ORTHOPEDIC CASE SHEET

2-Month-Old (Neglected) Fracture Neck of Femur

PATIENT IDENTIFICATION

CHIEF COMPLAINTS

1. Pain in the right/left hip - 2 months
2. Inability to bear weight on right/left lower limb - 2 months
3. Shortening of the right/left lower limb - 2 months
4. Limp/antalgic gait - ___ weeks/months
5. Difficulty in activities of daily living (squatting, climbing stairs) - ___ months

Note: In a 2-month-old (neglected) fracture, some patients may have adapted to the deformity and present with pain and disability as predominant complaints rather than acute inability to walk.

HISTORY OF PRESENTING ILLNESS

Mode and Mechanism of Injury

• Date and time of injury: _______________
• Mode of injury: Fall from standing height / Road traffic accident / Trivial trauma / Spontaneous (pathological) / Unknown
• Mechanism: Direct injury to greater trochanter / Indirect - twisting force on the hip / Fall on outstretched lower limb
• Side of injury: Right / Left
• Position at the time of fall: Forward / Backward / Sideways
• Surface fallen on: Hard floor / Soft surface
• Height of fall: _______________

Initial Period (At time of injury)

• Immediate onset of severe pain in the groin/hip
• Inability to stand or walk immediately after injury
• Swelling around hip - Present / Absent
• External rotation and shortening noticed - Yes / No
• Any audible crack/snap heard - Yes / No
• Loss of consciousness at time of injury - Yes / No
• Any head injury associated - Yes / No

Why Neglected / Delayed Presentation (2-month History)

• Was medical attention sought initially? Yes / No
• If yes, where? PHC / Private clinic / Not investigated properly
• Any treatment given initially? Native/traditional treatment (bone-setter) / Analgesics / Bandaging / Traction
• Reason for delay in seeking definitive care:
  • Financial constraints
  • Rural area / poor accessibility
  • Lack of awareness
  • Native treatment sought first
  • Misdiagnosed as soft tissue injury/sprain
  • Patient refused surgery initially
  • Other: _______________
• Progression of symptoms over 2 months:
  • Pain - improving / same / worsening
  • Mobility status - bedridden / partially ambulatory with support
  • Any wound/discharge - Yes / No (rule out open fracture/infected nonunion)
  • Pressure sores developed - Yes / No (from prolonged bed rest)

Present Status

• Current level of pain: VAS score ___/10 (at rest ___/10, on movement ___/10)
• Current ambulatory status: Non-ambulatory / Ambulatory with aid (stick/walker/crutches) / Ambulatory unaided
• Any groin/thigh swelling - Present / Absent
• Any fever/discharge from hip area suggesting secondary infection - Yes / No
• Bladder and bowel - Normal / Affected

PAST HISTORY

• Similar injury/fracture in the past: Yes / No
• Previous surgeries: Yes / No - if yes, details: _______________
• Medical comorbidities:
  • Diabetes mellitus - Yes / No (since ___, on treatment: Oral/Insulin)
  • Hypertension - Yes / No (since ___, on treatment)
  • Cardiac disease (IHD, heart failure) - Yes / No
  • Pulmonary disease (COPD, Asthma) - Yes / No
  • Renal/hepatic disease - Yes / No
  • Neurological disease (stroke, Parkinson's) - Yes / No
  • Hypothyroidism / Hyperthyroidism - Yes / No
• History of prolonged steroid use: Yes / No (risk factor for AVN and osteoporosis)
• History of alcohol use: Yes / No (risk for AVN and osteoporosis)
• History of malignancy (to rule out pathological fracture): Yes / No
• Osteoporosis / Vitamin D deficiency / metabolic bone disease: Yes / No
• History of tuberculosis: Yes / No (to rule out septic arthritis/TB hip)

DRUG HISTORY

• Current medications: _______________
• Steroids (short or long term): Yes / No
• NSAIDs / Bisphosphonates: Yes / No
• Anticoagulants: Yes / No
• Any known drug allergy: Yes / No - if yes: _______________

PERSONAL HISTORY

• Diet: Vegetarian / Mixed
• Appetite: Normal / Reduced
• Sleep: Normal / Disturbed (due to pain)
• Bowel habits: Regular / Constipated (important in bedridden patient)
• Bladder: Normal / Incontinence (important in elderly)
• Menstrual history (females): LMP ___, Post-menopausal - Yes / No (postmenopause is a major risk factor for osteoporosis and fragility fractures)
• Smoking: Yes / No - Packs/year: ___
• Alcohol: Yes / No - Duration/quantity: ___
• Occupation: (Manual labor vs. sedentary - relevance to cause and future function)

FAMILY HISTORY

• Any osteoporosis in family - Yes / No
• Any malignancy in family - Yes / No
• Similar fractures in siblings/parents - Yes / No

SOCIO-ECONOMIC HISTORY

• Income group: Lower / Middle / Upper
• Living arrangement: Alone / With family (important for rehabilitation planning)
• Home environment: Stairs / Ground floor / Rural / Urban
• Support system available: Yes / No

GENERAL PHYSICAL EXAMINATION

• Height: ___ cm | Weight: ___ kg | BMI: ___ kg/m²

LOCAL EXAMINATION - HIP JOINT

LOOK (Inspection)

• Attitude of the limb:
  • Shortening - Present / Absent
  • External rotation of the limb (foot pointing outward) - Present / Absent (classic finding)
  • Adduction deformity - Present / Absent
  • Flexion deformity - Present / Absent
• Gait (if ambulatory):
  • Type: Antalgic gait / Trendelenburg gait / Short limb gait / Combined
  • Trendelenburg test: Positive / Negative (positive = abductor weakness from abductor mechanism disruption)
• Skin changes over hip/groin:
  • Swelling - Present / Absent
  • Bruising/ecchymosis (may have resolved at 2 months) - Absent
  • Scar / sinus / discharge (secondary infection) - Present / Absent
  • Skin creases - Symmetrical / Asymmetrical
  • Wasting of thigh musculature - Present / Absent (common after 2 months disuse)
• Spinal curvature:
  • Lumbar lordosis - Normal / Increased (compensatory for fixed flexion deformity)
  • Scoliosis - Present / Absent

In NOF fracture: True shortening is present due to proximal displacement of the femoral shaft. Typically 1-3 cm shortening. Both true and apparent shortening are present.

• Measured on both sides; base is reduced on the fractured side indicating proximal migration of the greater trochanter

• Greater trochanter lies above the Nelaton's line (drawn from ASIS to ischial tuberosity) on the affected side

• Line drawn from greater trochanter through ASIS on both sides - intersects above the umbilicus on the normal side; below on the affected side in NOF fracture

FEEL (Palpation)

• Skin temperature: Normal / Increased over hip region (infection/active inflammation?)
• Local tenderness:
  • Groin tenderness (anterior hip, medial to femoral vessels) - Present / Absent (characteristic of intracapsular fracture)
  • Greater trochanter tenderness - Present / Absent
  • Intertrochanteric region tenderness - Present / Absent
  • Shaft femur - Tender / Non-tender
• Bony landmarks:
  • Position of greater trochanter - Normal / Proximally displaced (above Nelaton's line)
  • Crepitus on passive movement - Present / Absent (may be present in neglected cases with fibrous union)
• Muscle tone: Normal / Reduced (disuse atrophy)
• Distal neurovascular status:
  • Femoral pulse - Present / Reduced / Absent
  • Popliteal pulse - Present / Reduced
  • Dorsalis pedis / Posterior tibial - Present / Reduced
  • Sensation: Normal / Decreased (L2-S1 dermatomes)
  • Capillary refill - < 2 sec / > 2 sec

MOVE (Range of Motion)

• Thomas test: Fixed flexion deformity (FFD) - ___ degrees (positive if hip flexion deformity present)
• Telescopy test: Positive (piston movement - proximal displacement of greater trochanter on pushing/pulling the limb along its axis) - indicates nonunion
• Trendelenburg test: Positive / Negative (standing - pelvis drops to opposite side = abductor weakness)

EXAMINATION OF RELATED AREAS

• Restricted movement - Yes / No
• Wasting of quadriceps - Present / Absent
• Any knee pathology - Yes / No

• Lower lumbar tenderness - Yes / No
• Lumbar range of motion - Normal / Restricted
• Straight leg raise - ___ degrees (to rule out associated radiculopathy)

• Motor power (MRC grading, hip flexors/abductors/extensors, knee/ankle)
• Sensation (anterior thigh - femoral nerve; medial thigh - obturator nerve; lateral thigh - lateral cutaneous femoral nerve)
• Reflexes: Knee jerk (L3-4) / Ankle jerk (S1)

SYSTEMIC EXAMINATION

• Heart sounds: S1 S2 heard / Any murmur
• JVP: Normal / Raised
• Peripheral pulses: Bilateral symmetric / Asymmetric

• Air entry: Bilateral equal / Reduced
• Any added sounds: Yes / No
• (Deep venous thrombosis from prolonged immobility: calf swelling, tenderness - rule out)

• Soft/rigid, organomegaly - Yes / No

• Orientation: Oriented to time/place/person
• Mini Mental State Examination (MMSE) if elderly: ___ /30

SUMMARY OF FINDINGS

PROVISIONAL DIAGNOSIS

• Garden's Classification: Stage III / IV (displaced)
• Pauwels' Classification: Type I / II / III
• With suspected: Nonunion / Fibrous union / Early avascular necrosis of femoral head

DIFFERENTIAL DIAGNOSES

1. Intertrochanteric fracture
2. Subtrochanteric fracture
3. Pathological fracture (secondary to TB / Metastases / Paget's disease)
4. Neglected hip dislocation
5. Septic arthritis of hip (if infection signs present)
6. Avascular necrosis hip (primary / secondary)

INVESTIGATIONS ADVISED

• X-ray pelvis with both hips AP view (gold standard)
• X-ray right/left hip lateral view (cross-table lateral / frog-leg lateral)
• X-ray full length femur
• CT scan hip (to assess fracture geometry, fibrous/bony callus, and plan osteotomy if needed)
• MRI hip (to assess viability of femoral head, extent of AVN - Ficat-Arlet staging)

• Complete blood count (CBC)
• ESR, CRP (to rule out infection/septic nonunion)
• Blood sugar (fasting & postprandial) / HbA1c
• Serum calcium, phosphorus, alkaline phosphatase (metabolic bone disease)
• Serum Vitamin D (25-OH)
• Serum uric acid
• Renal function tests (urea, creatinine)
• Liver function tests
• Coagulation profile (PT, aPTT, INR)
• Serum protein/albumin
• Blood group and crossmatch
• Urine routine and microscopy

• DEXA scan (if osteoporosis suspected)

TREATMENT PLAN (Brief)

• Valgus intertrochanteric osteotomy (if head is viable, no AVN) - restores vascularity and corrects biomechanics
• Hemiarthroplasty (Austin Moore / Bipolar) - if femoral head is non-viable (AVN) in elderly patients
• Total Hip Replacement (THR) - in elderly with AVN and acetabular involvement, or failed previous fixation

NOTES ON SPECIFIC ORTHOPEDIC POINTS FOR NOF FRACTURE