Treat the effect but never forget the cause !

Clinical scenario: 

             An elderly male was admitted in a hospital with severe pain in left hip and inability to stand up . On rounds the consultant saw the posture of the left leg Fig.1 and exclaimed " This is fracture  neck of femur !  while  pointing  to  externally rotated limb as shown in Fig 1 by red arrow 

Fig.1 Externally rotated limb in fracture neck of femur .

An X ray was done and  patient was scheduled for  surgery next day  .

Fig 2 X ray hip showing  fracture neck of femur on left side  

However, the vigilant resident had a detailed history from the patient. Patient denied history  offending drug, any chronic medication , steroids in particular but admitted having fainting spells of few days duration.

Examination: 

Patient was conscious , oriented in time place and person . Pulse was 72/min, it was irregular .There was no radio femoral delay and it had no special character .

Why irregular pulse ??? 

He  ordered an ECG fig 3 . 

Fig 3 ECG showing 3rd degree heart block 

ECG  showed 3rd degree heart block . Cardio consult was taken and a  temporary pacemaker was placed  before shifting him to operation room .
He  was operated (Hemi arthoplasty )and had uneventful postoperative course  . 

Later a  permanent pacemaker was implanted  .On discharge The patient walked out of the hospital  walking  .He had a successful surgery in the hip a pacemaker in the heart and a big  smile on the  face .

So the sequence of symptoms was very important to treat the patient .It was syncope due to heart block that lead to fracture neck of femur.
Fracture neck of femur :
It can occur in two settings
1.Elderly people with osteoporosis  and people on chronic steroid use are more prone to develop fracture neck of femur with minimum trauma
2. Active individuals with unaccustomed strenuous activity or changes in activity, such as runners or endurance athletes are also prone to develop fracture neck of femur 

Third  degree AV block frequently is associated with symptoms such as fatigue, dizziness, light-headedness, presyncope, and syncope most commonly. 

Syncopal episodes due to slow heart rates are called Adams-Stokes (AS) episodes, in recognition of the pioneering work of these researchers on syncope. 

Patients with third-degree AV block may have associated symptoms of acute myocardial infarction either causing the block or related to reduced cardiac output from bradycardia in the setting of advanced atherosclerotic coronary artery disease.

Any level of atrioventricular block leading to profound bradycardia may also lead to life-threatening torsades de pointes.

Permanent pacing is the therapy of choice in advanced AV block, and it does not require concomitant medical therapy. 

Take home message : 

Be a competent  team member and never ignore the cause while treating any clinical condition . 

For teaching purpose this case was contributed by 

Dr Shiekh Neyaz Ahmad

Dept of Orthopedics

Armed Forces Hospital

Abha Saudi Arabia 

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