What is the appropriate evaluation and management for an elderly female patient with severe groin pain radiating to the back?

Severe Groin Pain in an Elderly Female Patient with Radiation to the Back

This presentation demands immediate evaluation for hip fracture, which is a medical emergency requiring urgent imaging and surgical planning within 24-48 hours to reduce mortality and complications. 1

Initial Clinical Assessment

The clinical presentation of severe groin pain radiating to the back in an elderly female is highly suspicious for hip fracture, particularly femoral neck or intertrochanteric fracture. 1 Key examination findings to assess immediately include:

• Leg position: Look for shortened and externally rotated lower extremity, which is pathognomonic for hip fracture 1
• Neurovascular status: Document dorsalis pedis pulse and lower extremity sensation to light touch 1
• Pain with hip rotation: Increased discomfort with internal and external rotation of the hip strongly suggests fracture 1
• Ability to ambulate: Inability to walk or bear weight is a critical indicator 1

Critical pitfall: Initial radiographs can be falsely negative in up to 10% of hip fractures, particularly basicervical femoral neck fractures. 1 If plain radiographs are negative but clinical suspicion remains high based on persistent groin pain and inability to bear weight, MRI of the hip must be obtained within 2-3 days to identify occult fractures. 1

Immediate Diagnostic Imaging

Order AP pelvis and lateral hip radiographs immediately as the first-line imaging modality. 1 These will identify:

• Displaced or non-displaced femoral neck fractures
• Intertrochanteric fractures (stable vs unstable/comminuted)
• Basicervical fractures
• Subtrochanteric fractures

If radiographs are negative but clinical examination shows persistent severe groin pain with hip rotation and inability to bear weight, do not discharge the patient—proceed directly to MRI of the hip. 1

Essential Laboratory Workup

Obtain the following labs immediately upon presentation:

• Complete blood count: Baseline hemoglobin is critical (normal range ~11-13 g/dL in elderly females) 1
• Basic metabolic panel: Assess renal function and electrolytes for surgical clearance 1
• Coagulation studies: Particularly if patient is on anticoagulation 1

Interdisciplinary Care Activation

Immediately activate interdisciplinary care with orthogeriatrics/hospitalist consultation (strong recommendation, strong evidence). 1 This approach significantly decreases complications and improves outcomes in elderly hip fracture patients. 1

The hospitalist or orthogeriatric team should:

• Provide medical clearance for surgery
• Optimize comorbidities (hypertension, diabetes, cardiac disease)
• Coordinate timing to operating room within 24-48 hours 1

Pain Management Protocol

Implement multimodal analgesia immediately, including peripheral nerve block (iliofascial block) in the emergency department (strong recommendation, strong evidence). 1 This approach:

• Reduces opioid requirements and associated side effects in elderly patients 1
• Provides superior pain control compared to systemic opioids alone 1
• Should include intravenous acetaminophen every 6 hours as first-line treatment 1

Avoid relying solely on opioids in elderly patients due to increased risk of delirium, respiratory depression, and falls. 1

Surgical Timing and Planning

Surgery should occur between 24-48 hours after admission (moderate recommendation, limited evidence). 1 Earlier surgery (within 24 hours) reduces mortality and complications in hip fracture patients. 1

Surgical approach depends on fracture pattern identified on imaging:

• Displaced femoral neck fracture: Arthroplasty (hemiarthroplasty or total hip arthroplasty) with cemented femoral stem (strong recommendation, strong evidence) 1
• Unstable intertrochanteric/subtrochanteric fractures: Cephalomedullary nail fixation (strong recommendation, strong evidence) 1
• Stable intertrochanteric fractures: May use sliding hip screw or cephalomedullary nail 1

Perioperative Management

Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion requirements (strong recommendation, strong evidence). 1

VTE prophylaxis with LMWH or UFH should be initiated as soon as possible and continued for 4 weeks postoperatively, adjusted for renal function and bleeding risk (strong recommendation, moderate evidence). 1

Blood transfusion is indicated for symptomatic anemia or hemoglobin <8 g/dL in postoperative asymptomatic patients (moderate recommendation, moderate evidence). 1

Critical Pitfalls to Avoid

1. Never discharge an elderly patient with severe groin pain and negative initial radiographs without MRI follow-up within 2-3 days—occult fractures are common and delay increases mortality. 1

2. Do not use preoperative traction—it provides no benefit and may increase complications (strong recommendation against, strong evidence). 1

3. Do not delay surgery beyond 48 hours unless absolutely necessary for medical optimization—each day of delay increases mortality risk. 1

4. Do not rely on clinical examination alone in patients with altered mental status or dementia—they may not report pain accurately, and systematic evaluation for hip fracture is mandatory in any elderly patient with fall and inability to ambulate. 1

Postoperative Care

• Immediate weight-bearing as tolerated is recommended (limited evidence, limited strength option) 1
• Osteoporosis evaluation and treatment must be initiated, including vitamin D, calcium, parathyroid hormone levels, and DEXA scan referral (strong recommendation, strong evidence) 1
• Continue multimodal analgesia with peripheral nerve blocks, acetaminophen, and minimal opioids 1