Hip Fracture in Emergency Medicine Clinical Presentation

  • Author: Moira Davenport, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 2, 2012
 

History

  • In elderly patients, hip fracture most often results from a simple fall; in a small percentage, it occurs spontaneously, in the absence of any trauma.
  • Patient complains of pain and inability to move the hip.
  • With stress fractures in young athletes and nondisplaced fractures, patient may complain of pain in hip or knee and may be ambulatory.
  • Patient may have a history of other osteoporotic fractures, such as Colles or vertebral compression fractures.
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Physical

  • Perform a primary survey in trauma patients and stabilize as needed.
  • Complete a detailed secondary survey because of the high likelihood of associated injuries. Up to 70% of patients with femoral head fracture-dislocations experienced major associated injuries, including other extremity injuries, intra-abdominal or intrapelvic injuries, neck injuries, and head injuries.
  • Pay particular attention to vital signs and secondary manifestations of shock such as changes in skin, mental status, and urine output. Hip fractures are associated with blood volume losses of up to 1500 mL.
  • Inspect and palpate for deformity, hematoma formation, laceration, and asymmetry.
  • Observe the anatomical position of the extremity because this alone provides useful clues to the type of injury the patient has sustained.
  • Femoral head fracture: Posterior dislocation is most common (eg, a dashboard injury), in which case the extremity appears adducted and internally rotated. With anterior dislocation, the extremity is abducted, and externally rotated.
  • Femoral neck fracture: With partial or completely displaced fractures (types 3 and 4, respectively), the patient has severe pain and lies with the extremity slightly shortened, abducted, and externally rotated. In the case of a stress fracture or severe impaction fractures (types 1 and 2, respectively), the only physical findings may be minor pain with little or no limitation in range of motion.
  • Trochanteric fracture: With a greater trochanteric fracture, the patient presents with pain, especially with abduction and extension. No deformity may be apparent, but pressure through greater trochanters will result is pain. With a lesser trochanteric fracture, pain occurs during flexion and internal rotation.
  • Intertrochanteric fracture: The extremity appears shortened and significantly externally rotated, in contrast to the minimal deformities associated with femoral neck fractures. Pain, hip edema and ecchymosis, and pain with any movement may also be noted.
  • Subtrochanteric fracture: The proximal femur usually is held in flexion and external rotation.
  • In assessing range of motion (ROM), first test external and internal rotation with the extremity held in extension. If a fracture exists, especially one that is displaced, the remainder of ROM examination is extremely painful, of limited diagnostic use, and potentially dangerous. If the patient has pain with the initial ROM examination, obtain radiograph before completing the examination.
  • Perform a detailed distal neurovascular examination.
  • If the patient is a trauma victim, assess for pelvic fractures by stressing the pelvis anteriorly to posteriorly through iliac crests and symphysis pubis, and laterally to medially through iliac crests.
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Causes

  • In young persons, hip fractures generally result from trauma associated with significant force. For example, 75% of all femoral head fractures, more common among young patients, occur as a result of motor vehicle collisions.
  • In older persons, more than 90% of hip fractures result from trauma or torsion associated with a minor fall or, occasionally, in the absence of any obvious traumatic event.
  • Osteoporosis is the leading cause of hip fracture.
  • Other risk factors for hip fracture include the following:
    • Neurological impairment
    • Caucasian race
    • Cigarette smoking
    • Institutional living
    • Maternal history of hip fracture
    • Previous hip fracture
    • Physical inactivity
    • Tall stature
    • Alcohol abuse
    • Previous Colles or vertebral fracture attributed to osteoporosis
    • Low body weight
    • Impaired vision
    • Prolonged corticosteroid use
    • Use of medications that decrease bone mass, including furosemide, thyroid hormone, phenobarbital, and phenytoin
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Contributor Information and Disclosures
Author

Moira Davenport, MD  Attending Physician, Departments of Emergency Medicine and Orthopedic Surgery, Allegheny General Hospital

Moira Davenport, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD, FACEP  Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Gigi R Madore, MD, and Geoff Winkley, MD, to the development and writing of this article.

References

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Shenton line and angular anatomy of the femur.
Femoral head fractures. Top diagram is a single-fragment femoral head fracture. Bottom diagram is a comminuted femoral head fracture.
Femoral neck fractures. Top diagram is a nondisplaced, or incomplete, femoral neck fracture. Bottom diagram is an impacted femoral neck fracture.
Partially displaced femoral neck fracture.
Completely displaced femoral neck fracture.
Trochanteric fractures. Top diagram is a nondisplaced trochanteric fracture. Bottom diagram is a displaced trochanteric fracture.
Intertrochanteric fractures. Top diagram is a single fracture line intertrochanteric fracture. Bottom diagram is a displaced, or multiple fracture line, intertrochanteric fracture.
 
 
 
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