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Management of neck of femur fracture in an adult with short stature and learning disability
  1. Viraj Gandbhir,
  2. Ashok Ramavath and
  3. Asim Rajpura
  1. Orthopaedics, Wrightington Wigan and Leigh NHS Foundation Trust, Wrightington, UK
  1. Correspondence to Viraj Gandbhir; drvirajg{at}gmail.com

Abstract

Neck of femur fractures (NOFF) are one of the major health concerns, with their incidence and the cost of care rising each year. Though a plethora of literature remains available on NOFF and its management, we found very little evidence for management of NOFF in patients with short stature and learning disability. Because of this unique combination of conditions in our patient, we had to deviate from the standard practice in terms of the implant choice. The usage of cemented Asian C stem AMT with a 36 mm metallic head which is normally reserved for total hip replacements, helped us obtain the desired hip joint stability. This was supplemented by early involvement of the learning disability physiotherapy team and eventually the patient had a satisfactory outcome at 8 months of follow-up. This rare amalgamation of NOFF, short stature and learning disability deserves more attention which our case report hopes to achieve.

  • hip implants
  • memory disorders (psychiatry)
  • physiotherapy (rehabilitation)
  • orthopaedic and trauma surgery
  • trauma

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Background

Patients with neck of femur fractures (NOFF) present with significant morbidity and mortality risks.1 Their timely surgical management as well as comprehensive care is of paramount importance.2 The NICE guidelines for NOFF suggest the appropriate plan based on the patient profile.3 As our patient had a unique combination of short stature, Down’s syndrome and autism associated with a NOFF, we had to deviate from the normal as regards the implant choice. With out of the box thinking and involvement of the learning disability team, our patient had a satisfactory outcome.

Case presentation

An independently mobilising woman in her late 50s presented to the emergency department of our hospital following an unwitnessed fall at her sheltered accommodation. She was unusually short for her age at 142.2 cm and weighed 33 kg. She had a background of Down’s syndrome with learning disability in the form of autism and remained non-communicative, verbally or non-verbally. On admission, her left lower limb was found to be shorted and externally rotated without neurovascular deficit for which she underwent further radiological investigations.

Investigations

On the radiographs and Computed Tomography (CT) scan, she was found to have a left displaced intracapsular NOFF with a comminuted greater trochanteric fracture (figure 1). Her femoral head size measured from the CT images was 34.7 mm which corroborated with intraoperative findings (figure 2).

Figure 1

(A) and (B) Anteroposterior radiograph of the pelvis with both hips and coronal CT slice showing a left neck of femur fracture, respectively. (C) Axial CT slice showing comminuted left greater trochanteric fracture.

Figure 2

(A) Femoral head size measurement on sagittal CT slice. (B) Femoral head being measured intraoperatively.

Treatment

After discussing the risks and the benefits with her guardian, she underwent cemented hemiarthroplasty through anterolateral approach in the morning after her admission. The implants used for her were an Asian C stem AMT with a metallic femoral head of 36/+5. The greater trochanter was repaired with non-absorbable sutures in figure of 8 configuration. Postreduction, the joint was stable in all planes and the limb lengths were restored.

Outcome and follow-up

A day after her surgery she remained a bit hesitant to mobilise as a result of the communication difficulty faced with the local team. With the help of learning disability physiotherapy team on the second postoperative day, she could be mobilised from sitting to standing and subsequently full weight bearing using a Zimmer frame. On the 10th postoperative day, while the patient was being helped to the hospital bed, her operated leg was found to be excessively internally rotated and adducted. Clinical and radiological evaluation confirmed a posterosuperior dislocation (figure 3). The dislocation was reduced under anaesthesia and postreduction, the hip was found to be stable in flexion, adduction, external rotations and internal rotation of up to 30°. She was subsequently mobilised with an abduction brace due to her previous poor compliance to instructions. At 8 months of follow-up (figure 4), she was mobilising full weight bearing without a brace.

Figure 3

Anteroposterior X-ray of the left hip showing dislocation.

Figure 4

Anteroposterior X-ray of pelvis at 8 months showing satisfactory alignment.

Discussion

Hip fractures are one of the the most common fractures in the United Kingdom, with 70 000 to 75 000 occurring every year. The annual cost of care is estimated to be 2 billion pounds and increasing every year.3 Their prolonged hospital stay is often complicated by occurrence of infection which further adds to the costs.4 There is an abundance of research articles and guidelines related to neck of femur fractures and their management. But there seems to be a dearth of information about NOFF in patients with short stature and learning disability. To the best of our knowledge, our case report is the only one detailing the challenges faced and the management of NOFF in a patient with short stature and learning disability.

The prevalence of hip osteoarthritis and dysplasia in Down’s syndrome stands at 8%–28% for which total hip arthroplasty has been advised.5 However, the native hip morphology was normal in our patient (figure 1). The patient was planned for a hemiarthroplasty considering the patient’s cognitive impairment, limited functional requirements and poor bone quality, in line with the NICE guidelines.6 The anterolateral approach was chosen as in the general population, the posterior approach has almost eight times higher risk of dislocation postoperatively and found to have poorer end result.7 The risk of dislocation is even higher in patients with Down’s syndrome as the syndrome is associated with generalised muscular hypotonia and unstable gait pattern.8

We used CT scan to accurately gauge the true femoral head size as the radiographs which provide only a two-dimensional view, have been found to be inaccurate.7 The main challenge centred around obtaining a suitable implant for the small native femoral head which measured only 34.7 mm on the preoperative images. The smallest head sizes available for a unipolar or a bipolar hemiarthroplasty were 41 mm and 39 mm, respectively, and as a result could not be used. Patient-specific implants which could have been a viable option in an elective setting were found unsuitable as the waiting time for the implants would have significantly increased her morbidity and mortality risks.9 As a result of the unique set of limitations we faced, we had to think out of the box and make an exception. We replaced her femoral head with implants which are normally reserved for total hip replacement in patients with abnormal proximal femur anatomy (Asian C stem AMT with a metal femoral head). We took due care to maintain the offset and achieve equal limb lengths which has been shown to be crucial during total hip replacements in Down’s syndrome.10 The joint remained stable on intraoperative evaluation. Postoperatively she had an uneventful recovery till the dislocation episode on the 10th day. Ancillary measures such as hip spica and abduction braces have been recommended by a few studies to avoid dislocation immediately after a total hip arthroplasty or a hemiarthroplasty but their prophylactic use remains controversial.10 We believe the dislocation was more due to awkward positioning of the leg rather than an unstable joint. This is further corroborated with a stable joint postreduction and satisfactory mobilisation and recovery thereafter.

Patient’s perspective

I am writing this on behalf of my sister who suffers from learning disability and finds it difficult to understand what is happening to her. After the accident, I was contacted by the surgeon to explain the procedure and the possible risks involved with the surgery. We both agreed that it needed to be done to maintain her quality of life as her mobility has always been satisfactory. After the surgery her recovery was slow at first but that was mainly due to her hesitancy and lack of understanding. She was reluctant to use her leg and this contributed to a slow start to her recovery. Once she had gained her confidence with the help of the physiotherapists and learning disability team, she started to move much better. She is now fully mobile without any pain or problems.

Learning points

  • Neck of femur fracture (NOFF) remains an important health condition with incidence and economic burden rising each year.

  • There is paucity of literature on NOFF in patients with short stature and learning disability.

  • Usage of implants reserved for total hip replacement remains a viable option in NOFF patients with short stature.

  • Prompt involvement of learning disability physiotherapy team helped our patient recover satisfactorily.

  • There could be an argument for prophylactic use of abduction brace in patients with learning disability undergoing hip arthroplasty surgeries where compliance is a worry.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors VG - Writing of manuscript; performed ground work; collection of material; literature review. ARam - Idea behind the case report; guidance; review of manuscript. ARaj - Finalised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.