An elderly female presents after a fall. You were concerned about hip fracture but the x-rays were negative. You go back to examine her and she is able bear weight but she has a very slow and antalgic gait. You order a CT scan of the hip and this also comes back normal. You go back to examine her wondering whether you can use physical diagnosis to exclude a fracture.
LIMITATIONS OF ADJUNCTIVE TESTING
X-rays are only 90% sensitive for fractures, and CT has well-known limitations, though its sensitivity is not as well-described (Cannon J JEM 2009). MRI is currently considered the gold standard, but is less available in the ED for this condition.
PHYSICAL DIAGNOSIS OF HIP FRACTURE
Physical examination techniques for discovering an occult hip fracture include slow and gentle palpation to isolate the area of maximal tenderness. Internal and external rotation isolate hip joint movement. Ambulation is essentially a stress test of the hip, performed when the patient does well on the other tests. These tests have not been studied in an undifferentiated ED population with hip pain after a fall.
In any limb I suspect of having a fracture I try to hold the limb at non-painful areas above and below and then apply stresses in the X, Y, and Z planes (twisting, back and forth, and side to side). Exacerbation of pain suggests a fracture.
LIMITATIONS OF PHYSICAL DIAGNOSIS
Being good at physical diagnosis doesn’t mean using it to get the answer. Sometimes it means knowing it isn’t capable of giving you the answer.
If an elderly patient has persistent hip pain after a fall and negative x-rays, it might be a fracture. Period. This does not mean they all need admission to the hospital, but whatever plan is arranged must take this fact into account.
Can the patient still bear weight? So could 7/26 patients found to have an occult hip fracture in a retrospective study (Hossain Injury 2007). Does the patient have no pain with passive rotation of the hip? This is true of 10/26 patients with occult hip fracture. Can the patient perform a straight leg raise? So could 13/26. How about axial loading? 7/26 had no pain with this.
The patient with hip pain who is unable to walk usually is admitted for MRI the next day. But even the patient who CAN walk might still have a fracture. If discharge is chosen, the patient should be informed of this possibility, given crutches, and told to follow-up within a few days with the primary physician for reevaluation. If the patient is better, no MRI is needed. If the patient is still having significant pain, MRI is indicated.
The patient was discharged home. The hospitalist felt that she did not require admission for MRI because she was able to walk and had negative xrays and CT. The MRI was not done. A week after discharge from the ED she took a normal step and her femoral neck gave way to a displaced fracture.
Take home points:
-Even if the patient with hip pain can walk, he or she may have a fracture. Close follow-up is needed for elderly patients with persistent hip pain after a fall. Non-weight bearing status should be considered in selected patients.