What is the workup and management for an 87-year-old female with large bruises on the left side of her hip after a fall?

Workup and Management of Post-Fall Hip Bruising in an 87-Year-Old Female

Immediate Diagnostic Workup

Obtain plain radiographs (AP pelvis and lateral hip) immediately, followed by CT hip without IV contrast if radiographs are negative or indeterminate, as plain films miss 24.1% of hip fractures and CT changes management in 20% of cases. 1

Initial Imaging Protocol

• Plain radiographs are mandatory first-line imaging despite the presence of only bruising, as displaced fractures may present with deceptively mild external findings in elderly patients 1, 2
• If plain films are normal but clinical suspicion remains high (inability to bear weight, severe pain, significant bruising), proceed immediately to CT hip without IV contrast, which has 94% sensitivity and 100% specificity for occult fractures 1
• Do not rely on preserved range of motion or ability to bear weight to exclude fracture—patients with minimally displaced fractures can maintain function initially 3
• MRI is indicated if CT is unavailable or if soft tissue injury (hematoma, muscle tear) requires evaluation after fracture has been excluded 4, 2

Laboratory Investigations

• Complete blood count to assess for anemia from blood loss and leucocytosis indicating infection 4
• Comprehensive metabolic panel including electrolytes (hypokalemia increases atrial fibrillation risk; hyponatremia may indicate infection) and renal function 4
• ECG in all elderly hip trauma patients to identify cardiac abnormalities 4
• Coagulation studies if anticoagulation therapy is present or surgery is anticipated 5

Multifactorial Fall Risk Assessment

• Evaluate gait, mobility, balance, and lower limb strength using standardized tests like Timed Up and Go 4
• Medication review for drugs increasing fall risk (sedatives, antihypertensives, anticholinergics) 4
• Cognitive assessment for delirium or dementia 4
• Environmental hazards and footwear evaluation 4

Management Based on Imaging Results

If Fracture is Identified

Surgery within 24-48 hours of admission significantly reduces short-term and mid-term mortality rates and complications from immobility. 5, 4

Preoperative Management

• Immediate adequate pain relief using nerve blocks, which reduce acute pain more effectively than systemic analgesia alone 5
• Appropriate fluid management to correct hypovolemia, which is common in elderly fracture patients 5
• Multidisciplinary assessment including geriatric evaluation for malnutrition (present in 60% of hip fracture patients), cardiac/pulmonary disease, and cognitive function 5
• Prophylactic antibiotics against Staphylococcus aureus before surgery 2
• VTE prophylaxis with sequential compression devices during hospitalization and pharmacological prophylaxis (preferably low-molecular-weight heparin) for 4 weeks postoperatively 4, 2

Postoperative Management

• Orthogeriatric comanagement on a dedicated ward improves functional outcomes, reduces length of stay, and lowers 1-year mortality 5
• Continue regular paracetamol augmented by carefully prescribed opioid analgesia as needed 5
• Supplemental oxygen for at least 24 hours postoperatively, as older patients are at high risk of hypoxia 5
• Early mobilization with weight-bearing as tolerated to prevent complications and promote recovery 4
• Nutritional supplementation with dietetic support, as this may reduce mortality and length of stay 5
• Remove urinary catheters as soon as possible to reduce urinary tract infection risk 5

Rehabilitation and Secondary Prevention

• Comprehensive rehabilitation program coordinated by orthogeriatricians, including physiotherapy, occupational therapy, and social work support 5
• Referral to Fracture Liaison Service for secondary fracture prevention 4
• Bisphosphonate therapy to reduce risk of subsequent fractures (30-day mortality is 8.4%, and 15-30% die within one year) 5, 4
• Adequate calcium intake and vitamin D supplementation 4
• Weight-bearing impact exercise and resistance training to promote bone health 4
• Multifactorial fall prevention strategies including balance training 5, 4

If No Fracture is Identified (Isolated Contusion/Hematoma)

Allow weight-bearing as tolerated with assistive device (walker or crutches) for 2-3 weeks while monitoring for clinical deterioration, as occult fractures can present with delayed symptoms. 3

Conservative Management Protocol

• Analgesia with regular paracetamol and judicious opioid use for severe pain 5
• Early gentle range-of-motion exercises (hip flexion, abduction, adduction) after initial pain subsides at 3-5 days 3
• Do not prescribe complete bed rest, as immobility increases complications including pneumonia, pressure ulcers, and deconditioning 5, 3
• Progress to resistance exercises only after pain-free range of motion is achieved, typically 3-4 weeks 3

Follow-Up and Red Flags

• Repeat clinical evaluation at 1-2 weeks to confirm improvement 3
• If pain or edema worsens or fails to improve by 2 weeks, obtain MRI to evaluate for occult fracture, muscle tear, or expanding hematoma requiring intervention 3
• New inability to bear weight requires urgent re-evaluation with advanced imaging 3

Critical Pitfalls to Avoid

• Never assume normal radiographs exclude fracture in an elderly patient with significant trauma—24.1% of fractures are radiographically occult 1
• Do not delay surgery beyond 48 hours to "optimize" stable chronic conditions, as prolonged immobility increases mortality 5
• Avoid cyclizine for nausea in elderly patients due to antimuscarinic side effects that worsen delirium 5
• Do not use haloperidol or lorazepam routinely for postoperative confusion—only for short-term symptom control after addressing reversible causes 5
• Recognize that up to 50% of postoperative deaths are potentially preventable through optimal multidisciplinary care 5