Last reviewed: March 2026
Contents
MDM Templates
Hip Fracture
Patient presents after fall with hip pain, shortened and externally rotated lower extremity. Imaging confirms hip fracture without dislocation. Neurovascular exam distally intact with soft compartments.
Patient does not currently demonstrate complications of fracture such as compartment syndrome, neurovascular injury, or open fracture.
Orthopedics consulted: Regarding fracture pattern, pain control (fascia iliaca block versus systemic analgesia), and operative planning.
Plan: Analgesia. Fascia iliaca block performed for pain control.
Disposition: Admit for surgical fixation.
Hip Dislocation
Patient presents after high-energy mechanism with severe hip pain and inability to move the affected extremity. Imaging confirms hip dislocation. Neurovascular exam distally intact prior to reduction.
Hip dislocation is a time-sensitive emergency — risk of avascular necrosis increases significantly after 6 hours. Emergent reduction performed under procedural sedation.
Post-reduction imaging confirms anatomic reduction. Neurovascular status intact before and after reduction. CT hip obtained post-reduction to evaluate for occult acetabular fracture.
Orthopedics consulted: Regarding post-reduction imaging, weight-bearing restrictions, and disposition.
Plan: Knee immobilizer to limit hip flexion beyond 90 degrees. Non-weight-bearing on affected extremity.
Disposition: Orthopedic follow-up within 1 week for further management.
Pelvic Fracture — Stable
Patient presents after fall with pelvic pain. Imaging demonstrates isolated pubic rami fractures without ring disruption. They are hemodynamically stable with soft abdomen. Neurovascular exam of bilateral lower extremities intact. No blood at urethral meatus or perineal ecchymosis.
History, exam, and imaging consistent with stable pelvic fracture without evidence of ring disruption, hemorrhage, or urologic injury.
Plan: Analgesia. Weight-bearing as tolerated with assistive device.
Disposition: Discharge with return precautions if safe to mobilize. Follow up with PCP within 1 week. Consider PT referral.
Pelvic Fracture — Unstable
Patient presents after high-energy mechanism with pelvic pain and hemodynamic instability. Imaging demonstrates unstable pelvic ring disruption. FAST exam performed.
Concern for significant hemorrhage from pelvic fracture. Pelvic binder applied. Massive transfusion protocol initiated.
Trauma surgery consulted: Regarding hemodynamic instability, pelvic fracture pattern, and need for angioembolization versus operative management.
Plan: Pelvic binder. Resuscitation with blood products. Foley catheter (after ruling out urethral injury).
Disposition: Admit to trauma service.
Procedure Notes
Fascia Iliaca Block
Location: *** lower extremity, anterolateral approach
Time Out: Correct patient, correct procedure confirmed
Anesthesia: Ultrasound-guided regional block
Approach: The anterolateral hip was prepped and cleansed in sterile fashion. The femoral nerve, fascia lata, and fascia iliaca were identified with ultrasound guidance
Methods: 0.5% bupivacaine plain injected just lateral to the nerve bundle. An expanding anechoic collection just below the fascia iliaca was visualized. A total of 30 mL was used to infiltrate around the femoral nerve
Complications: None. Patient tolerated procedure well with excellent analgesia.
Hip Reduction
Location: *** hip
Time Out: Correct patient, correct procedure confirmed
Consent: Verbal consent obtained with risks, benefits, and alternatives discussed
Anesthesia: Procedural sedation with ***
Position: Supine
Method: Gentle downward pressure placed on the pelvis. The extremity was elevated to 90 degrees of hip flexion. Traction-countertraction technique used to reduce the hip in standard fashion
Post-procedure: Hip joint appears clinically reduced with full range of motion. X-ray confirms anatomic reduction. Neurovascular status intact before and after reduction
Complications: None. Patient tolerated procedure well.
Clinical Education
Hip Fracture Pearls
Hip fracture location drives management. Femoral neck fractures (intracapsular) have a tenuous blood supply — displaced femoral neck fractures in elderly patients often get hemiarthroplasty rather than fixation because of high avascular necrosis rates. Intertrochanteric fractures (extracapsular) have better blood supply and are typically treated with intramedullary nailing. Both need surgery, but the urgency and approach differ.[1]
One-year mortality after hip fracture in elderly patients is 20–30%. The hip fracture itself is often a marker of frailty rather than the direct cause of death. Early surgery (within 24–48 hours) is associated with reduced mortality and complications. This is why admission and expedited surgical planning matter.[2]
Occult Hip Fracture
If clinical suspicion is high and X-ray is negative, the fracture is not ruled out. Approximately 2–10% of hip fractures are occult on initial plain films. The elderly patient who can’t bear weight after a fall, has groin pain, and has pain with log-roll of the hip needs further imaging even with normal X-rays. MRI is the gold standard. CT is a reasonable alternative if MRI isn’t available — its sensitivity is ~90–95% for occult fractures.[3]
Hip Dislocation Pearls
Reduce within 6 hours to minimize AVN risk. Posterior dislocations (~90% of traumatic hip dislocations) present with the leg shortened, internally rotated, and adducted. Anterior dislocations are rare and present with the leg externally rotated and abducted. The clock starts at time of injury, not time of arrival.[4]
Always get a CT after reduction. Occult acetabular fractures are present in up to 70% of hip dislocations and are often not visible on plain films. The CT findings frequently change management — loose bodies in the joint may need arthroscopic removal, and certain acetabular fracture patterns need operative fixation.
Post-reduction precautions: Don’t bend hip past 90 degrees (knee immobilizer helps enforce this). Don’t cross the midline with the affected leg. Non-weight-bearing until orthopedic follow-up.
Pelvic Fracture Classification
The key question: is the pelvic ring intact? A single break in the ring (isolated ramus fracture) is stable. Two or more breaks in the ring create instability. The Young-Burgess classification categorizes by mechanism (lateral compression, AP compression, vertical shear) and predicts hemorrhage risk.[5]
| Pattern | Stability | Hemorrhage Risk |
| Isolated ramus fracture | Stable | Low |
| Lateral compression (LC) | Variable | Moderate (ring closes) |
| AP compression (open book) | Unstable | High (ring opens, venous plexus) |
| Vertical shear | Unstable | Highest |
Fascia Iliaca Block Pearls
The fascia iliaca block is the go-to regional technique for hip fracture pain in the ED. It’s safer and more effective than systemic opioids for elderly hip fracture patients. Under ultrasound, identify the femoral nerve, fascia lata (superficial), and fascia iliaca (deep). Inject 30–40 mL of dilute local anesthetic (0.25–0.5% bupivacaine) just deep to the fascia iliaca, lateral to the nerve. Watch for the expanding anechoic fluid collection tracking under the fascia.[6]
This blocks the femoral, lateral femoral cutaneous, and obturator nerves — covering the anterior hip, lateral thigh, and medial thigh. Onset is 15–20 minutes. Duration is 8–12 hours with bupivacaine.
Elderly Falls — The Bigger Picture
The hip fracture is the injury you found — make sure you haven’t missed the reason they fell. In elderly patients, always consider syncope (cardiac or orthostatic), stroke, medication effects (anticoagulants, sedatives, antihypertensives), and infection as precipitants. An ECG and basic labs (glucose, hemoglobin) are reasonable in elderly fall patients even when the chief complaint seems purely orthopedic.[7]
References
- Bhandari M et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck: a meta-analysis. J Bone Joint Surg Am. 2003;85(9):1673-1681. PubMed
- Brauer CA et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573-1579. PubMed
- Hakkarinen DK et al. Magnetic resonance imaging for occult hip fractures following femoral neck fracture: systematic review and meta-analysis. Emerg Radiol. 2012;19(5):367-373. PubMed
- Clegg TE et al. Time to reduction is correlated with osteonecrosis after traumatic hip dislocation. Clin Orthop Relat Res. 2010;468(12):3321-3325. PubMed
- Young JW, Burgess AR. Radiological management of pelvic ring fractures. Urban & Schwarzenberg. 1987.
- Morrison RS et al. A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery. J Am Geriatr Soc. 2009;57(1):1-10. PubMed
- Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off.” JAMA. 2010;303(3):258-266. PubMed
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