Simulated Patient Scenario

Elderly Fall with Suspected Neck of Femur Fracture

Scenario Details

Scenario: Elderly Fall - Suspected Right Neck of Femur (#NOF) Fracture

Simulated Patient: 88-year-old Mannequin (Elderly Face Overlay if available)

Actor/Actress: Son/Daughter (present on scene, provides history)

MDT Information

Non-urgent response - Fall
88-year-old female fallen at home
Unable to get up, complaining of hip pain
? Hip fracture
Patient is on the floor

On Arrival

Patient is lying on the floor in the hallway between the bedroom and bathroom. She is supine, with her right leg visibly shortened and externally rotated. Her son/daughter is kneeling beside her, looking distressed. There are no obvious hazards around the patient.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Appears distressed, guarding right hip.
Response	Awake but appears confused, moaning with pain. (AVPU = V)
Airway	Clear and self-maintaining.
Breathing	Respirations appear slightly fast but unlaboured.
Circulation	Skin looks pale, feels warm. No obvious external bleeding.
Disability	Obvious deformity of the right lower limb, unable to move it.
Exposure/Environment	Indoor home environment, floor is cool. Patient wearing nightclothes.

Secondary Survey and Simulation Progression

History

Allergies	NKDA (No Known Drug Allergies)
Medications	Perindopril 5mg daily, Atorvastatin 40mg nocte, Apixaban 5mg BD, Alendronate 70mg weekly.
Past Medical History	Osteoporosis, Hypertension, Atrial Fibrillation, Mild Cognitive Impairment, History of 2 falls in the past year (no previous fractures).
Last Oral Intake	Small bowl of cereal and tea, approximately 4 hours ago.
Events Preceding	Son reports he found her on the floor this morning when he arrived for his daily visit. She stated she fell during the night on the way to the bathroom. She remembers falling but details are unclear. Complained immediately of severe right hip pain and couldn't move.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	22
Lung Sounds (L/R)	Clear bilaterally
SpO2 (%)	96% (Room Air)
EtCO2 (mmHg)	N/A
Pulse Rate (/min.)	95, Irregular
CRT (sec.)	< 3 sec
ECG rhythm	Atrial Fibrillation
12-lead ECG	Atrial Fibrillation, no acute ischaemic changes.
BP (mmHg)	145/80
Skin	Pale, warm, dry.
Pain (/10)	9/10 (Patient able to point to number scale, moans frequently). Consider PAINAD/Abbey if unable to rate.
GCS (/15: E,V,M)	14/15 (E4, V4 - confused, M6)
BGL (mmol/L)	6.5
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive
Pupil reac. (L/R)	Equal and Reactive
Temp. (°C)	36.7

Physical Examination

Right Lower Limb: Obvious shortening and external rotation compared to the left leg. Significant tenderness on palpation over the greater trochanter and inguinal region. Unable to lift leg or tolerate passive movement.
Neurovascular Status (Right Foot): Distal pulses (dorsalis pedis/posterior tibial) palpable and strong. Capillary refill < 3 seconds. Sensation intact to light touch. Able to wiggle toes slightly when prompted (assess motor function cautiously).
Head-to-Toe: Check for other injuries associated with the fall (head injury, wrist fracture, spinal tenderness). No other obvious injuries noted on initial assessment.

Assessment and Treatment

Appropriate Management

Primary survey (ABCDE) and immediate life threats.
Effective teamwork and communication (with partner, patient, family). Use clinical pauses.
Thorough history taking (AMPLE) from patient and family member.
Systematic assessment including head-to-toe examination and neurovascular assessment of the affected limb.
Obtain and monitor vital signs frequently.
Pain Management: Prioritise early and effective analgesia.
- Consider Methoxyflurane (if not contraindicated).
- IV Paracetamol.
- IV access establishment.
- Consider IV opioids (e.g., Fentanyl titrated dose, or Morphine) cautiously due to age, frailty, and cognitive impairment. Note Apixaban use - low risk for IV opioids but relevant if considering regional blocks/surgery.
- (If protocols allow and trained: Consider Fascia Iliaca Compartment Block).
Immobilisation: Keep patient comfortable. Support the injured leg with pillows/blankets in the position found. Avoid unnecessary movement. Do NOT apply traction splint. Consider vacuum splint if available and tolerated for extrication.
Fluid Therapy: IV fluids if hypotensive or signs of shock, administer cautiously to avoid fluid overload. Maintenance fluids may be appropriate depending on transport time.
Maintain patient warmth (blanket).
Pre-notify receiving hospital (potential #NOF, elderly, anticoagulated, relevant history).
Careful extrication minimising movement of the hip (e.g., scoop stretcher).
Ongoing reassessment of vital signs, pain score, and neurovascular status.
Clear communication and reassurance provided to the patient and son/daughter.