Hip Fracture

A confused elderly patient found on the floor with a shortened, externally rotated leg may lose independence permanently — your early assessment and preoperative management determine the outcome.

Hip fractures occur most often in older adults after low-energy falls, especially those with osteoporosis. The classic presentation is a shortened, externally rotated affected leg with groin or hip pain and inability to bear weight. Intracapsular fractures (femoral neck) risk disrupting blood supply to the femoral head, potentially causing avascular necrosis. Extracapsular fractures (intertrochanteric, subtrochanteric) bleed more heavily into surrounding tissue and carry higher risk for hypovolemia. Preoperatively, the nurse monitors neurovascular status of the affected limb (circulation, sensation, movement distal to the fracture), manages pain, and watches for signs of hemorrhage — tachycardia and hypotension may appear before visible blood loss since bleeding is internal. Buck traction may be applied preoperatively to reduce muscle spasm and immobilize the limb, not to reduce the fracture. Surgical repair — pinning, hemiarthroplasty, or total hip arthroplasty — typically occurs within 24–48 hours because delays beyond 48 hours significantly increase morbidity and mortality. Preoperative teaching about postoperative hip precautions, incentive spirometry, and DVT prophylaxis begins on admission.

Key Distinctions

Don't confuse hip fracture presentation (shortened, externally rotated leg) with posterior hip dislocation (internally rotated, flexed, adducted). Students often attribute tachycardia to pain alone — in hip fracture, always suspect occult hemorrhage first. Buck traction is temporary stabilization, not definitive treatment; the fracture still requires surgical repair.

Clinical Pearl

Shortened and externally rotated = hip fracture. Shortened and internally rotated = posterior dislocation. Let the leg position tell you the diagnosis before the X-ray does.