Assignment: The Intraoperative Fluoroscopic Radiograph Femoral Neck Fracture Question

Assignment: The Intraoperative Fluoroscopic Radiograph Femoral Neck Fracture Question

Clinical Case #5 84yo female tripped over her dog in the kitchen during a family Christmas celebration. She could not stand on her own power and had exquisite pain in her left hip. She was taken to the emergency department via ambulance. Physical exam noted a shortened and externally rotated left lower extremity. Radiographs were obtained demonstrating an injury. After medical clearance by the hospitalist she underwent surgical intervention. Presented are her final intraoperative fluoroscopic radiographs. Provide a short synopsis in the discussion board forum of the patient’s pathology, how that pathology contributed to her symptoms and eventual treatment. *Clinical Cases are optional/ungraded and are provided solely to enhance students’ educational experience. A/P Left Hip Lateral Left Hip Femoral Neck Fracture (Medullary Implant Pinning) 84 y/o pt tripped over dog at home. Non weight bearing w/o assistance with extreme pain in left hip. Taken to ER with noted shortened and externally rotated left lower extremity. Surgical intervention used. AGE is the dominant factor in hip fractures. Hip fracture in elderly women is extremely common unfortunately. Every year over 300,000 people 65 and older are hospitalized with hip fractures. 1 More than 95% of fractures are caused by a fall (usually sideways).

Women experience 3/4 of all these fractures. 1 in 3 adults over the age of 50 dies within 12 months of hip fracture.2 Post menopausal women are at increased risk of fracture due to osteopenia or osteoporosis. The lack of hormones progesterone and estradiol results in dysfunctional bone remodeling. The bones become less dense and more brittle as a result. As the body ages and metabolism slows we also see mitochondrial dysfunction increase. A slowed thyroid slows all metabolic processes leading to dysfunctions at all biologic levels to include the brain, cardiovascular system etc. Coordination and activities of daily living are severely impacted over time. Proprioception and balance are ultimately compromised. Lack of movement over time, compromised biomechanics, hormonal deficiencies and neurological disorders predispose the elderly to hip fracture. This patient underwent implantation of an intermedullary device with nail fixation. This should allow for early mobilization and weight bearing. References 1. HCUPnet. Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.govexternal icon. Accessed 5 August 2016. 2. Parkkari J, Kannus P, Palvanen M, Natri A, Vainio J, Aho H, Vuori I, Järvinen M. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int, 1999;65:183-7. 3. Hayes WC, Myers ER, Morris JN, Gerhart TN, Yett HS, Lipsitz LA. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcif Tissue Int 1993;52:192-198. 4. Katsoulis M, Benetou V, Karapetyan T, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project.] Intern Med. 2017;281(3):300-310. doi:10.1111/joim.12586 The patient in this clinical case has suffered from a hip fracture. From the age of the patient, accompanied by her physical symptoms, one can suspect that the probability of a hip fracture is relatively high. Le Blanc et al. (2014) notes, “Women experience 80% of hip fractures, and the average age of persons who have a hip fracture is 80 years”. The patient meets the statistical criteria for a hip fracture. The patient describes the immense pain she had felt when putting weight on the leg along with the shortening appearance of her leg. The symptoms that the patient is experiencing is consistent with a hip fracture. Reference: LeBlanc, K. E., Muncie, H. L., Jr, & LeBlanc, L. L. (2014). Hip fracture: diagnosis, treatment, and secondary prevention. American Family Physician, 89(12), 945–951. The clinical case indicates a left femoral neck fracture. In normal physiology, the hip joint is a multiaxial ball and socket joint that serves as a synovial articulation in between the head of the femur, and the acetabulum of the pelvic bone. The joint provides dynamic support for the body and facilitates load transmission.

The capsular ligaments of the hip include the pubofemoral ligament, that prevents excess extension and abduction, the iliofemoral ligament, that prevents hyperextension, and the ischiofemoral ligament, that prevents extreme extension. The ligament of the head of the femur, or the ligamentum teres, carries the foveal artery. Dislocations of the hip can result in injury of the ligamentum teres,

causing lesions of the foveal artery, leading to osteonecrosis of the femoral head. 2,3 Prognostic indicators of femoral neck fractures include extreme pain characterized by a declined range of motion of the hip. Indicators such as these may suggest there is a decreased blood supply caused by possible tearing of the ascending cervical branches. If there is decreased blood supply, this can lead to a poor prognostic outcome. Pathogenesis of the hip joint usually involves rubbing of the bones causing deterioration of the joint cartilage, further resulting in a decrease of the protective joint space, and the development of bone spurs. 3,4 The preferred treatment of a femoral neck fracture is dependent on whether the femoral neck is displaced or non-displaced. In the case of a displaced femoral neck fracture, the preferred method of intervention is a total hip arthroplasty. In the case of a non-displaced femoral neck fracture, the preferred method of intervention is intramedullary fixation of the hip. Benefits of intramedullary fixation include retention of the patients femoral head, slight decrease in mortality in more elderly patients, and decreased surgical trauma. However, intramedullary fixation can lead to increased risk of avascular necrosis, nonunion, delayed union, and higher risk of reoperation. In the clinical case of the eighty-four year old female, the extreme pain upon falling, and her inability to stand on her own are indicative of a femoral neck fracture. Upon viewing her intra- operative fluoroscopic radiographs, it is clear she did not have a displaced femoral neck fracture requiring a total hip arthroplasty. Rather, she suffered from a non-displaced femoral neck fracture requiring intramedullary nailing. Her radiographs show she underwent a successful intramedullary nailing of the femoral neck. Although procedure went well, she could still suffer from postoperative complications including risk of avascular necrosis, and nonuinon. 1 References 1. Babcock S, Kellam JF. Hip Fracture Nonunions: Diagnosis, Treatment, and Special Considerations in Elderly Patients. Advances in Orthopedics. 2018;2018:1-11. doi:10.1155/2018/1912762 2. Drake, R. L., Gray, H., Vogl, W., Mitchell, A. W.M., Tibbitts, R., Richardson, P., & Horn, A. (2020). Gray’s Anatomy For Students (4th ed.). Philadelphia: Elsevier. 3. Gold M, Munjal A, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Hip Joint. StatPearls. April 2020. https://www.ncbi.nlm.nih.gov/books/NBK470555/. 4. Kazley J, Bagchi K. Femoral Neck Fractures. StatPearls. February 2020. https://www.ncbi.nlm.nih.gov/books/NBK537347/. Clinical cases are provided throughout the course. Students are asked to read the case, research the pathoanatomical condition, and provide a short synopsis in the discussion board forum of the patient’s pathology, how that pathology contributed to the symptoms and discuss treatment. The professor will provide a short explanation of the case the following week as well as help guide student discussion. Clinical Cases are provided solely to enhance student educational experience and participation is OPTIONAL. 5 extra credit points will be awarded per Clinical Case Discussion Board Post that either answers the questions posed or substantively contributes to class discussion (limit 5 points per week/topic). Clinical Cases will be open for discussion/extra-credit for exactly one week after they are posted (credit WILL NOT be given to late posts). USING THE AMA FORMAT The AMA format is widely used for citing sources in medical research. This information, created by the American Medical Association, is taken from AMA Manual of Style: A Guide for Authors and Editors (10th Edition). For additional guidelines, please consult the manual at the Client Services Desk of the Medical Sciences Library. CITATIONS IN THE BODY OF THE PAPER Cite each source in numerical order using superscript Arabic numerals (1, 2, 3…). Put these numerals outside commas and periods, and inside semicolons and colons (see examples below). Put a comma (no space in front) between the numbers for multiple citations (see Example 2). Join a closed series with a hyphen (see Example 3). Example 1: A review of regulations has been complete by the WHO. 15 Example 2: The data were as follows 3.4. Example 3: As previously reported, 11-1425 CITATIONS IN THE REFERENCE LIST At the end of the document, list references numerically in the order by which they were cited in the text. Single-space within citations and double-spaces between citations. (Cite references parenthetically in the text if a work is not yet accepted for publication or is a personal communication. See AMA Manual of Style, 10th Edition, for more specifics.) BOOKS Book with One Author: 1. Sacks O. Uncle Tungsten. New York, NY: Alfred A Knopf; 2001. Book with Two to Six Authors: Separate the authors’ names using a comma. Book with Seven or More Authors: List the first three authors, and then put “et al.” Book with an Editor: 2. Galanter M, ed. Services Research in the Era of Managed Care. New York, NY: Kluwer Academic/Plenum; 2001. Book by an Organization: 3. World Health Organization. Injury: A Leading Cause of the Global Burden of Disease, 2000. Geneva, Switzerland: World Health Organization; 2002. Book of Second or Later Edition: 1. Adkinson N, Yunginger J, Busse W, Bochner B, Holgate S, Middleton E, eds. Middleton’s Allergy: Principles and Practice. 6th ed. St. Louis, MO: Mosby; 2003.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource