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An older woman who can't stand after a fall
An 81-year-old woman with osteoporosis trips at home and can't get up. She has right groin pain and can't bear weight. Her right leg is shortened and externally rotated.
Step 1 of 4
What is the most likely injury?
Correct answer: A
A low-energy fall in an older adult with osteoporosis and a shortened, externally rotated leg is a hip fracture. A posterior hip dislocation (dashboard injury) leaves the leg shortened but internally rotated (see femur).
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A
A low-energy fall in an older adult with osteoporosis and a shortened, externally rotated leg is a hip fracture. A posterior hip dislocation (dashboard injury) leaves the leg shortened but internally rotated (see femur).
Step 2 of 4
AP pelvis and lateral hip radiographs are read as normal, but she still can't bear weight.
What is the most appropriate next step?
Correct answer: B
An occult hip fracture may not show on the first radiographs; MRI detects it.
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B
An occult hip fracture may not show on the first radiographs; MRI detects it.
Step 3 of 4
MRI shows a displaced intracapsular femoral neck fracture.
Why is the femoral head at risk of avascular necrosis?
Correct answer: A
The head is supplied mainly by the medial circumflex femoral artery through retinacular branches that run up the neck. A displaced intracapsular fracture tears them, causing avascular necrosis and nonunion.
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A
The head is supplied mainly by the medial circumflex femoral artery through retinacular branches that run up the neck. A displaced intracapsular fracture tears them, causing avascular necrosis and nonunion.
Step 4 of 4
What is the usual treatment for this fracture in an older adult?
Correct answer: D
Displaced intracapsular neck fractures in older adults are usually treated with arthroplasty. Intertrochanteric (extracapsular) fractures keep their blood supply and are fixed with a nail or sliding hip screw. Surgery within about 24–48 hours reduces mortality.
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D
Displaced intracapsular neck fractures in older adults are usually treated with arthroplasty. Intertrochanteric (extracapsular) fractures keep their blood supply and are fixed with a nail or sliding hip screw. Surgery within about 24–48 hours reduces mortality.
Key points
- Fall + shortened, externally rotated leg → hip fracture; normal X-ray with high suspicion → MRI.
- Medial circumflex femoral artery → AVN after a displaced intracapsular fracture → arthroplasty.
Study: Femur, Hip joint, Bony pelvis