Bilateral lower extremity lymphedema-like swelling associated with a painless femoral trochanteric fracture in an older patient: a case report

Femoral trochanteric fractures in older adults usually cause hip pain, but they may present atypically with acute immobility and no pain, leading to delayed diagnosis. We report an older patient in whom a painless femoral trochanteric fracture was initially misattributed to sequelae of cerebral infarction. Progressive bilateral lower-extremity lymphedema-like swelling prompted medical evaluation and ultimately led to the diagnosis. An 87-year-old female with a history of cerebral infarction and preserved baseline cognition had a 3-month history of immobility after sudden inability to get out of bed and right lower limb weakness without hip pain; this was attributed to stroke sequelae. Twenty days before admission, she developed progressive bilateral lower-extremity swelling with skin desquamation, crusting, and exudation. She was afebrile, with a normal white blood cell count (4.32 × 10⁹/L) but elevated C-reactive protein (51.4 mg/L) and erythrocyte sedimentation rate (24 mm/h). Examination showed non-pitting edema below both knees, right lower-limb external rotation and shortening, and bilateral inguinal lymphadenopathy. Superficial exudate cultures from both lower extremities grew Enterobacter hormaechei subsp. hormaechei; however, colonization cannot be excluded, and blood cultures were not obtained. Hip MRI revealed a right femoral trochanteric fracture. After empirical piperacillin-tazobactam treatment, skin exudation and swelling improved markedly. This case suggests that femoral trochanteric fractures in older patients may follow an insidious course due to the absence of typical pain. Infection or inflammation may coexist without fever or leukocytosis, although infection was not confirmed and colonization cannot be excluded. Bilateral lower-extremity lymphedema-like swelling may have multifactorial causes. These atypical features can delay the recognition of a painless fracture and complicate the diagnostic process.Clinicians should remain vigilant for such atypical presentations. Not applicable.