In an 87‑year‑old woman with left hip pain and a possible impacted femoral neck fracture on X‑ray, left ventricular hypertrophy on ECG, markedly elevated NT‑proBNP, normal troponin I, elevated C‑reactive protein and D‑dimer, and low‑normal vitamin D, what are the likely diagnoses and recommended management?

Likely Diagnoses and Management

This 87-year-old woman most likely has an impacted femoral neck fracture requiring urgent MRI confirmation and surgical fixation, with concurrent heart failure (likely HFpEF given LVH and markedly elevated NT-proBNP) that necessitates cardiology optimization before surgery.

Primary Diagnosis: Hip Fracture

Diagnostic Approach

The "possible impacted fracture" on plain radiograph in an elderly patient with hip pain is a red flag requiring immediate advanced imaging 1. Plain radiographs can miss occult hip fractures in up to 10% of cases, particularly impacted or basicervical fractures. Order an MRI of the left hip immediately - this is the gold standard for detecting occult fractures and will show bone marrow edema and fracture lines not visible on X-ray 1, 2.

Critical pitfall: Do not send this patient home with "possible" fracture on imaging. The case evidence shows patients with initially negative or equivocal radiographs who returned days later with worsened pain had confirmed fractures on MRI 1. Delayed diagnosis risks fracture displacement and worse outcomes.

Surgical Management

Once fracture is confirmed:

• Proceed to surgery within 24-48 hours after medical optimization 1
• For impacted femoral neck fractures, treatment options depend on displacement and patient factors 1
• Use multimodal analgesia including peripheral nerve block (iliofascial block) for pain control - this has strong evidence for improved outcomes 1
• Administer tranexamic acid at surgery start to reduce blood loss and transfusion needs 1
• Allow immediate weight-bearing as tolerated postoperatively 1

VTE Prophylaxis

Mandatory VTE prophylaxis for 4 weeks postoperatively - use enoxaparin or other anticoagulation 1. This has strong recommendation strength given high thrombotic risk in elderly hip fracture patients.

Secondary Diagnosis: Heart Failure

Cardiac Risk Assessment

The NT-proBNP of 3569 pg/mL is markedly elevated and indicates significant cardiac dysfunction 3. Research specifically in hip fracture patients shows:

• NT-proBNP >600 pg/mL predicts postoperative cardiac complications with 79% sensitivity and 81% specificity 3
• This patient's level is nearly 6-fold above that threshold
• Odds ratio of 13 for cardiac complications with NT-proBNP >600 pg/mL 3

The combination of LVH on ECG + elevated NT-proBNP + normal troponin suggests chronic heart failure, most likely HFpEF (heart failure with preserved ejection fraction) given the LVH pattern 4. This patient is at minimum Stage B (Pre-HF) with structural heart disease, possibly Stage C if she has any dyspnea or exercise intolerance 4.

Preoperative Cardiac Optimization

Obtain urgent cardiology consultation before surgery 1. Specific workup needed:

• Echocardiogram to assess ejection fraction, diastolic function, and valvular disease 5
• Assess volume status - elevated NT-proBNP with LVH suggests possible fluid overload
• Optimize diuretics if volume overloaded
• Continue beta-blockers if already on them; consider starting if not contraindicated
• Do NOT delay surgery >48 hours - the goal is rapid optimization, not perfect optimization 1

Additional Considerations

Inflammatory Markers

CRP 44 mg/L and D-dimer 13 mg/L are both elevated but non-specific in this context:

• Elevated in acute fracture due to tissue injury and inflammatory response
• D-dimer elevation is expected with trauma and does not indicate PE in this setting without other clinical signs
• These do not change management but document baseline inflammatory state

Vitamin D and Bone Health

Vitamin D at 35 nmol/L (assuming units) is low-normal to insufficient 6, 7:

• Draw vitamin D, calcium, PTH, and parathyroid hormone levels during hospitalization 1
• Order outpatient DEXA scan for osteoporosis assessment 1
• Refer to Orthopedic Bone Health Clinic for long-term osteoporosis management - this has strong evidence for preventing future fractures 1
• Start calcium and vitamin D supplementation immediately
• Consider bisphosphonate or other anti-osteoporosis therapy after fracture healing

Perioperative Management Algorithm

1. Immediate (within 6 hours):

   • MRI left hip to confirm fracture
   • Cardiology consultation
   • Echocardiogram
   • Optimize volume status if needed

2. Within 24 hours:

   • Proceed to surgery once medically optimized
   • Multimodal analgesia with peripheral nerve block
   • Tranexamic acid administration

3. Postoperative:

   • Weight-bearing as tolerated
   • Enoxaparin for 4 weeks
   • Monitor hemoglobin - transfuse if <8 g/dL and symptomatic 1
   • Continue cardiac medications

4. Before discharge:

   • Bone health labs drawn
   • DEXA scan ordered
   • Bone health clinic referral
   • Cardiology follow-up arranged

The elevated NT-proBNP significantly increases perioperative cardiac risk, but surgery should not be delayed beyond 48 hours as hip fracture mortality increases with surgical delay 1, 3.