What is the appropriate approach to examining an adult or elderly patient with a history of trauma and potential underlying conditions such as osteoporosis or previous hip fractures, presenting with a hip injury?

Hip Examination in Trauma: Evidence-Based Approach

In adult and elderly trauma patients with suspected hip injury, immediately obtain AP pelvis radiographs with 15 degrees internal rotation and a cross-table lateral view of the affected hip—physical examination alone cannot reliably diagnose or exclude hip fractures, and imaging delays directly increase mortality. 1, 2

Critical Time-Sensitive Principles

Hip fractures cannot be diagnosed or excluded definitively via physical examination alone, making immediate imaging essential rather than optional. 1, 2 Surgical delays beyond 12 hours significantly increase 30-day mortality risk in patients over 50 years of age. 1

Key Physical Examination Findings (But Never Sufficient Alone)

• Classic presentation includes: inability to ambulate, shortened and externally rotated affected limb, and severe pain with any movement. 2
• Obligate external rotation during passive hip flexion is a characteristic finding in displaced fractures. 3
• Despite these findings, approximately 10% of proximal femoral fractures are not identified on initial radiographs, and physical examination has insufficient sensitivity to rule out fracture. 2, 3

Immediate Imaging Protocol

First-Line Imaging (Always Required)

Obtain standard hip radiographs immediately, which must include: 1

• AP view of the pelvis with 15 degrees internal hip rotation
• Cross-table lateral view of the affected hip (NOT frog-leg lateral, which risks fracture displacement)
• Many institutions appropriately include an AP pelvis view for bilateral hip symmetry assessment

Radiographs can be performed portably in the trauma bay, enabling rapid diagnosis without moving the patient and reducing morbidity from acute fracture or dislocation. 1

When Initial Radiographs Are Negative or Indeterminate

If clinical suspicion persists despite negative radiographs, immediately proceed to CT hip without IV contrast as the next imaging study. 1 The relative speed of CT acquisition versus MRI supports its use when rapid diagnosis is critical to decreasing fracture-related morbidity. 1

• CT detects radiographically occult fractures in 39% of patients with negative initial radiographs and clinical suspicion for hip fracture. 1
• If CT remains negative or equivocal but clinical concern persists, obtain MRI hip without IV contrast as the definitive study. 1

Essential Clinical Assessment Components

Preoperative Multidisciplinary Evaluation

Comprehensive assessment must include: 1, 2

• Chest X-ray
• ECG
• Full blood count and clotting studies
• Renal function testing (approximately 40% have moderate renal dysfunction requiring medication adjustment)
• Cognitive baseline function assessment
• Evaluation for malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary disease, and delirium

Approximately 70% of hip fracture patients are ASA physical status 3-4 with multiple comorbidities requiring immediate medical optimization. 2

Pain Management (Before Diagnostic Investigations)

Provide pain relief before starting diagnostic investigations: 1, 2

• Nerve blocks (femoral or fascia iliaca) significantly reduce acute pain and should be administered by trained emergency department staff
• Regular paracetamol with cautious opioid use
• Formalized analgesia protocols improve outcomes

Critical Management Timeline

Surgery must occur within 24-48 hours of admission to significantly reduce mortality rates and medical complications from immobility (decubitus ulcers, pneumonia, increased length of stay). 1, 2 The most recent evidence suggests surgical delay beyond 12 hours increases adjusted 30-day mortality risk. 1

Orthogeriatric Comanagement

Joint care between geriatrician and orthopaedic surgeon on a dedicated orthogeriatric ward has been shown to achieve: 1, 2

• Shortest time to surgery
• Shortest length of inpatient stay
• Lowest inpatient and 1-year mortality rates

Common Pitfalls to Avoid

Never obtain frog-leg lateral views in suspected unstable fractures—this positioning can worsen displacement and should be replaced with cross-table lateral views. 1, 3

Office-based evaluation is inadequate for trauma patients because it lacks capability for immediate orthogonal radiographic views, IV access, continuous monitoring, and rapid surgical consultation. 2

Do not delay imaging to "complete the physical examination"—physical examination findings, while helpful for clinical suspicion, have insufficient sensitivity and specificity to guide definitive management decisions. 1, 2

Special Population Considerations

Elderly/Osteoporotic Patients

• One-year mortality rates: 22% for women, 33% for men. 2
• Low-force trauma (ground-level falls) frequently results in proximal femur or pelvic fractures. 1
• These patients require comprehensive geriatric assessment as part of multidisciplinary care. 1

Bilateral Imaging Considerations

Obtain bilateral hip imaging when evaluating younger patients, as 20-40% may develop contralateral pathology. 4, 3 An AP pelvis view accomplishes this efficiently. 1