Immediate placement of the left lower extremity in skeletal traction

Cevap

Magnetic resonance imaging of the left hip is the next best step to evaluate for a radiographically occult fracture.
This patient's clinical presentation (elderly, osteoporosis, ground-level fall, inability to bear weight, groin pain with internal rotation) is highly suspicious for a hip fracture. Up to 10% of hip fractures are radiographically occult, meaning they do not show up on initial plain radiographs. When clinical suspicion remains high despite negative X-rays, the standard of care is to keep the patient non-weight-bearing and obtain a magnetic resonance imaging (MRI) scan of the hip. MRI is the gold standard for detecting occult fractures, as it can clearly demonstrate bone marrow edema and hidden fracture lines. Identifying these non-displaced fractures is critical because early surgical stabilization prevents displacement, reducing morbidity and mortality.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation.
The patient is an elderly woman with osteoporosis who experienced a ground-level fall, presenting with inability to bear weight and groin pain exacerbated by internal hip rotation.
These findings are classic clinical signs of a femoral neck or intertrochanteric hip fracture.
2
Evaluate the initial imaging results.
Initial plain radiographs are negative for any fracture.
Up to 10% of hip fractures in the elderly can be radiographically occult on initial plain films, especially in the presence of severe osteopenia.
3
Determine the appropriate advanced imaging modality.
Magnetic resonance imaging (MRI) of the hip should be ordered.
MRI is highly sensitive and specific for detecting bone marrow edema associated with occult fractures, dictating the need for definitive surgical intervention.

Anahtar Kavram

In an elderly patient with a high clinical suspicion for a hip fracture (e.g., inability to bear weight, groin pain) but negative initial plain radiographs, an MRI of the hip is the next best step to diagnose a radiographically occult fracture.

Alternatif Yöntem

If a patient has an absolute contraindication to MRI (such as a non-compatible pacemaker or severe claustrophobia), a computed tomography (CT) scan of the hip without contrast or a nuclear bone scan can be used as an alternative to detect an occult fracture, though MRI remains superior for detecting acute bone marrow edema.
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