> Protectors may not prevent fractures, I agree, largely as the pelvis
> still
> undergoes a very rapid deceleration when it hits the floor, which is
> only
> minimally offset by the presence of the worn protector. However, that
> does
> not support your assertion that around 50% of fractures actually occur
> before the patient even begins to fall! I don't believe this for a
> moment,
> Rowley, and all of my patients clearly give a history of a simple
> mechanical
> "trip" which then results in a heavy collision with the ground which
> produces the fracture. I wonder who your memorable teacher was, and does
> anyone else hold this viewpoint?
>
> Adrian
As usual when Adrian pops his head up I struggle to find the paper that matters! However, a
little searching on things like "spontaneous subcapital fracture" throws up a few gems, such as
this:
"Clin Orthop. 1993 Jul;(292):202-9.
Insufficiency stress fractures of the femoral neck in elderly women.
Tountas AA.
Division of Orthopaedic Surgery, Northwestern General Hospital, Toronto, Ontario, Canada.
Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82
years) were studied retrospectively. All occurred in Caucasian women with severe
osteoporosis. A vague pain about the hip, of spontaneous onset, was the main symptom on
first visit. The diagnosis was delayed in most cases because the clinical findings were minimal
and the early roentgenographic features were absent or subtle. Bone scintigraphy was found
more useful than roentgenography for diagnosing this entity. A completely displaced stress
fracture of the femoral neck could not be distinguished clinically or roentgenographically from a
traumatic subcapital femoral fracture. Internal fixation was the treatment method associated with
the more favorable results. The histologic examination of removed femoral heads indicated that
this entity is a dynamic metabolic process. Insufficiency stress fractures of the femoral neck in
the elderly are not uncommon, but unless suspected, the condition can be easily overlooked,
and if displaced, mistaken for trauma-induced subcapital femoral fractures."
The stress fracture of the femoral neck is also seen in younger patients, with athletes and
amenorrhoeic women at particular risk, as well as those with bone cysts, renal bone disease and
so on.
I encourage you all today to seek out some patients with hip fractures and ask then if they had
pain and then the leg couldn't bear the weight and how many were fine until a mechanical or
other collapse. You will find a fair few who fall off their femur. As I can't find a paper directed
specifically to that question, "Did you fall off your hip?" sounds like a wonderful title for a
paper.
Best wishes,
Rowley Cottingham
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http://www.emergencyunit.com
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