Hip Fracture

  • Hip (proximal femur) fractures are generally categorized as:
    • Neck (subcapital, mid/transcervical, basicervical)
    • Intertrochanteric
    • Subtrochanteric
    • Head
  • Isolated fractures of the greater or lesser trochanter may also occur, but present a different clinical picture
  • Mandates an orthopaedic consult
    • Patients are typically admitted for definitive (operative) treatment
    • Early operative treatment (< 48 hours) has been shown to improve outcomes and mortality rates

  • Mechanism
    • If it is a fall, determine mechanical or syncopal
      • Implications for further medicine workup and injury prevention in the future
    • Common fragility fracture in the elderly
    • In young, healthy patients with history of high energy trauma, consider pathologic fracture
  • Timing of injury
    • Goal is to perform hip fracture surgery within 48 hours
      • Improved outcomes and decreased mortality
    • Other locations of pain
      • Distracting injury
      • Other fragility fractures may be present
    • Numbness or tingling
    • Antecedent hip pain
      • Especially if low energy mechanism - consider and look for pathologic fracture
    • Baseline ambulation (assistive device? Community vs home ambulator?)
      • Functional status has implication on total hip arthroplasty vs. hemiarthroplasty
      • Healthy, high functioning = THA (generally)
      • Sick, low functioning = Hemiarthroplasty (generally)
      • Knowledge of baseline ambulation will help set realistic postoperative goals
    • Comorbidities: heart disease, diabetes, lung disease, smoking, etc.
    • Anticoagulation
      • Timing of last dose
    • Last time patient last ate (NPO status)


  • Resting position of the injured lower extremity
    • Most commonly shortened and externally rotated
  • Assess skin - bruising, swelling, ecchymosis
  • Pain with logroll
  • Palpate remainder of the extremity to assess for ipsilateral injuries

Motor Exam:
    Motor Exam:
    • Tibialis Anterior - Dorsiflexion
    • Gastroc/Soleus - Plantar flexion
    • EHL/FHL - Extension/Flexion of the great toe
    Sensory Exam:
    • Sural (Lateral)
    • Saphenous (medial)
    • Superficial Peroneal(dorsum)
    • Deep Peroneal (1st web space)
    • Tibial (plantar)
  • Vascular Exam:
    • Dorsalis Pedis/Posterior Tibial
    • Capillary refill to toes

  • Motion at the hip and knee limited secondary to pain

  • AP pelvis, AP/Lateral (cross table) injured hip, AP/Lateral femur & knee
  • Characterize the fracture
    • Fracture types:
      • Subcapital (intracapsular)
      • Transcervical (intracapsular)
      • Basicervical (extracapsular)
    • Intertrochanteric fracture
    • Subtrochanteric fracture (within 5cm of lesser trochanter)

     Medical Decision Making

Hip fracture (femoral neck fx, intertrochanteric fx, subtrochanteric fx) :
*** is a *** y/o ***M/F with hx of *** who presents with an injury to the ***R/L hip which occurred while mechanism***, found to have a ***femoral neck/intertroch/subtroch fracture. The patient denies antecedent pain but uses a ***cane/walker for assistance with ambulation. On exam, the patient is neurovascularly intact with pain on logroll and a shortened, externally rotated ***R/L lower extremity. Radiographs reveal ***. Orthopaedics and internal medicine were consulted. The patient was made npo and last ate ***.

Hip fracture:
  • Consult Orthopaedic Surgery & Internal Medicine
  • WB status: Non-weight-bearing injured lower extremity
  • Diet:  NPO
  • Labs: Type and screen, INR, aPTT,  CBC, BMP
  • Analgesia: oral analgesia with IV narcotic for breakthrough
    • Ex: 5-10mg oxycodone q4, 0.5mg hydromorphone q4 prn, tylenol 975mg q8hr scheduled
      • At some institutions, regional blocks can be placed in the ED for pain control. If this is a capacity of your institution, notify anesthesia who would perform this.
  • Immobilization: None
  • Disposition: Admission to internal medicine

Common ICD-10 Codes Brief Description
S72.0 Fracture of head and neck of femur
S72.02 Fracture of epiphysis (separation) (upper) of femur
S72.03 Midcervical fracture of femur
S72.04 Fracture of base of neck of femur
S72.06 Articular fracture of head of femur
S72.11 Fracture of greater trochanter of femur
S72.12 Fracture of lesser trochanter of femur
S72.14 Intertrochanteric fracture of femur