What is the initial management for a patient with a fracture of the proximal shaft of the femur?

Local Examination of Right Leg in Proximal Femoral Shaft Fracture

On local examination of the right leg in a patient with proximal femoral shaft fracture, you should identify the classic triad: hip pain (particularly on movement), inability to weight-bear, and a shortened, externally rotated leg on the affected side. 1

Key Physical Examination Findings

Classic Presentation

• The affected leg will appear shortened and externally rotated - this is the pathognomonic finding that enables early clinical recognition even before radiography 1
• Severe pain on movement is characteristic, as hip fractures are particularly painful with any attempted motion 1
• Complete inability to weight-bear will be present in virtually all cases 1

Additional Examination Components

• Assess skin condition and pressure areas carefully, as elderly patients are at high risk for pressure injuries 1
• Evaluate for musculoskeletal abnormalities including osteoarthritis, kyphoscoliosis, and fixed flexion deformities that may complicate management 1
• Document neurovascular status of the affected limb to establish baseline function 2

Immediate Management Priorities

Pain Control

• Immobilize the limb immediately to minimize pain and prevent further injury 1
• Administer regular paracetamol routinely unless contraindicated 1
• Use opioids cautiously - approximately 40% of hip fracture patients have moderate renal dysfunction (GFR <60 ml/min/1.73m²), requiring dose reduction until urea and electrolytes are reviewed 1
• Avoid NSAIDs as they are relatively contraindicated due to high prevalence of renal dysfunction 1
• Consider femoral or fascia iliaca nerve blocks administered by appropriately trained emergency department, orthopedic, or anesthetic staff for superior analgesia 1

Supportive Care

• Initiate intravenous fluid therapy to maintain adequate hydration 1
• Implement patient warming strategies to prevent hypothermia, particularly important in elderly patients 1
• Maintain pressure care throughout emergency department stay, especially if ward admission is delayed beyond 4 hours 1

Critical Pitfalls to Avoid

• Do not delay pain assessment and management - document pain scores at rest and on movement before and after analgesia administration 1
• Do not prescribe NSAIDs without checking renal function first - this population has extremely high rates of renal impairment 1
• Do not use standard opioid dosing in elderly patients - reduce both dose and frequency, particularly in those with renal dysfunction 1
• Do not neglect warming measures - hypothermia significantly increases morbidity in this population 1

Clinical Context

The examination findings guide immediate triage and enable fast-track systems that allow early radiography and diagnosis, facilitating rapid ward admission for further medical workup 1. Remember that early fracture fixation provides the most effective analgesia, so expedited surgical planning is paramount 1.