Hip Fracture in the ED Clinical Presentation

Updated: Aug 12, 2021
  • Author: Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

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.

Patients complain of pain and an inability to move the hip.

With stress fractures in young athletes and nondisplaced fractures, patients may complain of pain in the hip or knee and may be ambulatory.

The 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 anatomic position of the extremity because this alone provides useful clues to the type of injury the patient has sustained.

Foe demoral 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.

For 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.

For trochanteric fractures, 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 in pain. With a lesser trochanteric fracture, pain occurs during flexion and internal rotation.

For 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.

For 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 radiographs 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. Digital x-ray radiogrammetry (DXR) of hand or wrist radiographs predicted hip fracture risk in a study of 5,420 women and 2,837 men. Bone mineral density equivalent, calculated from DXR, was significantly lower in the 122 patients who later suffered a hip fracture than in the patients who did not experience a hip fracture. The age-adjusted hazard ratio per standard deviation change in DXR score for hip fracture in the study was 2.52 and 2.08 for women and men, respectively. [31]

Other risk factors for hip fracture include the following:

  • Neurologic impairment
  • White 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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