MSGM Clinical Case Discussion March 2026

Hip fracture and multiple unstable comorbidities in an octogenarian - a conundrum for surgery

Prepared by: Dr Sofiatulakmal binti Ashari

Supervised by: Dr Yusliza Azreen binti Mohd Yusoff

Puan Z, an 82-year-old lady with Type 2 Diabetes Mellitus, Hypertension,

Dyslipidaemia, and Ischaemic Heart Disease complicated by Non-Valvular Atrial

Fibrillation; on Apixaban, Bisoprolol, and Frusemide had multiple admissions in 2025 for acute decompensated heart failure, predominantly precipitated by pneumonia.

During this admission, she presented following a fall on 5 January 2026 while

ambulating from the bathroom to her bed. She struck the edge of the bed and fell forward, landing in a seated position. There was no loss of consciousness or head injury. She developed immediate right hip pain and was unable to weight bear. She was brought to the Emergency Department of Hospital Raja Perempuan Zainab II. On arrival, she was haemodynamically stable, with a pain score of 5/10. Examination was limited by pain but showed restricted right hip movement. Pelvic radiography confirmed a closed right femoral neck fracture extending to the lesser trochanter. She was admitted under the Orthopaedic

team on 6 January 2026 for definitive surgical management and multidisciplinary

perioperative optimisation.

She was referred to the Geriatric Medicine team for comprehensive preoperative

assessment. She was noted to have delirium during assessment. Collateral history was/ obtained from her daughter. Prior to admission, she was independently mobile without assistive devices, despite a history of recurrent falls. She was independent in basic activities of daily living and able to perform light household tasks. However, progressive cognitive decline was noted where duration of symptoms were unclear. In the weeks before admission, she developed increasing fatigue and intermittent exertional dyspnoea.

On examination, she was comfortable at rest. Her visual acuity revealed only finger counting. Speech was fluent but inappropriate, and she was disoriented to time and place. She was edentulous and using dentures. She was haemodynamically stable, with capillary blood glucose of 6.1 mmol/L. Respiratory examination revealed minimal scattered crepitations with good air entry bilaterally. Cardiovascular examination revealed a systolic murmur loudest at

the apex with radiation to the axilla. The abdomen was soft and non-tender. Baseline investigations showed a white cell count of 5.65 × 10⁹/L and haemoglobin of 13.7 g/dL, with thrombocytopenia (platelets 102 × 10⁹/L). Renal function was markedly impaired, with an estimated creatinine clearance of 19 mL/min. Electrocardiography demonstrated atrial fibrillation with a ventricular rate of approximately 96 beats per minute, without acute ischaemic changes. Chest radiography showed cardiomegaly. A prior computed tomography brain scan (October 2025) revealed left frontal hypodensities consistent with chronic small

vessel ischaemic changes. Given her significant cardiac comorbidities and high perioperative risk, urgent transthoracic echocardiography was arranged for further risk stratification.

On day four post-trauma, she developed acute dyspnoea with oxygen desaturation to 88–90% on room air. Examination revealed reduced air entry bibasally, elevated jugular venous pressure, and bilateral pitting oedema. Cardiac monitoring showed atrial fibrillation/ without ischaemic changes. Arterial blood gas demonstrated compensated metabolic acidosis with respiratory alkalosis and elevated lactate, while chest radiography showed cardiomegaly with interstitial oedema. She was diagnosed with recurrent acute decompensated heart failure.

Intravenous frusemide 40mg improved her urine output and oxygenation. Although pulmonary embolism was suspected, computed tomography pulmonary angiography excluded embolism and confirmed pulmonary oedema with pericardial effusion. Echocardiography was arranged, and diuretics were continued. Urgent transthoracic echocardiography demonstrated severely reduced left ventricular systolic function, with an estimated ejection fraction of approximately 30%. There was biatrial enlargement and right ventricular dilatation. A small circumferential pericardial effusion (maximum 1.4 cm) was

present without echocardiographic features of cardiac tamponade. Valvular assessment revealed mild mitral regurgitation and moderate tricuspid regurgitation, with otherwise structurally normal valves. No vegetations or intracardiac thrombi were identified. In the context of recurrent acute decompensated heart failure and severe systolic dysfunction, she

was deemed to be at very high perioperative cardiac risk.

She underwent right dynamic hip screw fixation on 14 January 2026 under general anaesthesia after 9 days of trauma. Intraoperatively, she developed haemodynamic instability due to atrial fibrillation with rapid ventricular response, with heart rates up to 130 beats per minute. Intravenous inotropic support and an amiodarone infusion were initiated for rate control. Haemodynamic stability was subsequently achieved, with ventricular rate reduced to below 100 beats per minute, allowing completion of the two-hour procedure. Intraoperative

findings confirmed a closed right femoral neck fracture extending to the lesser trochanter. Postoperatively, she was transferred to the Intensive Care Unit (ICU) for close monitoring and further management.

During her Intensive Care Unit (ICU) stay, she showed steady improvement and was successfully extubated. Oxygen was weaned from 60% Venturi mask to 3L/min via nasal prongs, with arterial blood gas confirming adequate oxygenation. She tolerated oral intake, noted to have improving delirium, and reported minimal pain. She was transferred to the orthopaedic ward on 17 January 2026. Postoperative pain was controlled with oral analgesia Radiography confirmed satisfactory implant positioning, and wound inspection on day three

was unremarkable. Delirium resolved, and she participated in physiotherapy with wheelchair mobilisation. She was discharged home stable on 19 January 2026 with follow-up arranged.

DISCUSSION

1. Was this genuinely a mechanical fall, or was it a manifestation of underlying cardiac instability?

2. What is the dominant cause of risk in this patient? Is it frailty, cardiac dysfunction or acute delirium?

3. Was surgery truly the best option, or should non-operative (palliative) management have been considered?

4. Should surgery be delayed for cardiac optimisation or is early surgery still the safer option?

5. How do we balance cardiac instability verses risks of prolonged immobilisation

(delirium, pneumonia, VTE, pressure injuries)?

6. How should we optimize heart failure with reduced ejection fraction in the presence of delirium?

7. Is delirium a reason to delay hip fracture surgery or a reason to expedite it?

8. What is the cause of the pre operative delirium? How aggressively should we

investigate?

9. Was general anaesthesia the optimal choice for this haemodynamically fragile

patient?

10. How should anticoagulation be managed perioperatively in severe renal impairment (CrCl 19mL/min) and thrombocytopenia?

11. What is the realistic rehabilitation trajectory in a patient with EF 30% and recent ADHF?