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

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hip pain.
  2. Review the DDx considerations in a patient with hip pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hip pain.


Physical Exam


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.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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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.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Watch our video

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.
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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. 

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