An atypical presentation of a femur fracture

Abstract

A 56-year-old woman with a past medical history signifi cant for sarcoidosis, hypertension, and osteoporosis presented to the ED via emergency medical services after sustaining a right leg injury in a fall at home. She said she was carrying groceries into her house when she tripped over the threshold, landing on a fl exed right knee. She had immediate pain to her right thigh and was unable to bear weight. She denied any symptoms of syncope before the fall, had no loss of consciousness or neck pain, and denied any other injuries. Her medications include lisinopril 20 mg once daily and prednisone 10 mg once daily for the past several years. She took alendronate 10 mg once daily for 5 years for osteoporosis, but discontinued this drug about 8 months ago after bone mineral density testing revealed an improvement in her bone mass. Actual data from the testing were unavailable to the ED staff at the time of her visit. On physical examination, she was a well-developed, well-nourished woman in moderate distress secondary to right thigh pain. She was in a cervical collar and a right leg traction splint. Despite a potentially distracting injury, her cervical spine was cleared clinically based on the low mechanism of injury, and cervical spine radiographs were not obtained. Extremity examination demonstrated a shortened right leg, with an obvious deformity to the mid-thigh. Skin was intact. Dorsalis pedis and posterior tibial pulses were 2+ and bounding. Sensation was intact to all regions. The remaining extremities were noted to be atraumatic. The rest of the physical examination was unremarkable. After administration of parenteral analgesics, anteroposterior (AP) and lateral right femur radiographs were obtained (Figures 1 and 2). What would be most appropriate to order next? • AP pelvis radiograph • CT scan of the right femur • MRI of the right femur • Left femur radiograph The correct answer is a left femur radiograph. The oncall orthopedic surgery resident was paged for the patient’s An atypical presentation of a femur fracture