1. Matthew Augusta OMSIV – University of New England College of Osteopathic Medicine
2. Jared Lutsic OMSIII – Michigan State University College of Osteopathic Medicine
3. Seth Lutsic OMS1 – Campbell University School of Osteopathic Medicine
4. Brandon Lentine MD – Kent Hospital Department of Orthopedic Surgery

Abstract

Introduction
The worldwide annual incidence of femur fractures is estimated to be over 6.26 million by 2050. There is an 84.4% mortality associated with these fractures without surgical intervention. Surgery within 48 hours of admission results in a significant decrease in mortality. Intertrochanteric fractures are common among the elderly. Reports on treatment of centenarian hip fractures are limited in this particularly frail subset of patients.

Case
A 104-year-old female with chronic kidney disease and severe aortic stenosis presented status-post mechanical fall complaining of left hip pain. Vitals were significant for hypertensive urgency at 196/65. On exam, the left hip was tender to palpation, and the left leg was shortened and externally rotated. Distal pulses were intact. X-ray revealed a left reverse oblique intertrochanteric fracture of the left femur. The fracture was treated with an intramedullary nail. She returned to baseline ambulation.

Conclusion
Limited data exists on intertrochanteric fractures in patients over 104 years old. Surgical intervention can provide a safe and effective return to baseline functional status.

Keywords: Centenarian, intertrochanteric fracture, elderly, super elderly, intramedullary nail, cephalomedullary nail

Introduction
The worldwide annual incidence of hip fractures is estimated at over 6.26 million by 2050. (1) There is a 84.4% mortality associated with these fractures. Surgery within 48 hours of admission results in a significant decrease in mortality: 30%. (2) Intertrochanteric fractures are common among the elderly, especially females with a female to male ratio up to 8:1. (3) Reports on treatment of centenarian hip fractures are limited in this particularly frail subset of patients. In review of literature, no case reports were published about utilizing an intramedullary nail in a patient who was 104 years old.  

Case Presentation
A 104-year-old female with history of chronic kidney disease and severe aortic stenosis presented status post mechanical fall down three stairs complaining of left hip pain. Initial vitals were significant for hypertensive urgency at 196/65. On exam, the left hip was tender to palpation, and the left leg was shortened and externally rotated. Areas of bruising were found along the lateral left hip. Distal pulses were intact with no peripheral edema. There was no focal or global neurological deficit, however the patient was alert to only person and place. A non-contrast CT scan was performed to rule out a brain bleed. Multiple radiographic views of the left hip demonstrated a reverse oblique intertrochanteric fracture of the left femur (Figures 1,2,3). Her blood pressure was controlled utilizing hydralazine and amlodipine. Orthopedic surgery was consulted, and after detailed discussion with the patient, her son as power of attorney, and the medical team, surgical intervention with an intramedullary nail was chosen as the treatment with the goal of returning her to her baseline status as ambulatory and independent in activities of daily living. She was given cefazolin as skin and soft tissue infection prophylaxis.

In the operating room, traction and internal rotation were used to reduce the fracture to anatomic length. The guidewire was passed to the level of the mid-patella with subsequent reaming. A long intramedullary nail was placed and fixed proximally with a lag screw centered in the femoral head and bicortical purchase with the distal interlock (Figures 4,5,6,7). The patient received postoperative occupational and physical therapy while in the hospital. She was discharged on post-operative day four to a local rehab facility. She missed her follow-up appointment with orthopedics. On follow up with PCP two months later, she was continuing therapy and had returned to baseline ambulation.

Discussion
A detailed review of Pubmed and University of New England online library databases utilizing the key words “intertrochanteric hip fracture,” “centenarian,” and “intramedullary nail” yielded no published case reports on utilization of an intramedullary nail in a patient over 102 with an intertrochanteric hip fracture. It also revealed limited studies on centenarians with proximal femur fractures. Due to its unstable nature and potential effect on mortality, intertrochanteric fractures must be diagnosed and corrected quickly. It is recommended that the decision for operative vs nonoperative treatment be the at the determination of the physician based on fracture type, prefracture mobility and functional status, and comorbidities. (4) Operative management is associated with shortened hospital stay, improved rehabilitation, and decreased mortality in patients over 100. (5,6,7,8) This case report demonstrates the viability of intramedullary nailing as an effective and safe course of treatment for centenarians with intertrochanteric fractures. It also highlights the importance of treating patients based on their current status and not based on their age as a number. Though age has been historically cited as a risk factor on its own, but recent studies have shown comorbidities are the true drivers of increased risk. (9) However, other studies have shown that the injury itself is responsible for the morbidity risk in patients over ninety. (10) Thus, treatment course should always be decided in conjunction with the medical team, the patient, and the family if pertinent.

Clinical Message
This case report was written to highlight the importance of treating a patient based on their current status and not based on their age. It also provides a case showing the safety and effectiveness of utilizing an intramedullary nail in the treatment of intertrochanteric fractures in a centenarian, specifically one at the age of 104 years old.

Consent
Consent was obtained from the patient’s power of attorney, her son. It has also been approved by the IRB at the University of New England.

The authors declare that they have no competing interests.

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5 | Figure 6 | Figure 7

References

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