Hip Fracture in Emergency Medicine Workup

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

Laboratory Studies

  • Laboratory studies are not useful in the diagnosis of fracture. Preoperative laboratory studies usually are drawn.
Next

Imaging Studies

  • Anteroposterior (AP) and lateral views demonstrate most fractures.
    • If a fracture is not obvious, look for alteration of the Shenton line and compare it to the other hip. In addition, check the neck-shaft angle, which is determined by measuring the angle created by lines drawn through the centers of the femoral shaft and femoral neck. This should be approximately 120-130°.
    • For patients in whom femoral neck fracture is strongly suspected but standard x-ray findings are negative, an AP view with internal rotation provides a better view of the femoral neck.
  • If radiographic findings are equivocal but the history and physical examination are concerning for fracture, CT scan should be considered, particularly in unstable patients or those for whom MRI would be significantly delayed. A recent retrospective study has questioned the sensitivity of plain radiography in detecting hip and pelvis fractures.[13]
  • MRI and bone scan
    • If standard radiograph findings are negative and hip fracture still is strongly suspected, MRI and bone scan have high sensitivity in identifying occult injuries.
    • MRI is 100% sensitive in patients with equivocal radiographic findings.
    • Traditionally, bone scan has been thought to be unreliable before 48-72 hours after fracture, but one study found a sensitivity of 93% regardless of time from injury, including fractures less than 24 hours old.
    • For patients in whom a fracture is strongly suspected and radiographs are negative, consider admission if MRI or bone scan is not readily available.
Previous
Proceed to Treatment & Management
 
 
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

  1. Egan M, Jaglal S, Byrne K, Wells J, Stolee P. Factors associated with a second hip fracture: a systematic review. Clin Rehabil. Mar 2008;22(3):272-82. [Medline].

  2. Sennerby U, Melhus H, Gedeborg R, Byberg L, Garmo H, Ahlbom A, et al. Cardiovascular diseases and risk of hip fracture. JAMA. Oct 21 2009;302(15):1666-73. [Medline].

  3. Carbone L, Buzkova P, Fink HA, Lee JS, Chen Z, Ahmed A, et al. Hip fractures and heart failure: findings from the Cardiovascular Health Study. Eur Heart J. Jan 2010;31(1):77-84. [Medline].

  4. Trimpou P, Landin-Wilhelmsen K, Oden A, Rosengren A, Wilhelmsen L. Male risk factors for hip fracture-a 30-year follow-up study in 7,495 men. Osteoporos Int. Mar 2010;21(3):409-16. [Medline].

  5. Kettunen JA, Impivaara O, Kujala UM, Linna M, Maki J, Raty H, et al. Hip fractures and femoral bone mineral density in male former elite athletes. Bone. Feb 2010;46(2):330-5. [Medline].

  6. Jalbert JJ, Eaton CB, Miller SC, Lapane KL. Antipsychotic use and the risk of hip fracture among older adults afflicted with dementia. J Am Med Dir Assoc. Feb 2010;11(2):120-7. [Medline].

  7. Calmy A, Fux CA, Norris R, Vallier N, Delhumeau C, Samaras K, et al. Low bone mineral density, renal dysfunction, and fracture risk in HIV infection: a cross-sectional study. J Infect Dis. Dec 1 2009;200(11):1746-54. [Medline].

  8. Kim SH, Meehan JP, Blumenfeld T, Szabo RM. Hip fractures in the United States: Nationwide emergency department sample, 2008. Arthritis Care Res. Dec 2011.

  9. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. Jan 2008;90(1):34-42. [Medline].

  10. Bryson DJ, Knapp S, Middleton RG, Faizi M, Bhansali H, Uzoigwe CE. Representation to the accident and emergency department within 1-year of a fractured neck of femur. J Orthop Surg Res. Dec 2011;6:63.

  11. Maggi S, Siviero P, Wetle T, Besdine RW, Saugo M, Crepaldi G. A multicenter survey on profile of care for hip fracture: predictors of mortality and disability. Osteoporos Int. Feb 2010;21(2):223-31. [Medline].

  12. Marshall LM, Zmuda JM, Chan BK, Barrett-Connor E, Cauley JA, Ensrud KE, et al. Race and ethnic variation in proximal femur structure and BMD among older men. J Bone Miner Res. Jan 2008;23(1):121-30. [Medline].

  13. Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol. Apr 2010;194(4):1054-60. [Medline].

  14. O'Malley NT, Blauth M, Suhm N, Kates SL. Hip fracture management, before and beyond surgery and medication: a synthesis of the evidence. Arch Orthop Trauma Surg. Nov 2011;131:1519-27.

  15. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. Mar 23 2009;169(6):551-61. [Medline].

  16. Delee JC. Fractures in Adults. Lippincott-Raven Publishers; 1996:1659-63.

  17. Geiderman J. Hip injuries. In: Harwood-Nuss A, Linden CH, eds. The Clinical Practice of Emergency Medicine. Lippincott-Raven Publishers; 1991:407-409.

  18. Gurr DE, Gibbs MS. Femur and hip. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby Inc; 2002:643-674.

  19. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. Feb 1990;174(2):509-15. [Medline].

  20. LaVelle DG. Fractures of hip. In: Campbell's Operative Orthopaedics. 10th ed. Mosby Inc; 2003:2873-2938.

  21. Lin JT, Lane JM. Osteoporosis: a review. Clin Orthop Relat Res. Aug 2004;126-34. [Medline].

  22. Lu-Yao GL, Baron JA, Barrett JA, Fisher ES. Treatment and survival among elderly Americans with hip fractures: a population-based study. Am J Public Health. Aug 1994;84(8):1287-91. [Medline].

  23. McGuire KJ, Bernstein J, Polsky D, Silber JH. The 2004 Marshall Urist award: delays until surgery after hip fracture increases mortality. Clin Orthop Relat Res. Nov 2004;294-301. [Medline].

  24. Norton R, Campbell AJ, Lee-Joe T. Circumstances of falls resulting in hip fractures among older people. J Am Geriatr Soc. Sep 1997;45(9):1108-12. [Medline].

  25. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. May 1993;187(2):469-71. [Medline].

  26. Simon RR, Koenigsknecht SJ. Emergency Orthopedics: The Extremities. 3rd ed. McGraw-Hill Professional Publishing; 1995:251-262.

  27. Steele MT, Ellison SR. Trauma to the pelvis, hip and femur. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. The McGraw-Hill Companies Inc; 2004:1717-1726.

  28. Van Balen R, Steyerberg EW, Polder JJ, et al. Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence. Clin Orthop Relat Res. Sep 2001;232-43. [Medline].

  29. van de Kerkhove MP, Antheunis PS, Luitse JS, Goslings JC. Hip fractures in nonagenarians: perioperative mortality and survival. Injury. Feb 2008;39(2):244-8. [Medline].

  30. Zuckerman JD. Hip fracture. N Engl J Med. Jun 6 1996;334(23):1519-25. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.