Crozet Annals of Medicine: Forgetting

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By Dr. Robert C. Reiser

My house is quiet these days. The kids have all grown and gone. So when the phone rings at midnight my heart rate jumps up a little bit.

Last week when the phone rang at midnight an ER doctor was on the other end of the line—never good, but at least familiar. We both spoke the same coded language and shared a culture where midnight is little different from noon and things happen and have to be dealt with.

My 90-year-old aunt had fallen at her nursing home and broken her hip again. She was going to be transferred to an orthopedic specialty hospital if they could find a bed. I verified with the doctor that she was not in pain and confirmed to him that she was pleasantly but deeply demented. This was her third hip fracture but she remembered none of them including this one. A small blessing.

The femur has the distinction of being the strongest bone in the body but also the most frequently fractured, due to the high incidence of hip fractures in the elderly.

Hip fractures hospitalize over 350,000 Americans each year at a cost of 15 billion dollars. They often herald the last year of life. Twenty per cent of patients who suffer a hip fracture will be dead in a year.

My aunt had outlived those odds, sailing on through all adversities and improbably surviving massive heart attacks and calamitous falls, major operations and stubborn infections. One day in a brief lucid moment she asked me if it was possible that God had forgotten her. Who knows?

Due to the economic impact and the high morbidity and even mortality of hip fractures, many strategies for prevention have been studied. None work very well. Osteoporosis prevention drugs like aledronate may help some patients with very low bone density and a history of fractures, but even in this subgroup the benefits are small. Hip protectors, special underwear with pads over the bony prominences of the hips, do not work and are unflattering as well.

The best strategy for hip fracture prevention is to engage in high-impact exercise while young and on into middle age. This builds bone density, which has long-term benefits in hip fracture prevention. Moderation is required, however. Avoiding a hip fracture in old age while wearing out your knees in mid-life is a poor trade-off.

Well, my aunt got transferred to the orthopedic specialty hospital that night and her very nice orthopedic surgeon called me the next day. Based on her x-rays he could not tell whether she actually had a new fracture or not. There were fractures seen, but also cement, plates, wires and screws from her previous surgeries patching everything together. He recommended a CT scan of her hip to further delineate the extent of her injury. He called toward the end of the day after the CT scan had been done to report that as far as he could tell there was no new fracture. All of the damage was old.

Hip fractures, though, can be tricky. Sometimes the fracture can be occult, meaning that although the bone is actually fractured, it cannot be seen on x-ray. This is a big problem because if not recognized, the fracture will eventually give way into a displaced fracture, the patient will fall and then need an invasive repair or full joint replacement. In fact a significant portion of hip fractures do not result from a fall. Rather, the fracture occurs while standing or walking, and then the patient falls. The fracture comes first.

When recognized, occult hip fractures can be easily repaired with a minimally invasive procedure and the patients do well.

In the ER we see this a lot, and we have a simple test to rule out an occult hip fracture. If the x-ray is negative we stand the patient up. If she has no pain and can bear weight she has no fracture. If she can’t bear weight we obtain an MRI of the hip, which is a definitive test for occult fracture.

So I asked the orthopedist the simple ER doc question.

“Can she bear weight?”

“I see no reason based on her CT why she can’t.”

He then gave me a detailed breakdown of the CT findings, the state of the cement, the fit of the plates, the orientation of the screws, the position of the wires. I was really impressed with his willingness to explain in depth the CT. But I still had my question.

“No. I mean when she stands up, does she have pain?”

An awkward pause followed.

“Well, I haven’t actually seen your aunt.”

Oh.

It took another consult, to Physical Therapy, (the next day), to get a professional ruling on whether she could stand up. Turns out she could. She did not have a hip fracture, occult or otherwise. It took another day to arrange insurance coverage and transportation back to her nursing home.

When she arrived right back in the same nursing home bed three days later she looked around bewildered.

“Do I live here?” she asked.

“Yes, you do.”

“Well, I am ready to go.” she declared. She folded her hands across her chest, closed her eyes and went straight to sleep.

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