An 87-year-old Japanese woman was transferred to our emergency room with a right hip pain after she fell in her nursing home in April 2020. In Japan, up to 5000 patients were COVID-19 positive, the beginning of COVID-19 outbreak, and one-fifth of patients were from our province at the time. She had past history of controlled arrhythmia and had no dementia. She had no history of fever, fatigue, or respiratory symptoms within the 14 days before presenting to our hospital. Physical examination on admission revealed: body temperature, 36.8 C, peripheral oxygen saturation (SpO2), 94% under room air; respiratory rate, 16 breaths/min; blood pressure, 169/66 mmHg; and heart rate, 57 beats/min. Tenderness was noted in the right Scarpa's triangle and greater trochanter of the femur, accompanied by limited range of hip motion due to pain. Blood testing showed elevations in C-reactive protein (0.55 mg/dL) and white blood cell count (12,000 cells/mm2) with neutrophilia (80.3%) and lymphopenia (14.3%). Radiography showed right femoral intertrochanteric fracture (AO/OTA classification: type 31-A2.3) (Figure 1A,B), and only 2 nodular shadows in the upper lobe of the left lung (Figure 1C). Given the global COVID-19 pandemic, chest computed tomography (CT) was performed on admission and showed ground-glass opacities with consolidation in the dorsal segment of the right lower lung field. From this CT image, aspiration pneumonia was speculated as a diagnosis (Figure 1D-I). However, to confirm whether the pneumonia was due to COVID-19, qualitative real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay testing for severe acute respiratory syndrome coronavirus (SARS-CoV-2) from nasopharyngeal swabs was carried out, yielding a positive result. Femoral intertrochanteric fracture with concomitant COVID-19 infection was thus diagnosed.
Because of the infection, conservative treatment was applied to the fracture and delayed operation was planned. Rehabilitation under partial weight-bearing was started after hospital admission. On day 2, temperature increased to 37.4 C, and low SpO2 (<90%) appeared, required supplemental oxygen (1 L/min) by day 5. The patient recovered from the disease and was free of oxygen by day 10, and RT-PCR testing yielded negative results on both day 14 and day 16. Full weight-bearing was permitted from day 14. At this moment, the patient was able to ride a wheelchair and she had no hope for surgical treatment. Therefore, conservative treatment was continued. No recurrence of positive RT-PCR was seen on day 28, and she was returned to her welfare facility, able to use a wheelchair as she had before. Treatment was ongoing and she showed no other complications such as infection, dementia or deep vein thromboses. Throughout the treatment period, no cross-infection from the patient was identified in our hospital.
This case report was produced in accordance with the CARE reporting guidelines.