Management of Acute Right Hip Pain with Suspected Pelvic/Hip Fracture
Immediately obtain AP pelvis and cross-table lateral right hip radiographs as ordered, administer IV paracetamol for pain control, and activate orthopedic consultation now—this patient requires urgent fracture evaluation and potential surgery within 24-48 hours to reduce mortality and complications. 1, 2
Immediate Diagnostic Imaging (Already Appropriately Ordered)
The pelvis AP and cross-table lateral right hip views are the correct first-line imaging studies for acute traumatic hip pain, as they rapidly detect hip fractures and dislocations without moving the patient, reducing morbidity 1.
The cross-table lateral view is specifically preferred over frog-leg lateral due to risk of fracture displacement with the frog-leg technique 1.
Critical caveat: Initial radiographs can be falsely negative in up to 10% of hip fractures 2. If radiographs are negative or indeterminate but clinical suspicion remains high (severe pain, inability to bear weight, pain score 9/10), proceed immediately to CT hip without IV contrast (94% sensitivity, 100% specificity) or MRI hip without contrast (gold standard) 1, 3.
Immediate Pain Management
IV paracetamol 300 mg now is appropriate as part of multimodal analgesia 1, 2.
Strongly consider adding a peripheral nerve block (fascia iliaca or femoral nerve block) immediately, as the American Academy of Orthopaedic Surgeons strongly recommends multimodal analgesia including peripheral blocks to reduce opioid requirements and associated side effects in elderly patients with hip fractures 1, 2.
Avoid relying solely on NSAIDs or opioids—this patient already failed etoricoxib (an NSAID), and opioids alone increase delirium, respiratory depression, and fall risk in this population 2.
Laboratory Workup (Already Appropriately Ordered)
CBC to assess for anemia from occult blood loss and leukocytosis indicating infection 3.
Urinalysis to rule out urinary tract infection as a confounding factor 3.
Add comprehensive metabolic panel (electrolytes, renal function, calcium) and ECG in all elderly hip trauma patients 3.
Add coagulation studies if anticoagulation therapy is present or surgery is anticipated 3.
Urgent Orthopedic and Medical Consultation
Activate orthopedic surgery consultation immediately—do not wait for imaging results if fracture is suspected based on clinical presentation (severe pain 9/10, antecedent trauma from climbing escalator, inability to ambulate) 2.
Activate hospitalist or orthogeriatric consultation simultaneously—the American Academy of Orthopaedic Surgeons strongly recommends immediate interdisciplinary care to decrease complications and improve outcomes, with surgery ideally within 24-48 hours of admission 1, 2.
The hospitalist team should provide medical clearance, optimize hypertension and dyslipidemia, and coordinate surgical timing 2.
Management Based on Imaging Results
If Fracture Confirmed on Radiographs:
Surgery within 24-48 hours significantly reduces short-term and mid-term mortality rates and complications from immobility 1, 2, 3.
Surgical approach depends on fracture pattern: arthroplasty for displaced femoral neck fractures, cephalomedullary nail fixation for unstable intertrochanteric/subtrochanteric fractures 1, 2.
Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements (strong evidence) 1, 2.
Initiate VTE prophylaxis with enoxaparin or unfractionated heparin as soon as possible, adjusted for renal function 1, 2.
If Radiographs Negative but High Clinical Suspicion Persists:
Proceed immediately to CT hip without IV contrast (preferred for speed) or MRI hip without contrast (gold standard, 100% sensitivity for occult fractures) 1, 3.
Do not discharge the patient or delay advanced imaging—occult fractures can present with severe pain and preserved range of motion initially 3.
Multiple studies demonstrate that CT after negative radiographs finds occult hip fractures in 24.1% of cases and changes management in 20% 1.
If All Imaging Negative:
Consider alternative diagnoses: trochanteric bursitis, iliopsoas tendinitis, lumbar radiculopathy (given history of lower back pain), or referred pain from lumbar spine pathology 1.
However, given pain severity (9/10) and functional impairment, maintain high suspicion and consider repeat imaging in 2-3 days if symptoms persist 2, 3.
Common Pitfalls to Avoid
Do not rely on preserved range of motion or lack of trauma history to exclude fracture—patients with minimally displaced fractures can maintain function initially, and this patient has a clear mechanism (climbing escalator) 3.
Do not discharge without advanced imaging if radiographs are negative but clinical suspicion remains high—this is a medical emergency requiring urgent diagnosis 2, 3.
Do not delay orthopedic consultation until imaging is complete—activate consultation immediately based on clinical presentation 2.
Do not use bone scan—there is insufficient evidence to support bone scan for acute traumatic hip pain evaluation 1.
Postoperative Management (If Fracture Confirmed and Surgery Performed)
Immediate weight-bearing as tolerated to prevent complications and promote recovery 1, 2, 3.
Osteoporosis evaluation and treatment with bisphosphonates, calcium, and vitamin D supplementation to reduce risk of subsequent fractures 1, 3.
Comprehensive rehabilitation program coordinated by orthogeriatricians, including physiotherapy and fall prevention strategies 3.