What's the next management step for an elderly female patient with a right femoral neck fracture, who is able to walk with mild pain, after a recent fall, and has signs of redness and hip pain?

Immediate Surgical Referral for Femoral Neck Fracture

This elderly patient with a confirmed femoral neck fracture requires urgent orthopedic surgical consultation and admission for operative management within 24-48 hours, regardless of her current ability to ambulate. 1, 2

Critical Understanding: Ability to Walk Does NOT Exclude Serious Fracture

• The fact that this patient can walk is misleading and dangerous—patients with basicervical and minimally displaced femoral neck fractures can maintain weight-bearing ability and function initially, but this does not indicate a stable fracture. 3
• The presence of redness suggests possible skin compromise, infection risk, or inflammatory response that requires immediate evaluation and may influence surgical timing. 2
• Her two-month history of hip pain after the first fall strongly suggests she may have had an occult fracture that has now displaced with the second fall. 3

Immediate Management Steps

1. Urgent Orthopedic Consultation and Hospital Admission

• Admit the patient immediately for surgical planning within 24-48 hours of presentation, as this timing significantly reduces short-term and mid-term mortality rates. 2
• Implement interdisciplinary care with orthogeriatric comanagement to decrease complications and improve outcomes (strong strength recommendation). 1

2. Preoperative Workup

• Obtain complete blood count (CBC) to assess for anemia and leucocytosis that may indicate infection. 2
• Check basic metabolic panel for electrolyte disturbances, particularly hypokalemia and hyponatremia. 2
• Obtain ECG in this elderly patient. 2
• Evaluate for malnutrition, volume status, and cardiac/pulmonary diseases. 2

3. Immediate Supportive Care

• Keep patient non-weight-bearing or protected weight-bearing with assistive device until surgical evaluation is complete. 3
• Initiate VTE prophylaxis with sequential compression devices immediately. 1, 2
• Assess and optimize pain control.

Surgical Treatment Decision

For Displaced Femoral Neck Fractures (Most Likely in This Case):

• Arthroplasty is the treatment of choice for displaced femoral neck fractures in elderly patients (strong strength recommendation). 1, 4
• Hemiarthroplasty is appropriate for most elderly patients with displaced fractures. 1, 4
• Total hip arthroplasty may be considered if the patient is active and has pre-existing hip arthritis. 1
• Use cemented femoral stem (strong strength recommendation). 1
• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion need (strong strength recommendation). 1

Surgical Approach:

• Either spinal or general anesthesia is appropriate (strong strength recommendation). 1
• No preferred hip arthroplasty approach (anterolateral, posterior, or direct anterior are all acceptable). 1

Postoperative Management

• Allow immediate weight-bearing as tolerated after surgery (limited strength option). 1
• Continue VTE prophylaxis for 4 weeks postoperatively with enoxaparin or equivalent (strong strength recommendation). 1, 2
• Transfuse for symptomatic anemia or hemoglobin <8 g/dL in asymptomatic patients (moderate strength recommendation). 1
• Refer to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation and secondary fracture prevention (strong strength recommendation). 1, 2

Critical Pitfalls to Avoid

• Do NOT delay surgery because the patient can walk—this is a false reassurance and the fracture requires definitive surgical treatment. 3
• Do NOT treat conservatively with observation or protected weight-bearing—femoral neck fractures in elderly patients require surgical intervention. 1, 4
• Do NOT assume the redness is benign—evaluate for infection, skin breakdown, or other complications that may affect surgical planning. 2
• Do NOT miss the opportunity to investigate why she had two falls—comprehensive falls risk assessment and secondary prevention are essential. 2