Hip Fracture

Fracture Incidence/
Mechanism Clinical Findings Concomitant Injuries ED Management Disposition and Follow-Up Complications
Femoral Head Isolated fracture rare; seen in 6%–16% of hip dislocations; usually result of high-energy trauma; dashboard to flexed knee most common Superior aspect or impaction fracture in anterior dislocation; inferior aspect in posterior dislocation Limb shortened and externally rotated (anterior dislocation); shortened, flexed, and internally rotated (posterior dislocation) Closed head injury; intrathoracic and/or intra-abdominal injuries; pelvic fracture, knee injuries Immediate orthopedic consultation;
Emergent closed reduction of dislocation; ORIF if closed unsuccessful
Admission to orthopedic or trauma service AVN; post-traumatic arthritis; sciatic nerve injury; heterotopic ossification
Femoral Neck Common in older patients with osteoporosis; rarely seen in younger patients Low-impact falls or torsion in elderly; high-energy trauma or stress fractures in young Ranges from pain with weightbearing to inability to ambulate; limb may be shortened and externally rotated Ipsilateral femoral shaft fracture Orthopedic consultation; ranges from nonoperative to total hip arthroplasty Admission to orthopedic service AVN; infection; DVT and/or pulmonary embolus
Greater trochanteric Uncommon; older patients or adolescents Direct trauma (older patients); avulsion due to contraction of gluteus medius (young patients) Ambulatory; pain with palpation or abduction - Analgesics; protected weight-bearing Orthopedic follow-up 1-2 wk;
Possible ORIF if displacement >1 cm
Nonunion rare
Lesser trochanteric Uncommon; adolescents (85%) > adults Avulsion due to forceful contraction of iliopsoas (adolescents); avulsion of pathologic bone (older adults) Usually ambulatory; pain with flexion or rotation - Analgesics; weight-bearing as tolerated; evaluate for possible pathologic fracture Orthopedic or PCP follow-up in 1-2 wk; admit or urgent follow-up for pathologic fracture Nonunion rare
Intertrochancteric Common in older patients with osteoporosis; rare in younger patients Falls; high-energy trauma Severe pain; swelling; limb shortened and externally rotated Anemia from blood loss into thigh; concomitant traumatic injuries Orthopedic consultation Admit for eventual ORIF; may need preoperative testing and clearance by PCP or hospitalist DVT and/or pulmonary embolism; infection
Subtrochanteric Similar to intertrochanteric; 15% of hip fractures Falls; high-energy trauma; may also be pathologic Severe pain; ecchymosis; limb shortened, abducted, and externally rotated Vascular injuries, anemia/hypovolemic shock from fracture itself or other traumatic injuries Orthopedic consultation; Hare or Sager splint Admit for ORIF DVT and/or pulmonary embolism; infection; malunion (shortened limb); nonunion

ED Care & Disposition:

  1. Treatment according to table above
  2. If clinical suspicion of an occult fracture (condition with clinical signs of fracture but no radiographic evidence) is high, obtain either a CT or MRI scan. Alternatively, arrange urgent follow-up for imaging & have the pt. remain non-weight-bearing.
  3. Traction Device: