Hip Fracture in the Elderly, ABOS Oral Boards Preparation

This is a 79-year-old woman who lives in an assisted living facility. She fell from standing in her room, a mechanical, ground-level fall. Prior to this, she was ambulatory with a walker within the facility and required assistance with some ADLs. Her medical history includes type 2 diabetes, atrial fibrillation on warfarin, moderate dementia with an MMSE of 18 out of 30, and a prior right total knee arthroplasty. She presented with left hip pain and inability to bear weight. On exam, her left lower extremity was shortened and externally rotated. Distal pulses and sensation were intact. Skin was intact.

AP pelvis and cross-table lateral radiographs showed a displaced left femoral neck fracture, Garden IV. The femoral head contour was maintained without AVN changes. The acetabulum was concentrically congruent without significant arthritis. Labs showed an INR of 2.4, hemoglobin of 10.8, and creatinine of 1.1.

Given her displaced femoral neck fracture, her age, her low functional demand, and her cognitive status, I discussed the options with her family. We reversed her anticoagulation with 4-factor PCC and proceeded within 24 hours of admission.

I performed a cemented bipolar hemiarthroplasty through a posterior approach. The hip was stable through a functional range of motion.

Post-operatively, she was made weight-bearing as tolerated and began physical therapy on post-operative day one. We restarted her warfarin on post-operative day two and bridged with prophylactic-dose enoxaparin. At two weeks, her wound was healing well. At six weeks, she was ambulating with a walker at her baseline level. At three months, she had minimal pain and was approaching her prior functional status. Her family reported she was doing well. The patient and her family were satisfied with the outcome, she returned to near-baseline ambulation status, which was the realistic goal. In retrospect, I would have involved geriatric medicine earlier in the co-management. We managed her anticoagulation and diabetes appropriately, but a formal comanagement protocol from admission would have streamlined her medical optimization and potentially shortened her time to the operating room. I monitored her closely for periprosthetic infection and implant loosening throughout the first year, and she remained asymptomatic.