Table of Contents  

Nduka and Benjamin-Laing: Bilateral hip fractures

Summary

We present, to our knowledge, the first case of bilateral intracapsular femur neck fractures in a healthy 50-year-old man. This patient presented with bilateral hip pain and an inability to weight bear following repeated falls while under the influence of alcohol. His bilateral hip fractures were successfully managed with bilateral hip hemiarthroplasty the following day and he was subsequently discharged after a non-eventful post-operative period.

Background

Bilateral hip fractures involving the neck of the femur are rare. When they occur, they are usually pathological fractures resulting from primary bone disease or the effects of other systemic abnormalities. In cases of systemic abnormalities, minimal trauma can lead to fractures involving the neck of the femur. To the best of our knowledge, the case presented here is the first reported in the literature of bilateral hip fractures following traumatic falls in an otherwise healthy 50-year-old man with no previously known primary bone or systemic pathologies that would result in predisposition to pathological fractures. We aim to add to the gradually increasing literature pertaining to the management of this rare condition.

Case presentation

A 50-year-old man presented to the accident and emergency department with bilateral painful hips and an inability to bear weight and was subsequently admitted. He provided a history of injuring himself by tripping and falling down a set of stairs after consuming alcohol. He reported that he was initally able to get to his feet, but immediately fell again and, thereafter, he was unable to bear weight. He did not sustain any other significant injuries and did not lose consciousness. He was brought to the emergency department approximately an hour after the fall.

The patient did not report any significant issues from his past medical history and had no known drug allergies. He was independently mobile prior to the fall, smoked an average of 20 cigarettes per day and drank an average of 15–20 units of alcohol per week.

On examination, he was fully alert and conscious, and his observations were stable; both legs were externally rotated but showed no evidence of shortening. He had bilateral groin pain and was reluctant to move both hips, but neurovascular function in both lower limbs was grossly intact. He showed no other obvious injuries.

Investigations

Blood tests on admission showed a normal haemoglobin level of 169 g/l and a white blood cell count of 22 × 109/l, with differential neutrophilia of 18.65 × 109/l. The patient had normal urea and electrolyte levels, and a raised alanine transaminase level of 111 IU/l was the only abnormality in liver function tests. Gamma-glutamyl transferase was also raised, at 149 IU/l, and his blood ethanol level was 291 mg/dl. Bone profile results revealed low levels of calcium and phosphate, at 2.08 mmol/l and 0.54 mmol/l, respectively. A radiograph of the pelvis showed bilateral displaced intracapsular neck of femur fractures (Figure 1).

FIGURE 1

Radiograph of the pelvis showing bilateral hip fractures before the operation.

9-2-4-fig1.png

Differential diagnosis

The diagnosis was quite clear in this instance and pathological causes were investigated but ruled out.

Treatment

The patient was treated the following day with bilateral cemented bipolar hip hemiarthroplasty. The procedure was carried out with the patient in the lateral position, and a full instrument change, re-draping and prepping of the patient was carried out before sugery on the second hip and while the patient was receiving antibiotic cover. A course of thromboprophylaxis was instituted.

Outcome and follow-up

Immediate post-operation rehabilitation was satisfactory, with the patient mobilizing on the first day; check radiographs (Figure 2) showed satisfactory implant positions. The patient was discharged 10 days after the operation but did not attend two follow-up outpatient appointments at the fracture clinic.

FIGURE 2

Radiograph of the pelvis showing bilateral hemiarthroplasty after the operation.

9-2-4-fig2.png

Discussion

Cases of bilateral hip fractures involving the proximal femur are rarely reported and are even extremely uncommon in normal, healthy bone.1 Causes of bilateral hip fractures in otherwise healthy bone include falls and high-energy trauma, while causes of fractures occurring in diseased bone include primary and secondary malignancies, osteomalacia, osteoporosis,24 vitamin D deficiency and steroid use.5 Cases have been reported following convulsive fits from any cause including electroconvulsive therapy and eclampsia.611 Post-radiation bilateral hip fractures have also been reported.12,13 It is important to note that the exact nature of this injury may go undiagnosed for a period of time following injury, which is especially true if the cause is non-traumatic. The diagnosis is most often confirmed by a plain radiograph of the pelvis with posteroanterior views and, in some instances, cross-table lateral views. If there is uncertainty about the diagnosis on a plain radiographs, which can be the case in undisplaced fractures, then further imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), may confirm the diagnosis. CT is particularly good for viewing bone and is more widely available than MRI, but MRI is more sensitive and will show underlying bone oedema. It is important to exclude pathological causes of bone fracture as this has an effect on subsequent case management. Other investigations may be required to prepare the patient for surgery and confirm a diagnosis of underlying pathology, for example routine full blood count, renal profile test, liver function tests, bone profile, parathyroid gland hormone assay and vitamin D assay, as well as tumour marker tests and CT of the chest, abdomen and pelvis.

In a 50-year-old man with bilateral hip fractures, the treatment is likely to be operative if no contraindications exist. This would be either bone-conserving surgery or arthroplasty. Treatment options for bilateral hip fractures include bilateral hip hemiarthroplasty, as in our case report, total hip replacements or Girdlestone procedures.14 Furthermore, hip-preserving surgical management employing cannulated screw fixations has been documented.15 Complications could be caused by the injury or surgical treatment and include bleeding, infection, pressure sores, deep-vein thrombosis, pulmonary embolism and the risks associated with anaesthesia. Dislocation of the hip implants and the need for further surgical procedures can cause long-term complications. In addition, avascular necrosis could be a late complication if hip-preserving treatment methods have been used.16

Further post-operative investigations such as a dual energy X-ray absorptiometry (DEXA) scan can be performed to confirm the diagnosis of the primary cause of a fracture.

Learning points

  1. There needs to be a high index of suspicion and early diagnosis of hip fractures.

  2. Further use of imaging techniques such as MRI and CT should be employed if the clinical diagnosis is not confirmed by radiography.

  3. Early treatment of the fracture is essential to prevent/reduce complications.

  4. Robust investigation is required to rule out underlying bone or systemic pathologies.

References

1. 

Shah HM, Grover A, Gadi D, Sudarshan K. Bilateral neck femur fracture following a generalized seizure – a rare case report. Arch Bone Jt Surg 2014; 2:255–7.

2. 

De Marchi J, Bajwa R, Duggan SN, et al. Suspected coexistent osteoporosis and osteomalacia with atraumatic bilateral neck of femur fractures in a 53-year-old man without apparent risk factors. BMJ Case Rep 2014; 2014:pii.

3. 

Bircher C, Afors K, Bircher M. Transient osteoporosis of the hip in pregnancy resulting in bilateral fracture of the neck of the femur. Int J Gynaecol Obstet 2012; 116:176–7. http://dx.doi.org/10.1016/j.ijgo.2011.09.013

4. 

Lidder S, Lang KJ, Lee HJ, et al. Bilateral hip fractures associated with transient osteoporosis of pregnancy. J R Army Med Corps 2011; 157:176–8. http://dx.doi.org/10.1136/jramc-157-02-10

5. 

Carter T, Nutt J, Simons A. Bilateral femoral neck insufficiency fractures secondary to vitamin D deficiency and concurrent corticosteroid use – a case report. Arch Osteoporos 2014; 9:172. http://dx.doi.org/10.1007/s11657-014-0172-5

6. 

Brennan SA, O’Neill CJ, Tarazi M, et al. Bilateral neck of femur fractures secondary to seizure. Pract Neurol 2013; 13:420–1. http://dx.doi.org/10.1136/practneurol-2013-000669

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Kelly JP. Fractures complicating electro-convulsive therapy and chronic epilepsy. J Bone Joint Surg 1954; 36B:70–9.

8. 

Powell HDW. Bilateral simultaneous fractures of the neck of femur. J Bone Joint Surg 1960;42B:236–52.

9. 

Copuroğlu C, Ozcan M, Dülger H, et al. Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure. Ulus Travma Acil Cerrahi Derg 2012; 18:92–4.0

10. 

Rahman MM, Awada A. Bilateral simultaneous hip fractures secondary to an epileptic seizure. Saudi Med J 2003; 24:1261–3.

11. 

Kause J, Parr MJ. Bilateral subcapital neck of femur fractures after eclamptic seizures. Br J Anaesth 2004; 92:590–2. http://dx.doi.org/10.1093/bja/aeh105

12. 

Ayorinde RO, Okolo CA. Concurrent femoral neck fractures following pelvic irradiation: a case report. J Med Case Rep 2009; 3:9332. http://dx.doi.org/10.1186/1752-1947-3-9332

13. 

Epps HR, Brinker MR, O’Connor DP. Bilateral femoral neck fractures after pelvic irradiation. Am J Orthop (Belle Mead NJ) 2004; 33:457–60.

14. 

Siddique K, Athanatos L, Housden P. Spontaneous bilateral neck of femur fractures and shoulder dislocation. BMJ Case Rep 2011; 2011:pii.

15. 

Ichikawa J, Amano R, Haro H, et al. Fatigue fracture of the bilateral femoral neck in the elderly. Orthopedics 2008; 31:1141. http://dx.doi.org/10.3928/01477447-20081101-09

16. 

Goost H, Kabir K, Wirtz D, et al. [Bilateral femoral neck fracture after seizure.] Z Orthop Unfall 2009; 147:567–9.




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