How Doctors Miss Femoral Neck Fractures

What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery
by Ronald P. Grelsamer, M.D.

(Page 6 of 6)

“Can you believe they missed my mother's fracture over at City General? Sent her right out of the emergency room!!!

We took her to County General a few days later, where they said the fracture was very clear.”

If I had a dollar for each time I've heard this story... So how does this happen?

First of all, missed fractures occur in every part of the body. And the reason is simple: They don't necessarily show up initially. They start off as a tiny, invisible crack. The body's initial response to a fracture is to “resorb” bone at the edges of the fracture; i.e., bone at the edge of the fracture is taken away.

Remember: Bone is a living tissue that is constantly breaking itself down and rebuilding. This resorption of bone at the fracture edges leads the fracture to temporarily widen, thus making it more visible. Consequently, a fracture is sometimes more visible on Day 4 than it is on the day of the injury.

For many parts of the body, missing a little fracture is of no great importance. If the doctor treats you for a bad bruise of the shoulder or a bad sprain of the ankle, the treatment will be the same as for a small, hard-to-see fracture. But the hip is different- at least the femoral neck portion of the hip. A small crack across the femoral neck can be treated with pins that look like knitting needles. These are put in through a small skin incision, the blood loss is negligible, you can put all your weight on the leg immediately, and healing is essentially guaranteed.

If you are young and healthy enough, it can be an out-patient procedure. If the crack goes unrecognized, however, the neck of the hip can snap in two. Now you need a hip replacement- a very different operation. It is, therefore, critical for emergency room doctors to detect the slightest fracture of the femoral neck. The way for them to do so in the twenty-first century is to obtain an MRI. The MRI is the most sensitive test for a hip fracture; in other words, it is the test most likely to detect a fracture. Although I've gone on record as stating that MRIs are seriously abused in the United States, the finding of a normal X-ray in the face of severe hip pain readily justifies an MRI.

Orthopedists as well as a growing number of emergency room doctors will, therefore, quickly resort to an MRI in this setting. If you are not able to undergo an MRI, a CT scan is the next best option.

Patient Satisfaction Is In the Eye of the Beholder

Who is more satisfied with her hip replacement? The patient suffering from arthritis or the one who's broken her hip? The one with arthritis.

The patient with arthritis has been suffering a long time. Pain walking. Pain going up and down stairs. Pain clipping toenails and putting on socks. Any significant relief is welcome.

If the pain score goes down from a 10 to a 3, the patient thanks his lucky stars. If the operated leg is a little long, so be it. Not so the patient with a hip fracture. The day before sustaining her fracture, Mrs. Smith had no pain whatsoever in her hip. Her leg lengths were identical. She expects the surgeon to return her to that exact state, especially if she is relatively young.

A pain score of 3 is not as acceptable nor is a slight difference in her leg lengths. Also, in the setting of a fracture the surgeon hasn't had the time to review these subtleties with his new patient (nor has the patient had the time to read this book!).

Summary: Arthritis is the number one condition necessitating a total hip replacement. Partial hip replacements are most commonly used for hip fractures. AVN is relatively uncommon compared to arthritis and hip fractures. Both total and partial hip replacements are utilized for this condition.

Copyright © 2004 by Ronald Grelsamer, M.D.

About the Author

RONALD P. GRELSAMER, M.D., is the chief of hip and knee reconstruction at Maimonides Medical Center, and a staff orthopaedic surgeon at the NYU Hospital for Joint Diseases/Orthopaedic Institute.