Femoral Neck Fracture in a 79-Year-Old Woman

Helen Kenealy, BHB, MBchB

Disclosures

April 30, 2015

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 79-year-old woman presents to the emergency department with left hip pain. She mildly twisted her left leg 3 days ago and has since had increasing pain and difficulty walking. The pain is sharp and radiates down to her left knee. It is mild when she is at rest, but it becomes severe when she attempts to walk. She has not had any weakness or numbness, and denies having had any fever. She has not had any direct trauma to the hip or falls, and there has not been any notable swelling of the leg, skin changes, or rash.

The patient has unintentionally lost 8.8 lb over the past 6 months. She denies having any nausea, vomiting, night sweats, cough, or shortness of breath. She has a history of multiple rib fractures that resulted from vigorous coughing 2 years ago; at that time, she was diagnosed with osteoporosis as the cause of these fractures. She denies having had any other previous fractures.

The patient's medical history also includes chronic obstructive pulmonary disease, although she has never been a smoker. She also has known osteoarthritis of the hips, scoliosis of the thoracic spine, and a presumptive diagnosis of Paget disease on the basis of a single elevated serum alkaline phosphatase level.

The patient's medications include budesonide/formoterol (Symbicort®) and terbutaline inhalers, oral calcium and vitamin D supplements, and weekly alendronate (Fosamax®). A bisphosphonate was started after dual-energy x-ray absorptiometry (DXA) showed a T score of -2, which is consistent with osteopenia.

Both her mother and sister broke their hips later in their lives.

The patient lives independently and is still driving. She denies experiencing physical abuse, and the family members who have accompanied her in the emergency department show concern for her.

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