> All a bit more complex than one would hope. And that's before starting
> on
> the racial differences.
> One paper that supports Rowley's view is Astrom et al. Physical
> activity in
> women sustaining fracture of the neck of the femur. JBJS 69B, 1987
> pp381 -
> 383- the original paper that showed that activity decreased rather than
> increased the incidence of PFF, supporting the osteoporosis rather than
> trauma view. This was the paper that swayed me until the papers
> favouring
> hip pads came out in the early 90s.
Of course these papers were supposition, noting that people with a greater BMI were less at
risk of fracture after fall.
> On a related issue: if you suspect PFF but x-rays are negative, do you
> admit
> the patient, discharge with or without review, CT, bone scan or what?
I admit; a bone scan will usually give the answer. Incidentally, you can massively reduce the
incidence of missed impacted hip fractures by instituting a protocol that states that all patients
over 60 presenting with hip pain or following a fall receive an X-ray.
This arose out of a complaint. An elderly woman was having Christmas dinner with her family.
As she stood up from the table, she had a pain in her hip. She walked into A&E with a normal
gait, was examined by an SHO and discharged. She represented 2 days later with a subcapital
fracture. We could not show that the fracture had not arisen as she stood up (indeed, I think it
did) and apologised. However, after instituting the above policy, there were no further missed
fractures in the succeeding 5 years, although I cannot answer the obvious question of the yield
of the policy.
Best wishes,
Rowley Cottingham
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