Chapter IV-4. Hip Fractures—Occult Hip Fracture

Patient 4A

A 77-year-old woman standing at a bus stop was accidentally pushed and fell, landing on her left side.

She was able to get up, but noted pain in the left groin when standing. The pain persisted over several hours and therefore she came to the ED. She was able to ambulate with a cane, but noted pain in the left hip on weight bearing.

On examination, there was no foreshortening or external rotation of the left hip. Range of motion was full with pain on internal rotation. There was slight tenderness over the greater trochanter but no ecchymosis.

Radiographs of the left hip and pelvis were obtained and interpreted as showing degenerative changes (Figure 1). She had previously had a fracture and hemiarthroplasty of her right hip.

The patient was discharged on ibuprofen, with instructions to rest, and referred to an orthopedist if her pain persisted.

• What would you have done?

See patient outcome.

Patient 4B

A 72-year-old woman tripped on the sidewalk and fell on to her left side. Her husband helped her get up after the fall.

She was able to walk, but had a limp due to left hip pain. The pain persisted and therefore, on the following day, she decided to come to the ED. On examination, there was localized tenderness over the hip and pain on internal and external rotation. She was able to fully flex and extend the hip without pain.

Radiographs of the hip were reported as negative for a fracture (Figure 2) and the patient was discharged with the diagnosis of hip contusion. She was instructed to limit weight bearing, take a mild pain reliever, and contact her doctor if pain persisted.

• Do you agree with this management?

See patient outcome.

The typical patient with a fractured hip (proximal femoral fracture) is an elderly individual who has fallen from a standing position. The patient presents lying on the stretcher with the involved leg externally rotated and foreshortened. However, a patient with a nondisplaced fracture can present with subtle clinical and radiographic findings (2–9% of cases), and the diagnosis can be missed on initial evaluation (Perron et al. 2002, Dominguez et al. 2005). In some instances, the radiographs are entirely negative for a fracture (an “occult ...