You evaluate an elderly female who has tripped and fallen at home. She denies any chest pain, shortness of breath or other acute medical symptoms and was well until the event.
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She does complain bitterly of persistent right hip pain. EMS has transported her on a long spine board, and administered 4mg IV of morphine sulfate. Vitals are unremarkable except for tachycardia of 105. On physical exam, she has a slight flexed posture to her right leg without shortening or rotation. There is pain in the right hip region with axial loading, and some pain over the pubic ramus on the right side.
You order the usual hip fracture evaluation, including pre-operative labs, suspecting a non-displaced hip fracture (likely a femoral neck fracture) or possibly a ramus fracture. However, the initial X-ray (shown), as well as a pelvis view of both rami, fail to demonstrate the expected fracture. The patient is requesting more pain meds for increased symptoms. Earlier, you had informed the family that you thought the patient had a hip fracture. Now, with the X-rays failing to deliver the expected diagnosis, the family is now concerned that you – the doctor – don’t know what is going on. You again verify that there were no preceding symptoms to this injury, making a septic hip or other non-traumatic process less likely.
What else could be going on? What’s the next move?
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This case shows how difficult it is to diagnose certain fractures in the osteopenic elderly, as well as the problem of missing less common problems. In the case of some pubic rami and acetabular fractures, not to mention non-displaced femoral neck injuries, the fracture line can be very difficult to see on plain X-rays. The traditional solution for a suspected fracture with negative X-rays is additional imaging with either CT or MRI of the affected area. Although CT is often more available, MRI is the study of choice. In this case, a CT of the R hip and pelvis revealed a somewhat occult R acetabular fracture (see arrows). In retrospect, a fullness or asymmetry of the acetabulum may be appreciated on the right side.
In addition to the occult hip fracture, a few other items would bear consideration in diagnosis. Septic hip is number one, and would be characterized by persistent non-traumatic hip pain, perhaps without fever, in the setting of known or suspected bacteremia. A psoas abscess would also present with similar symptoms. For both, CT would be helpful and likely diagnostic as long as you include the local pelvic region as well as the hip on the CT image.
Back to this patient. This fracture is generally a non-operative problem, with treatment consisting of pain medication, rehab and “don’t do it again”. After ensuring that the patient’s pain was under control, she was discharged home with orthopedic follow-up. Beats a femoral neck fracture any day.
John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course.
www.emprepcourse.com
2 Comments
A negative plain film of a traumatic hip injury should almost always be followed up with further imaging. The real management issue here is whether this patient is safe for discharge. How well can she ambulate? How well can she perform her activities of daily living now with this fracture and her new pain medications? Does she have adequate psychosocial support to assist her on this simple “rehab” journey?
On osteopenic patients you always suspect a fracture of some sort when an accident occurse especially when they are elderly. X-ray is a good tool for initial evaluation but should always be followed up with more screening especially in the geriatric populatoin.