History and physical examination

3.1.1 Anamnesis

In general, the femoral neck fracture in the elderly results from a single trauma after a simple fall. Not infrequently it is accompanied by a fracture of the upper limb (distal radius, proximal humerus), often due to osteoporosis. In young persons a neck fracture is usually caused by a major trauma. Typically for an undisplaced fracture is the preserved or slowly deteriorating ability to walk. The inability to walk may also occur after repeated falls. Stress fractures are characterized by slowly increasing pain after prolonged or sudden overexer-tion. If the anamnesis reveals no trauma but a known systemic disease, a pathologic fracture must be suspected.

If at all possible, time and details of the accident, ability to walk and activities before the injury (could the patient leave his/her house, did he/she use walking aids?) must be documented. It is also helpful to question relatives, as the mental condition of older patients often does not permit to obtain information concerning the details of the accident. Data must also be gathered as to systemic diseases and medications. This information must be used when determining the kind of anesthesia and the operability. It is important for the success of later rehabilitation to gather the past history concerning the mobility and the neurologic status of the patient.

3.1.2 Inspection

The recognition of a displaced hip fracture does not present difficulties. The patient barely moves, is unable to walk and the injured lower limb is usually in external rotation and shortened (Fig. 74).

The clinical examination does not always allow to differentiate between a trochanteric and a neck fracture. The externally rotated and shortened limb is characteristic for both. In femoral neck fractures both signs are initially often less pronounced. The trochanteric fractures cause generally more pain. Local swelling is present but hematomas and suffusions occur later. A further typical sign is the marked limitation of hip movements.

If no external rotation of the limb is present, the diagnosis of an undisplaced fracture should come to mind. It is also seen in neck or trochanteric fractures where an anterior angulation at the fracture site, a recurvatum, is present. This is also of importance during the reduction of the fracture.

Hip Fracture Physical Exam

Fig. 74. Position of legs in displaced hip fracture.

a. View from anterior; b. View from inferior b

Fig. 74. Position of legs in displaced hip fracture.

a. View from anterior; b. View from inferior

No limb shortening is seen in fractures displaced in valgus, the limb might even be slightly longer.

3.1.3 Palpation

The site of maximum pain, exaggerated by palpation or compression, may reveal an important clue. Pain at the trochanteric area speaks in favor of a trochanteric fracture, whereas pain in the groin is typical of a neck fracture. Pain in the groin may also be due to a fracture of the pubic ramus that is not infrequently caused by the same injury mechanism in the elderly. Here the exact localization is of value as the patient mostly complains about pain on pressure over the pubic sym-physis. Pain provoked by tapping against the heel should raise the suspicion for an impacted fracture.

Radiation of pain into thigh or knee is not infrequently reported. This may deceive the physician performing only a superficial examination and he may not request the appropriate radiographs.

Of course, examination and documentation must include circulation and innervation of the limb. In the elderly the pedal arteries are often not palpable. Transient damage to the peroneal nerve may occur sometimes during forced internal rotation on the traction table. Damage to the peroneal nerve will cause an inability to extend the foot. If, however, such a damage had occurred during the initial trauma, only a proper preoperative examination can exclude an iatrogenic cause.

3.1.4 Functional examination

Any movement of the injured limb provokes pain at the hip. Once the leg has been elevated, the patient is unable to hold it in that position. This maneuver should be done carefully. As a rule a radiograph of the entire pelvis should be requested, particularly in patients over 40/50 years to exclude a neck fracture. Suspicion of such a fracture is raised by pain in hip and thigh and the fact that the patient is unable to lift the extended leg from the examining table without pain (Böhler, 1996).

Patients with Garden-I and -II fractures are often able to bear weight on the involved leg with the knee in extension, in spite of the fact that this causes pain.

Not infrequently, often after weeks, the patient is admitted to hospital since during the initial examination the fracture had not been diagnosed but the patient was treated for rheumatic affection or sciatica (Perret, 1964; Pathak et al, 1997). Due to a faulty diagnosis the optimal moment for treatment and the possibility of an immediate, internal fixation less stressful to the patient have been missed. Due to a prolonged bed rest the patient's condition may have worsened to a point where surgery is not anymore possible.

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