Can a patient with a potential hip fracture be worked up in the office or should they be evaluated in the Emergency Room (ER)?

Patients with Suspected Hip Fracture Should Be Evaluated in the Emergency Room, Not the Office

A patient with suspected hip fracture requires immediate emergency department evaluation with ambulance transport for immobilization, pain management, and rapid diagnostic imaging. Office-based workup is inappropriate and dangerous for this population.

Why Emergency Department Evaluation is Mandatory

Immediate Clinical Needs That Cannot Be Met in Office Settings

• Ambulance transport enables essential immobilization, opioid analgesia administration, intravenous fluid therapy, and patient warming strategies that are critical for hip fracture patients 1
• Patients typically present with inability to ambulate, shortened and externally rotated affected limb, and severe pain on movement 1
• Hip fractures cannot be reliably diagnosed or excluded on physical examination alone, making immediate imaging essential 1

Time-Sensitive Nature of Hip Fractures

• Delays in diagnosis and treatment are associated with increased cost, complication rate, length of hospital stay, and both short-term and long-term mortality 1
• Surgery should occur within 24-48 hours of admission to significantly reduce mortality rates and medical complications 1
• Patients who spend ≥5 hours in the ED have increased cardiac events and prolonged hospital stays, emphasizing the urgency of rapid evaluation 2

Essential Emergency Department Capabilities

Immediate Diagnostic Imaging

• Standard radiographic evaluation requires AP pelvis and cross-table lateral hip views, which are the initial imaging of choice 1, 3
• Approximately 10% of proximal femoral fractures are not identified on initial radiographs, requiring MRI without IV contrast when clinical suspicion remains high 3
• Diagnostic imaging should be obtained within 27 minutes of arrival 2

Multidisciplinary Assessment and Stabilization

• Interdisciplinary care should be provided to decrease complications and improve outcomes (strong strength of evidence, strong recommendation) 1
• Comprehensive assessment must include chest X-ray, ECG, full blood count, clotting studies, renal function, and cognitive baseline evaluation 1
• Approximately 70% of hip fracture patients are ASA physical status 3-4 with multiple comorbidities requiring immediate medical optimization 1

Pain Management Protocols

• Pain relief should be provided before diagnostic investigations begin, with formalized analgesia protocols including regular paracetamol and cautious opioid use 1
• Nerve blocks (femoral/fascia iliaca) significantly reduce acute pain and should be administered by trained emergency department staff 1
• Approximately 40% of patients have moderate renal dysfunction requiring careful medication selection 1

Critical Pitfalls of Office-Based Evaluation

Inadequate Resources

• Office settings lack the capability for immediate orthogonal radiographic views, IV access, continuous monitoring, and rapid surgical consultation 1, 3
• Fast-track triage systems in emergency departments enable early clinical recognition and rapid ward admission 1

Risk of Missed or Delayed Diagnosis

• Patients may present with only vague pain in buttocks, knees, thighs, groin, or back, with preserved ability to walk and indeterminate initial findings 4
• Office-based imaging delays definitive diagnosis and increases the risk of complications from prolonged immobility 1

Mortality Impact

• Hip fractures carry a 1-year mortality rate of 22% for women and 33% for men 1
• Up to 50% of patients may die within six months, with the highest mortality in the first six months post-fracture 5

Special Considerations

• Even when patients can walk and have no documented trauma, localized hip pain in patients >65 years should prompt immediate ED referral 4
• Patients with negative initial radiographs but persistent clinical suspicion require advanced imaging (MRI) that is typically only available through emergency department protocols 3
• The emergency department provides essential coordination for orthogeriatric comanagement, which has been shown to have the shortest time to surgery and lowest mortality rates 1