An 82-year-old female resident of an assisted living facility is evaluated in the hospital… — USMLE Step 2 CK

An $82$ -year-old female resident of an assisted living facility is evaluated in the hospital following a mechanical fall. The patient reports that she tripped over an electrical cord in her room earlier today. She now experiences severe pain in her right groin and is completely unable to bear weight. Prior to this incident, she was ambulatory and walked independently with a cane. Her past medical history is notable for osteoporosis, type $2$ diabetes mellitus, and essential hypertension. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $135/85\text{ mm Hg}$ , pulse is $88/\text{min}$ , and respirations are $14/\text{min}$ . On physical examination, the right lower extremity is noticeably shorter than the left and lies in an externally rotated position. Distal pulses are strong and symmetric, and sensory function is intact in both legs. Plain radiographs of the pelvis and right hip demonstrate a complete, displaced fracture line extending across the transcervical region of the right femur. The greater and lesser trochanters are intact. What is the most appropriate definitive surgical management for this patient's injury?

Perform a right hip hemiarthroplastyCevap
B
Perform open reduction and internal fixation with cancellous screws
C
Perform internal fixation using a cephalomedullary nail
D
Apply skeletal traction and enforce strict bed rest
E
Administer empiric intravenous antibiotics and schedule joint lavage

Cevap

Perform a right hip hemiarthroplasty

The correct approach is performing a right hip hemiarthroplasty. This patient presents with a displaced intracapsular (transcervical) femoral neck fracture. In elderly individuals, intracapsular fractures frequently disrupt the retrograde blood supply to the femoral head, which is primarily provided by the medial circumflex femoral artery. Due to this vascular disruption, attempting internal fixation carries an unacceptably high risk of avascular necrosis and subsequent nonunion. Therefore, arthroplasty (such as a hemiarthroplasty or total hip arthroplasty) is the definitive standard of care. This approach removes the devascularized native femoral head, provides immediate structural stability, and permits early postoperative weight-bearing, which is critical to preventing complications associated with prolonged immobility in the elderly, such as pneumonia and deep vein thrombosis.

Adım Adım Çözüm

Analyze the clinical presentation and radiographic findings

Elderly patient presenting with a shortened, externally rotated leg and a displaced transcervical (intracapsular) fracture on plain radiographs.

To classify the fracture location (intracapsular versus extracapsular) and determine the degree of displacement.

Assess the vascular implications of the specific fracture pattern

Displaced intracapsular fractures physically disrupt the retrograde blood supply to the femoral head provided by the medial circumflex femoral artery.

To evaluate the inherent risk of avascular necrosis and nonunion associated with this injury.

Determine the most appropriate definitive intervention based on patient age and fracture anatomy

Hip arthroplasty (hemiarthroplasty or total hip arthroplasty) is indicated over internal fixation.

To permanently bypass the risk of avascular necrosis, provide immediate structural stability, and allow for early weight-bearing mobilization.

Anahtar Kavram

Displaced intracapsular (femoral neck) fractures in elderly patients are definitively treated with hip arthroplasty (such as hemiarthroplasty) to mitigate the high risk of avascular necrosis and to facilitate early postoperative mobilization.

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Cevap

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