One rainy evening, it was nearing 8pm and Mr OG wanted to show his gratitude and support for the NHS heroes who were risking their lives during the Covid-19 pandemic. Driven only by this motive, he ignored his osteoarthritic hip and struggled with his walking frame to the garden to clap for the NHS heroes.

Unfortunately, he lost his balance and fell over in the rain. Unable to stand or weight bear, he had to lie outside until the ambulance crew arrived. With the obvious deformity to his leg, he was taken to hospital with a suspected hip fracture.

Every fall is a story and every story have a beginning, a middle and an end. Colleagues always ask me why I spend so much time asking people how they fell and what were they doing before the fall. This is an important source of intelligence for me about which activities to avoid when I get older.

Activities currently on the list include: emptying the bin; walking the dog; picking up the post; tying shoes laces, closing the curtains and hugging grandchildren. With such an extensive list, I worry about how restricted my activities will be in older age as I attempt to avoid a hip fracture.

Since the days of Dr Bobby Irvine and Mr Michael Devas, the cofounders of orthogeriatric care in the 1950s, the key to success has been teamwork. The humble carpenter can provide the best biomechanical outcome, but needs a physician to tell them what’s wrong with the patient. All good stories need a rich vein of characters to contribute to the plot and this is reflected in our modern multidisciplinary approach to care.

 

A&E

 

Case study

The story (journey) of Mr OG started with the ambulance crew securing an IV line and giving the painkiller which relieved his agony. When he arrived in the A&E department, the neck of femur advanced nurse practitioner was immediately alerted. He was then assessed by the trauma and orthopaedics team, physiotherapy and occupational therapy rapid response teams.

Further pain management with nerve block was given in A&E and he was assessed by a geriatrician. This assessment focused on the possible cause of the fall including orthostatic hypotension, osteoarthritis, medication reviews and environmental factors.

Following this, his ECG, chest and pelvis X-rays were reviewed and a pre-operative fitness assessment was taken focusing on cardio-respiratory morbidities.

He also had a FRAX (fracture risk assessment tool) assessment, which is a diagnostic tool used to evaluate the 10-year probability of bone fracture risk, and plans for bone protection were done. An anaesthetist also assessed the patient and planned for spinal anaesthesia. Mr OG & his wife were kept updated about progression of care and he consented for the surgery early the next morning.

Sometimes we develop a particular kind of unconscious (unbiased) relationship with the patients that we care for. This was the case for Mr OG who fell whilst trying to show his appreciation to the NHS and its staff.

The integrated pathway for neck of femur fractures is very fair, clear and comprehensive. It covers all aspects of care starting from calling 999, pain management such as a fascia iliaca nerve block, right through to rehabilitation and discharge planning. Mr OG went through this journey safely and was discharged home with reablement support.

 


By Dr Abdulmugeet Hassan, MRCP, SCE, DGM (Geriatric Medicine)
Advanced Clinical Fellow, Orthogeriatric, New Cross Hospital, The Royal Wolverhampton NHS Trust