A 66-year-old man is brought to the emergency department with low back and left hip pain. The patient tripped at work and fell backwards, landing on his left side. He has no head injury or loss of consciousness. Medical history is unremarkable. Blood pressure is 148/90 mm Hg, pulse is 105/min, and respirations are 18/min. On examination, the left paraspinal lumbar area and left hip are tender to palpation. The neurovascular examination is intact. X-ray is obtained and is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 66-year-old man is brought to the emergency department with low back and left hip pain.  The patient tripped at work and fell backwards, landing on his left side.  He has no head injury or loss of consciousness.  Medical history is unremarkable.  Blood pressure is 148/90 mm Hg, pulse is 105/min, and respirations are 18/min.  On examination, the left paraspinal lumbar area and left hip are tender to palpation.  The neurovascular examination is intact.  X-ray is obtained and is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d85c_5761_bc81_e334432a4757_MD0003_00 This patient's x-ray reveals common features of a femoral neck fracture, including shortening of the neck, disruption of the normal cortical contour, and irregular lucency at the fracture plane. Femoral neck fractures are most common at age >65, typically presenting with hip pain after a fall. Displaced fractures may show shortening and external rotation of the affected extremity due to unopposed contraction of the iliopsoas and gluteus medius, but this finding is not always readily visible. femoral neck fracture Femoral neck fractures shortening and external rotation The femoral neck has a thin periosteum and a tenuous blood supply that can be disrupted by injury; femoral neck fractures have a significant risk of complications, including secondary instability, avascular necrosis, malunion, and degenerative changes in the femoral head. Therefore, surgical repair with either open reduction/internal fixation or (hemi)arthroplasty is indicated for most patients. open reduction/internal fixation or (hemi)arthroplasty (Choices A, D, and E) Most stable pelvic fractures are managed with pain control and early mobilization (eg, weight bearing as tolerated). Also, pubic rami fractures often can be managed nonoperatively with pain control and physical therapy. Sacral insufficiency fractures are often treated initially with pain control and non-weight bearing. Although nonoperative management is often recommended for nonambulatory, debilitated patients with femoral neck fracture, ambulatory patients require surgical repair. (Choice C) CT scan of the pelvis is not usually needed if fracture is confirmed on x-ray. In the case of a normal x-ray but high suspicion for fracture (eg, inability to bear weight), CT scan can be obtained. Educational objective: Femoral neck fractures are most common in elderly individuals, typically presenting with hip pain after a fall. Common x-ray findings include shortening of the femoral neck, disruption of the normal cortical contour, and irregular lucency at the fracture plane. Femoral neck fractures have a significant risk of complications (eg, secondary instability, malunion), and surgical repair is indicated for most patients.

A 66-Year-Old Man Is Brought to the Emergency Department with Low