Workup for Groin Pain After a Fall
The workup for groin pain post-fall must prioritize ruling out hip fracture through plain radiography, followed by MRI if radiographs are negative but clinical suspicion remains high, while simultaneously evaluating for pelvic fractures, urogenital injuries, and the underlying cause of the fall itself. 1, 2
Immediate Assessment and Imaging
Initial Imaging Strategy
For hemodynamically stable patients, obtain plain radiographs of the pelvis and hip first. 2 If the patient is stable, proceed directly to CT scan with intravenous contrast of the thorax, abdomen, and pelvis to comprehensively evaluate all injuries. 2
If plain radiographs are normal but clinical suspicion for fracture remains high, obtain an MRI to identify occult hip or pelvic fractures. 1 This is critical as occult fractures are common in elderly patients and can be missed on initial plain films.
For hemodynamically unstable patients, obtain pelvic X-ray upon arrival along with chest X-ray and E-FAST (Extended Focused Assessment with Sonography for Trauma). 2 These are the only imaging modalities compatible with ongoing resuscitation.
Specific Imaging Considerations
E-FAST should be performed in all patients with suspected severe trauma to identify hemoperitoneum and guide therapeutic decisions. 2 This has a 97% negative predictive value in patients with shock and helps distinguish between intra-abdominal versus pelvic sources of bleeding. 2
For patients with severe pelvic trauma who are hemodynamically stable, perform thoraco-abdomino-pelvic CT scan with contrast before considering angiographic embolization. 2 This allows complete inventory of injuries and identification of active bleeding sources.
Evaluation for Urogenital Injuries
Do not routinely perform urethral and bladder imaging unless specific clinical signs are present. 2 However, perform retrograde urethral and bladder opacification (ideally with CT) if the patient has: 2
- Inability to urinate
- Gross hematuria
- Blood at the urethral meatus
- Suprapubic tenderness
- Suprapubic penetrating wounds
This evaluation is particularly important before attempting urinary catheterization in men with pelvic fractures. 2 Lower urinary tract injuries occur in 3.5% of pelvic fractures for bladder and 4-19% for posterior urethral injuries. 2
Assessment of Fall Etiology
The history is the most critical component of evaluating a patient after a fall. 2 Ask yourself: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is no, perform a comprehensive assessment. 2
Key Historical Elements to Obtain:
- Age greater than 65 2
- Location and mechanism of fall 2
- Difficulty with gait and/or balance 2
- Previous falls 2
- Time spent on floor or ground 2
- Loss of consciousness or altered mental status 2
- Near-syncope or orthostasis 2
- Melena 2
- Specific comorbidities: dementia, Parkinson's, stroke, diabetes, prior hip fracture, depression 2
- Visual or neurological impairments including peripheral neuropathies 2
- Alcohol use 2
- Current medications (especially vasodilators, diuretics, antipsychotics, sedative/hypnotics) 2
- Activities of daily living 2
- Appropriate footwear 2
Physical Examination Components:
Perform orthostatic blood pressure assessment. 2
Conduct neurologic assessment with special attention to presence/absence of neuropathies and proximal motor strength. 2
Evaluate gait with a "get up and go test" before discharge—patients unable to rise from bed, turn, and steadily ambulate should be reassessed. 2
Laboratory Workup
Obtain the following laboratory tests: 1
- Complete blood count (leucocytosis may indicate underlying infection, commonly chest or urinary) 1
- Electrolytes (hypokalemia is associated with new-onset atrial fibrillation; hyponatremia may indicate infection or medication effects) 1
- ECG in all elderly patients with hip fracture 1
Maintain a low threshold for obtaining standard electrolyte panel, measurable medication levels, and appropriate imaging based on clinical presentation. 2
Hip-Specific Considerations
When evaluating for hip-related pain, exclude non-musculoskeletal and serious pathological conditions first: 2
- Tumors
- Infections
- Stress fractures
- Slipped capital femoral epiphysis
- Competing musculoskeletal conditions (e.g., lumbar spine pathology)
Clinical examination and diagnostic imaging have limited diagnostic utility for hip-related pain; therefore, a comprehensive approach is essential. 2 A negative flexion-adduction-internal rotation test helps rule out hip-related pain, though its clinical utility is limited. 2
Common Pitfalls
Traumatic injuries in geriatric patients may be "occult," presenting without classic signs or symptoms. 2 High-risk injuries such as blunt head trauma, spinal fractures, and hip fractures warrant a higher degree of suspicion and extensive workups. 2
Do not assume groin pain is simply a muscle strain. Differential diagnosis must include pelvic stress fractures, avulsion injuries, femoral neck fractures, acetabular labral tears, and even tumors. 3, 4
In patients with pelvic fractures, unstable fractures—particularly those with bilateral ischio-pubic rami and sacro-iliac dislocation—carry the greatest risk of associated lower urinary tract injuries. 2