The Complexity of Missed Fractures and Postural Instability in an Elderly Fall Patient: A Case Study

Title: The Complexity of Missed Fractures and Postural Instability in an Elderly Fall Patient: A Case Study

Introduction: Falls in the elderly population are a significant cause of morbidity and mortality, often leading to fractures, reduced mobility, and decreased quality of life. Diagnosing fractures can be challenging, particularly in frail or cognitively impaired individuals who may not report or recognize pain, or when the fracture is subtle on initial radiographs. Missed fractures, combined with postural instability, present unique challenges for clinicians, requiring a multi-faceted approach to both diagnosis and management. This case report describes a complex scenario where an elderly woman with recurrent falls was initially misdiagnosed, leading to a missed fracture, and highlights the importance of comprehensive assessment in managing falls and postural instability.

Case Presentation: Mrs. A is a 78-year-old woman with a history of osteoporosis, hypertension, and mild cognitive impairment, who presented to the emergency department following a fall at home. She was living independently but had a history of recurrent falls, usually associated with tripping or imbalance. On examination, she was alert but appeared frail, with slight difficulty in maintaining her balance while standing. Her gait was slow, and she had a slight forward lean while walking, consistent with postural instability. Despite the history of falls, she denied significant pain, stating that she "felt a little sore" but could not pinpoint the exact location.

Her vital signs were stable, and an initial assessment did not reveal any obvious deformities or signs of acute injury. A physical exam revealed mild tenderness in her right hip region but no obvious swelling or bruising. Given her frailty and cognitive impairment, the initial diagnosis was made of a simple fall without fracture, and she was discharged with advice on managing falls and referrals to physiotherapy for postural stability exercises.

Missed Diagnosis and Delayed Identification: One week after discharge, Mrs. A returned to the emergency department with worsening pain in her right hip. She was now unable to bear weight on that leg. The attending physician ordered an X-ray, which revealed a non-displaced intertrochanteric fracture of the right femur, which had been missed in the initial examination. The fracture was subtle, and the initial X-ray taken during her first visit had not been adequately reviewed, given her relatively minor complaint of pain and the assumption that her symptoms were simply due to soft tissue injury from the fall.

Upon further questioning, Mrs. A mentioned that she had been experiencing difficulty getting out of bed and walking around her home for several days. She also complained of occasional sharp pain when attempting to walk, but it had not been severe enough for her to report immediately. A CT scan confirmed the presence of a minimally displaced fracture, which required surgical intervention.

Management: Upon the diagnosis of the missed fracture, a multi-disciplinary team was assembled to plan her treatment. Given her age, cognitive impairment, and history of osteoporosis, a conservative approach with surgical fixation was deemed appropriate. The orthopedic team performed a closed reduction and internal fixation (CRIF) of the femoral fracture under spinal anesthesia. Postoperatively, Mrs. A was started on analgesia, calcium and vitamin D supplementation, and a bone-protecting regimen with bisphosphonates.

Simultaneously, a geriatric assessment was carried out to evaluate her postural instability. Mrs. A was found to have a significant fall risk due to a combination of factors including frailty, muscle weakness, impaired proprioception, cognitive decline, and medication side effects (mainly from antihypertensives and her long-term use of sedatives for sleep).

A comprehensive fall-prevention program was initiated, including:

• Physiotherapy: Focused on strength training, balance exercises, and gait retraining.
• Occupational therapy: Provided recommendations for home modifications, such as grab bars, non-slip mats, and ensuring clear pathways to reduce fall risk.
• Cognitive support: Mrs. A was referred for cognitive rehabilitation to address her mild cognitive impairment, which was contributing to poor judgment and a lack of awareness of her fall risk.
• Pharmacological Review: A review of her medications was conducted to discontinue any drugs that could contribute to dizziness or sedation, such as benzodiazepines, and to optimize her antihypertensive regimen.

Outcome: After three months of rehabilitation, Mrs. A regained functional mobility, with improvements in her balance and gait. Her pain from the femoral fracture was well-managed, and she was able to ambulate with the assistance of a walker. She no longer experienced the frequent falls she had prior to her fracture and had become more aware of her limitations. She was also more compliant with her fall-prevention program, including home modifications, physical therapy, and cognitive support.

Discussion: This case underscores the complexity of diagnosing and managing falls and fractures in older adults, particularly when the initial symptoms are vague and non-specific. The missed diagnosis of the intertrochanteric fracture highlights the importance of comprehensive and meticulous evaluation, including proper radiographic assessment and clinical examination, even when the initial presentation seems mild.

In the elderly, fractures often go undiagnosed, as pain may be underestimated or overlooked, particularly in patients with cognitive decline. Additionally, the presence of postural instability complicates both the diagnosis and the management of such fractures, as these patients often have multiple risk factors contributing to falls, including osteoporosis, muscle weakness, medications, and environmental hazards.

This case also emphasizes the importance of a multi-disciplinary approach in managing elderly patients with falls and fractures. Geriatric teams, including orthopedic surgeons, physiotherapists, occupational therapists, and geriatricians, must work together to create a tailored, holistic care plan that addresses not only the acute injury but also the underlying risk factors for falls, to prevent recurrence and improve long-term outcomes.

Conclusion: Missed fractures in elderly patients are a common and potentially devastating complication of falls. This case demonstrates the need for heightened clinical suspicion and thorough assessment, especially in patients with postural instability or cognitive impairment. A comprehensive, multi-disciplinary approach that addresses both the acute injury and the underlying causes of falls can significantly improve outcomes and reduce the risk of recurrent falls and fractures in older adults.

This case serves as a reminder to clinicians of the importance of considering fractures in the differential diagnosis of falls, even when pain and physical findings are subtle, and highlights the need for ongoing efforts in fall prevention and postural stability training to improve the health and safety of elderly patients.

Key Learning Points:

1. Falls in older adults are often under-reported, especially when there is cognitive impairment or a subtle injury.
2. Missed fractures, particularly in the hip, are common in the elderly and can lead to delayed treatment and worse outcomes.
3. A multi-disciplinary approach that includes physiotherapy, occupational therapy, medication review, and cognitive support is crucial in managing falls and preventing fractures in the elderly.
4. Proper fall risk assessment and postural stability interventions are essential components of a comprehensive fall-prevention strategy