Visual disturbance and Purtscher’s retinopathy heralding an occult femoral fracture

An 80-year-old fit and active gentleman presented with left hip pain and a new central scotoma in his right eye after falling from an electric bicycle. He was able to mobilise independently and presented to ophthalmic services where cotton wool spots were found in both eyes and a presumptive diagnosis of Purtscher's retinopathy (PuR) was made. The patient was referred to the emergency department for assessment of a potential fracture. The subcapital femoral neck fracture was subtle on X-ray and only detected the following day with radiological and orthopaedic review. Two screws were placed to stabilise the fracture with a good outcome for his hip and for his vision. PuR can be seen following trauma to the head, neck or chest, following long bone fracture and in renal failure or pancreatitis. Our case highlights how the non-specific finding of cotton wool spots becomes a highly specific diagnosis in the context of trauma and should lead to careful evaluation for fractures.