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The externally rotated leg: a trap for the unwary
  1. F Lam1,
  2. S Hussain2
  1. 1Department of Trauma and Orthopaedic Surgery, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK
  2. 2Department of Trauma and Orthopaedic Surgery, Royal Sussex County Hospital, UK
  1. Correspondence to:
 Mr F Lam

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A 91 year old man with known epilepsy was brought into the emergency department after a grand mal seizure. During the fit, he fell down two steps landing on his back. After the seizure, he complained of severe back pain and inability to move his legs. He was previously independently mobile but after the fall, was unable to weight bear.

On examination, both legs were held symmetrically in an externally rotated position. He was unable to actively straight leg raise and passive movements of his legs were painful in all directions. Pronounced motor weakness was noted proximally around the pelvic girdle. Otherwise, he was neurologically intact with normal reflexes, sensation, and anal tone.

Spinal abnormality was suspected and a radiograph of the lumbar spine showed marked osteoarthritic changes with no evidence of a fracture. Subsequently, a pelvic radiograph showed a bilateral subcapital fractured neck of femur (fig 1). The patient was later treated with bilateral hemiarthoplasties and was independently mobile on discharge.

Figure 1

Bilateral displaced sub-capital fracture neck of the femur is shown.


About 15% of epileptic seizures result in trauma with head injury being the most common.1 The occurrence of a bilateral fractured neck of femur after a seizure is a rare occurrence. The most commonly reported cause for this fracture pattern is electric shock, whether accidental or controlled (electroconvulsive therapy).2

Our case reinforces that a thorough physical examination is important in the assessment of elderly patients after a fall. The classic signs of a shortened and externally rotated leg occurring in a displaced fractured neck of femur, can be easily missed as in this case, where there was referred back pain.3 Careful assessment and constant awareness of an abnormal limb position will help reduce the incidence of missing this important fracture.


Both Mr F Lam and Miss S Hussain contributed to the writing of this case report and Mr F Lam will act as guarantor for this paper.