Demographic details:

NAME: Sauliah binti Ali

AGE: 69 years old
RACE: MALAY
ADRESS: kampung sungai terap, Selama, Perak.

Informant: patient

Chief complaint: Patient presented with pain at the left hip region.

History of presenting ilness:

69 yrs old , woman with a known case of stroke and poorly rehabilitated had a trivial
fall in toilet, fell on the left side. was unable ambulate after the fall.
.She presented with pain over the left hip region, pain score was 7 over 10, and she
had bruises over her left hip. Previously patient was able to walk using a walking
stick. Post trauma there was no loss of consciousness, ear nose throat bleeding,

Systemic review is unremarkable

Past medical history:

She had stroke at june 2008 and suffered from hemiparesis of right side of body.
Since then, she had poor rehabilitation and did not attend to any physiotheraphy
sesion since she is living in a rural area.She is taking aspirin daily.

Past surgical history:

Not remarkable

Allergic history:

Allergic to seafood, get rashes when eat.

Drug history:

Aspirin and takes traditional medicines (jamu).

Physical examination:

General examination:

Patient is conscious alert , not in respiratory distress , patient left leg kept on skin
traction with 3 kg weight and elevated.
Vital signs:

Respiratory rate: 20 b/m

Pulse rate: 90 bp/m
Capillary refill rate less than 2 seconds
Ideally should check for blood pressure, temperature,

Examination of limb:
Patient only able to flicker her toes , dorsalis pedis pulse was felt,there was no
obvious bruises seen.

Investigation:
1. Full blood count
2. Liver function test
3. Renal function test
4. ECG
5. Chest x ray
6. AP and lateral view of hip x-ray
7. X ray of knee

AP view of hip x -ray

-closed fracture of left

intertrochanteric fracture of
femur
- intact posteromedial cortex
-Extracapsular fracture (no risk of
AVN and non-union)
-In this patient, angle is ≈100° at
left hip, which is reduced.
(normal is 1350)
-Management: Internal fixation
 Management:

1.Buck's Traction= temporary traction to prevent muscle spasm while waiting for
surgery

2. Patient is given a option for surgery or kept on skin traction until there is a union of
bone for 12 weeks.

Complications of surgery is not done:

-patient is unable to ambulate, she will be totally ADL dependent on her husband
-patient can develop bed sores .
-patient will be lying down on bed whole day which may cause deep vein thrombosis
and lead to pulmonary embolism and cause death.

-patient may also suffer from orthostatic pneumonia .

3. If patient agrees for surgery:

Advantages:
-no risk of general anaesthesia, using spinal anesthesia
-no risk of bleeding( patient need to stop taking aspirin 10 days prior to surgery)
- short duration operation time 1-2 hours, less complication
-patient should be able to sit after operation and early rehabilitation.
-patient should be able to walk using walking frame 3 weeks after operation.

Complication:
-acute compartment syndrome 24-72 hours

Pre -op assesment :

Patient should be fit for surgery, for that need too do

-Blood pressure / pulse / temperature / height and weight.
-liver function test
Renal function test
-An electrocardiogram (ECG)
- chest x ray
- prophylactic antibiotic given 30 minutes before operation preferable 2nd generation
cephalosporin

Surgery ;
-ORIF – open reduction and internal fixation
-PROXIMAL FEMORAL NAIL insertion / dynamic hip screw

Post-op:

1. intramuscular diclonefac sodium given

2.Early immobilization – walking frame with full weight bearing
3.Quadriceps strengthening .
Primary anti-gravity muscle.
Largest muscle in the body.
4. Maintain/Improve ROM at hip, knee and ankle.
5.. Allow full weight bearing using a standard walker.
6.. Prevent further fall, educate the patient on
Install :
Bed rail.
Ramp with hand rail over steps.
Toilet hand rail.
Prevention of recurrent fracture:

Pharmalogical intervention:

Medication : bisphosphonate, SERM (Raloxifen), RANKL inhibitor (Denusumad),

injection of PTH hormone (Teriparetide)
After 6 weeks