What are the local examination findings and management of a neck of femur (NOF) fracture?

Local Examination Findings of Neck of Femur Fracture

The classic triad of clinical findings in a neck of femur fracture includes hip pain, inability to weight-bear, and a shortened, externally rotated leg on the affected side. 1

Physical Examination Findings

Limb Position and Appearance

• Shortened lower extremity on the affected side due to muscle spasm and fracture displacement 1
• External rotation of the affected leg, typically visible when the patient is supine 1
• The degree of shortening and rotation correlates with fracture displacement 1

Pain Assessment

• Severe hip pain, particularly exacerbated by movement or attempted weight-bearing 1
• Groin pain that increases with internal and external rotation of the hip 1
• Pain should be assessed both at rest and with movement using standardized pain scores 1

Functional Status

• Complete inability to weight-bear or ambulate independently 1
• Patient typically cannot lift the affected leg off the bed (inability to perform straight leg raise) 1

Neurovascular Examination

• Palpable dorsalis pedis pulse should be documented to confirm distal perfusion 1
• Intact sensation to light touch throughout the lower extremity should be verified 1
• Document motor function in all nerve distributions if patient cooperation allows 1

Critical Examination Pitfalls

Common Diagnostic Errors

• Up to one-third of femoral neck fractures are initially missed on clinical examination alone, emphasizing the need for radiographic confirmation even with subtle findings 2
• In patients with negative initial radiographs but persistent groin pain that worsens with hip rotation, obtain MRI imaging within 2-3 days to identify occult fractures 1
• Stress fractures of the femoral neck may present with more subtle findings and require high clinical suspicion, particularly in active patients 1

Additional Assessment Considerations

• Examine for skin condition and pressure areas given the immobility and need for positioning 1
• Assess cognitive function as approximately 40% of patients have some degree of cognitive impairment that affects pain reporting 1
• Document pre-injury functional status including use of assistive devices and living situation, as this impacts treatment decisions 1

Immediate Management Priorities

Pain Control

• Administer opioid analgesia immediately, but use cautiously in patients with renal dysfunction (present in ~40% of hip fracture patients) 1
• Prescribe regular paracetamol unless contraindicated 1
• Avoid NSAIDs in patients with renal impairment (GFR <60 mL/min/1.73m²) 1
• Consider femoral or fascia iliaca nerve blocks for superior analgesia 1

Supportive Care

• Initiate intravenous fluid therapy to address dehydration from immobility 1
• Implement patient warming strategies to prevent hypothermia 1
• Ensure pressure area care during emergency department stay 1
• Immobilize the limb during transport and positioning 1

Diagnostic Confirmation

• Obtain AP pelvis and lateral hip radiographs as the initial imaging study 1
• If radiographs are negative but clinical suspicion remains high, proceed to MRI rather than waiting for follow-up radiographs, particularly for femoral neck fractures which are high-risk for displacement 1