What physical exam should I perform on an older adult patient with suspected hip fracture and potential comorbidities such as osteoporosis?

Physical Examination for Suspected Hip Fracture

Perform a focused physical examination that includes assessment of limb position, leg length, range of motion testing, and weight-bearing ability, while recognizing that physical examination alone cannot definitively diagnose or exclude hip fracture. 1, 2

Critical Understanding: Limitations of Physical Examination

• Physical examination is often inconclusive and cannot reliably diagnose or exclude hip fractures, making imaging essential for definitive diagnosis 1, 2
• Approximately 10% of proximal femoral fractures are not identified on initial radiographs, underscoring the limitations of clinical assessment alone 2

Essential Physical Examination Components

Observation and Inspection

• Assess the affected limb for classic positioning: shortened, externally rotated, and abducted appearance in displaced fractures 3, 4
• Evaluate the patient's ability to ambulate: inability to bear weight is typical in hip fracture patients 2, 3
• Observe gait pattern if the patient can walk, as this is performed by 86% of hip specialists 5

Range of Motion Testing (Supine Position)

• Test hip flexion range of motion (performed 98% of the time by specialists) 5
• Assess flexion with internal rotation (performed 98% of the time) 5
• Evaluate flexion with external rotation (performed 86% of the time) 5
• Perform passive supine rotation test (performed 76% of the time) 5
• Note that severe pain on movement is characteristic of hip fracture 2

Functional Assessment

• Test single-leg stance if tolerated (performed 77% of the time by specialists) 5
• Assess straight leg raise against resistance (performed 61% of the time) 5

Additional Measurements

• Measure and document height and weight without shoes 1
• Test muscle strength as part of comprehensive fracture risk assessment 1
• Assess for spinal tenderness, deformity, and reduced space between lower ribs and upper pelvis to identify potential undiagnosed fractures 1

Critical Pitfall to Avoid

Do not rely on physical examination findings to rule out hip fracture. Even with a normal or equivocal physical examination, if clinical suspicion exists based on mechanism of injury (particularly ground-level fall in elderly patients), history of inability to bear weight, or groin pain, proceed immediately to radiographic imaging 1, 2. The sensitivity of physical examination alone is insufficient to exclude fracture, and delays in diagnosis are associated with increased mortality, complications, and hospital length of stay 1, 2.

Immediate Next Steps After Physical Examination

• Order anteroposterior (AP) pelvis radiograph with 15 degrees internal rotation and cross-table lateral view of the affected hip as the initial imaging of choice 1, 2
• If radiographs are negative but clinical suspicion remains high, proceed with MRI without IV contrast to detect radiographically occult fractures 1, 2
• Provide pain relief before diagnostic investigations begin, including nerve blocks (femoral/fascia iliaca) administered by trained staff 2