What is the best approach to manage left hip pain in a 66-year-old male with a history of Hepatitis C, recent fall, and past trauma to the hip?

Management of Left Hip Pain in a 66-Year-Old Male with Recent Fall and Past Trauma

The best approach for managing left hip pain in this 66-year-old male with recent fall and history of hip trauma is to obtain advanced imaging (MRI) if plain radiographs are negative but clinical suspicion for fracture remains high, followed by appropriate pain management with acetaminophen as first-line therapy and consideration of multimodal analgesia while avoiding opioids when possible. 1

Initial Assessment and Imaging

• Plain radiographs of the pelvis and left hip should be the first imaging study to evaluate for fracture following the recent fall 2, 1
• If radiographs are negative but clinical suspicion remains high (especially with pain that increases with hip rotation), an MRI should be obtained to identify occult fractures 1
• The patient's report of left hip pain that worsened after slipping in the shower, combined with his history of previous trauma to the same hip in 2011, warrants thorough evaluation for both acute injury and chronic conditions 2, 1

Pain Management Approach

• Regular intravenous or oral acetaminophen every 6 hours should be used as first-line treatment for pain management 2
• NSAIDs should be used with caution in this patient due to potential adverse effects, particularly considering his age and history of Hepatitis C which may affect liver function 2
• If NSAIDs are used, they should be co-prescribed with a proton pump inhibitor to reduce gastrointestinal complications 2
• Opioids should be avoided when possible to reduce side effects including respiratory depression, nausea, vomiting, and confusion in older patients 2
• If opioids are necessary for breakthrough pain, they should be administered at the lowest effective dose for the shortest period possible 2

Non-Pharmacological Interventions

• Immobilization of the affected limb and application of ice packs should be implemented alongside pharmacological therapy 2
• Physical therapy should be considered for mild-to-moderate hip pain if fracture is ruled out and osteoarthritis is suspected 2
• Weight-bearing as tolerated should be encouraged if no fracture is identified to maintain mobility and prevent deconditioning 2

Advanced Pain Management Options

• If pain is severe, consider peripheral nerve blocks to reduce opioid requirements 2
• For patients with confirmed hip fractures, regional anesthesia techniques such as epidural or paravertebral blocks should be considered to improve pain control and reduce opioid consumption 2

Surgical Considerations

• If imaging reveals a hip fracture, surgical management should be pursued within 24-48 hours of admission to reduce mortality 1
• For unstable intertrochanteric, subtrochanteric, or reverse obliquity fractures, cephalomedullary nail fixation is recommended 2
• For displaced femoral neck fractures, arthroplasty is the preferred treatment 2

Post-Management Follow-Up

• A multifactorial falls risk assessment should be performed to prevent future falls 1
• If chronic hip pain is determined to be from osteoarthritis, long-term management should include exercise programs, weight management, and appropriate pain control 3
• Venous thromboembolism prophylaxis should be provided if the patient requires hospitalization or surgery 2

Special Considerations for Hepatitis C History

• While the patient reports treatment for Hepatitis C in 2020, liver function should be assessed before prescribing medications metabolized by the liver 4, 5
• The history of Hepatitis C should not significantly alter the approach to hip pain management if the patient has been successfully treated and has normal liver function 5