Retake
M11) Hip pain after fall in a 72-year-old
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hip pain.
- Review the DDx considerations in a patient with hip pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hip pain.
History
A 72-year-old female with a history of osteoporosis experienced a fall after slipping on a wet surface, landing on her right hip. Following the fall, she reported severe right hip pain and was unable to get up or bear weight on her right lower extremity. Ibuprofen provided only minimal relief. She denies any presyncopal symptoms, including lightheadedness, dizziness, or loss of consciousness. She denies any functional limitations or deconditioning prior to her injury.
Physical Exam
BP: 130/80, HR 90, RR 20, Temp 98, O2 saturation 99%.
Musculoskeletal: Right leg is shortened and externally rotated, with limited range of motion secondary to pain. Bilateral dorsalis pedis pulses are 2+. No tenderness to palpation or acute findings in the remainder of the right lower extremity.
Labs
None
Provisional Diagnosis
Select the Dx you believe is most appropriate
Considering the patient's age, history of osteoporosis, mechanism of injury, and physical exam findings of a shortened and externally rotated right leg, a right hip fracture is the most probable diagnosis.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
Prompt diagnosis and management of hip fractures can reduce morbidity and mortality.
First Imaging Study
What is the first imaging study you will order?
The first imaging modality would be a radiograph for assessment of acute hip pain with suspected fracture. Radiographs are rapidly obtained, well-tolerated by patients, and often provide sufficient information of the fracture pattern for treatment planning purposes when a fracture is demonstrated.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
AP Pelvis XR
There is a femur fracture.
There is a mildly comminuted and impacted fracture through the right femur with minimal displacement or angulation. This is evidenced by the interruption of the cortical line and trabecular pattern.
The femur fracture can be described as a:
This is a subcapital neck fracture as it occurs in the femoral neck, just below the femoral head.
The calcified pelvic structure is likely a:
The well-defined, dense, radiopaque mass in the pelvis is likely a uterine fibroid. Its stippled pattern and large size help differentiate it from other calcified structures within the pelvis.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
More advanced imaging modalities are typically reserved for instances of clinically suspected fracture in the setting of negative or equivocal radiographs. In this case, the diagnosis is made with the X-ray.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient's presentation, physical examination, and imaging findings all align with a right subcapital hip fracture caused by a mechanical ground-level fall. The fracture is intracapsular as it is involves the proximal femoral neck just below the femoral head.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
Prompt diagnosis and management of hip fractures can reduce morbidity and mortality.
Assessment and Plan
Please provide your assessment and plan for this patient
A 72-year-old female with a history of osteoporosis presented with severe pain in her right hip and an inability to bear weight after slipping on a wet surface. Physical examination revealed a shortened and externally rotated right leg, indicating a subcapital fracture in the right femoral neck. The patient will be admitted for further management and pain control, and an orthopedic surgery consultation will be sought for a surgical evaluation. In-hospital rehabilitation involving physical therapy, occupational therapy, and case management will be initiated, followed by outpatient rehabilitation. Since the cause of the injury was a mechanical ground-level fall rather than syncope, additional syncopal workup procedures such as an echocardiogram, carotid ultrasound, or orthostatic vital signs assessment are not necessary.
Lessons Learned:
• Accurate characterization of fractures is crucial for medical decision making.
• Proximal femoral fractures, particularly those occurring at the neck, have a higher risk of avascular necrosis due to potential compromise of the medial circumflex femoral artery and its branches.
• Further assessment of fractures, including evaluating displacement and angulation, is important as it can further impact blood supply to the femoral head.
• Arthroplasty has demonstrated superiority over fixation in elderly patients with intracapsular hip fractures, offering benefits such as improved pain relief, post-operative function, and reduced complications.
• Early diagnosis is essential as prompt surgical intervention has been shown to decrease morbidity and mortality associated with hip fractures.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Next
View ACR Appropriateness Criteria
