Hip injuries are bread-and-butter emergency medicine, yet they are sometimes anything but straightforward. Hip fractures carry a 30-day mortality approaching six to seven percent and a one-year mortality of approximately 20 percent—comparable to acute coronary syndromes.¹ For many elderly patients, a hip fracture marks the beginning of functional decline, institutionalization, and death. Our role in the emergency department (ED) extends well beyond “get an X-ray and call orthopedics.” Emergency physicians can directly influence time-to-surgery, delirium risk, postoperative morbidity, and ultimately, survival.

Hip fractures are common because falls are common, but falls themselves are often a symptom of frailty and physiologic decline. Once elderly patients begin falling, the risk of recurrent falls and progressive loss of independence rises substantially. Many patients never regain their previous functional baseline after surgery. Mortality after hip fracture is driven less by the fracture itself than by complications including pneumonia, delirium, venous thromboembolism, pressure injuries, and myocardial infarction.^2-5 Even brief periods of immobilization accelerate deconditioning. The classic 1947 British Medical Journal essay, “The Dangers of Going to Bed,” remains remarkably relevant today.⁶

This principle underpins the modern push for expedited operative management. Several studies demonstrate improved outcomes when hip fracture surgery occurs within 24 hours, with mortality and complications rising when surgery is delayed beyond 24 to 48 hours.^7-10 The goal of surgery is not simply fracture fixation, it is mobilization.

What Actually Moves the Needle in the ED?

Emergency physicians cannot force a patient to the operating room faster, but we can eliminate delays. Early identification and management of barriers to surgery can substantially improve outcomes.

One of the most important interventions is clarifying anticoagulant status immediately. Determine precisely when the patient last took warfarin, apixaban, rivaroxaban, clopidogrel, or aspirin. Anticoagulation should not become the reason surgery drifts beyond the critical 24-hour window.¹¹ Routine preoperative investigations should be ordered immediately, including ECG; complete blood count; electrolytes; international normalized ratio when appropriate; and type and screen. Patients should be made NPO as soon as a hip fracture is suspected. Just as importantly, delirium prevention must begin in the ED. Delirium prolongs hospitalization, delays surgery, increases mortality, and contributes substantially to functional decline.^3,5

Pain control is central to delirium prevention. Ultrasound-guided femoral or fascia iliaca nerve blocks provide excellent analgesia, reduce opioid requirements, and likely reduce delirium risk.¹² Although regional hip blocks should generally be routine for elderly hip fracture patients, the treating physician should hesitate in younger patients with subtrochanteric or femoral shaft fractures who may be at risk for compartment syndrome because the block could potentially mask worsening pain. Ideally, EDs should develop “hip fracture kits” containing local anesthetic, needles, syringes, ultrasound instructions, and procedural aids to facilitate rapid bedside blocks.

Additional delirium-prevention measures include ensuring patients have access to hearing aids and glasses, avoiding benzodiazepines and anticholinergic medications, correcting dehydration and electrolyte abnormalities, and minimizing unnecessary urinary catheterization. Hip fracture pathways incorporating these interventions are associated with shorter hospital stays and lower mortality.¹³

Occult Hip Fractures

Occult hip fractures occur in approximately 2 to 10 percent of patients with normal initial radiographs.¹⁴ Many patients with nondisplaced femoral neck fractures or valgus-impacted fractures can still partially bear weight and may present walking with only a limp. Some elderly patients sustain the fracture before the fall itself; they twist awkwardly, experience sudden groin pain, and collapse afterward. In these cases, signs of trauma on physical exam may be absent, but don’t let this dissuade you from suspecting and working the patient up for a hip fracture.

History and physical examination remain critical. Groin pain strongly suggests intra-articular pathology. Pain reproduced with passive internal rotation is the most sensitive clinical sign of hip fracture.¹⁵ Pain with gentle log roll or axial loading may also support the diagnosis, though these findings are less specific.¹⁵ In contrast, a patient who can actively straight-leg raise comfortably and tolerate gentle hip rotation without pain is unlikely to harbor a clinically significant fracture.¹⁵

The patellar-pubic percussion test is an underutilized but highly sensitive adjunctive examination maneuver.¹⁶ With the patient supine, a stethoscope is placed over the pubic symphysis while the patella is gently tapped. Diminished sound transmission on the affected side suggests disruption of the femur-acetabulum-pelvis axis and may indicate occult fracture.

Physical examination should also assess for pelvic injuries. Tenderness over the pubic symphysis, sacrum, or iliac crests, pain with pelvic compression, and inability to perform a painless straight leg raise suggest pelvic ring injury rather than proximal femur fracture.¹⁷

A normal X-ray lowers the probability of fracture—it does not eliminate it. In elderly patients with persistent groin pain, inability to bear weight, pain with internal rotation, or abnormal gait despite normal radiographs, advanced imaging is warranted. Modern multi-slice CT has very good sensitivity approaching 95 percent but may still miss nondisplaced femoral neck fractures. MRI remains the gold standard with near-100 percent sensitivity and specificity.¹⁴

Understanding Fracture Patterns Matters

For emergency physicians, the most clinically useful distinction is not “subcapital versus intertrochanteric.” It is intracapsular versus extracapsular.

Intracapsular fractures involve the femoral neck within the joint capsule. Bleeding within this confined space can compromise femoral head blood flow, producing a compartment syndrome–like phenomenon that increases the risk of avascular necrosis.¹⁸ This distinction is particularly important in younger patients. A displaced femoral neck fracture in a young adult is an orthopedic emergency because preserving the native femoral head matters. Time to fixation matters. In contrast, elderly patients with displaced intracapsular fractures frequently undergo arthroplasty because femoral head viability is often already compromised.

Extracapsular fractures—intertrochanteric and subtrochanteric fractures—occur outside the capsule and bleed more substantially. Subtrochanteric fractures behave more like femoral shaft fractures and may produce significant blood loss, particularly in anticoagulated elderly patients. These fractures more commonly require transfusion and urgent operative fixation.

Isolated greater trochanter fractures are often managed nonoperatively, but caution is warranted. MRI studies demonstrate that up to one-half of apparently isolated greater trochanter fractures have occult intertrochanteric extension.¹⁴ Fractures extending beyond the midline may be unstable and require operative fixation. Another important exception is the young, active patient with a large, displaced greater trochanter fracture. In these patients, the injury may represent functional avulsion of the gluteus medius insertion, analogous to a full-thickness rotator cuff tear of the shoulder. Even in the absence of significant intertrochanteric extension, disruption of the hip abductor mechanism can result in substantial functional impairment. Unlike the typical elderly patient with an isolated greater trochanter fracture managed conservatively, these younger patients may require operative fixation to restore abductor function and optimize long-term mobility.¹⁹

The Differential Diagnosis of the Painful Hip with a Normal X-ray

Not all painful hips are fractures. The differential diagnosis of atraumatic hip pain is broad and nuanced. Septic arthritis, osteoarthritis flare, avascular necrosis, iliopsoas abscess, iliopsoas hematoma, subchondral insufficiency fracture, lumbar radiculopathy, and greater trochanteric pain syndrome (GTPS) should all be considered.

The distinction between intra-articular and extra-articular pathology is often clinically useful. Deep groin pain reproduced by passive internal rotation suggests intra-articular pathology such as fracture, osteoarthritis, or subchondral insufficiency fracture. In contrast, lateral hip pain with point tenderness over the greater trochanter and preserved passive range of motion suggests GTPS or gluteal tendinopathy.

Psoas pathology presents differently. Iliopsoas bursitis or tendinopathy typically causes anterior groin pain reproduced by resisted hip flexion rather than rotation. Iliopsoas abscess should be suspected in patients with fever, leukocytosis, immunosuppression, or pain worsened by passive hip extension. Iliopsoas hematoma, particularly in anticoagulated patients, may present with groin pain, anemia, femoral neuropathy, or flank ecchymosis.

Subchondral insufficiency fractures deserve special attention. These “stress fractures of the elderly hip” often present with acute groin pain, normal X-rays, and pain on internal rotation without major trauma. Diagnosis generally requires MRI.²⁰

The Role of Point-of-Care Ultrasound

Point-of-care ultrasound can occasionally assist in evaluating hip pathology. It is highly sensitive for detecting joint effusions and may expedite diagnosis in septic arthritis.²¹ However, the presence of an effusion broadens rather than narrows the differential diagnosis, as fracture, inflammatory arthritis, septic arthritis, and hemarthrosis can all produce effusions. Importantly, ultrasound should never be used to rule out fracture. Its greatest utility lies in identifying effusions and guiding hip aspiration when septic arthritis is suspected and interventional radiology is not available.

Hip injuries are deceptively nuanced. The challenge is not diagnosing the obvious shortened, externally rotated leg. The challenge is identifying the subtle occult fracture, recognizing mimics, preventing avoidable delays, and optimizing the vulnerable elderly patient before deterioration begins.

Next time you evaluate a patient with hip pain, resist the temptation to stop at the X-ray. Listen carefully to the history. Examine thoughtfully. Consider the patient’s physiology, not just the image. Those extra few minutes in the ED may profoundly alter the trajectory of that patient’s life.

Thank you to Dr. Arun Sayal and Dr. Matt DeStefano for their expert insights and practical clinical pearls from the EM Cases podcast that informed this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website (www.emergencymedicinecases.com).

References 

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Thank you to Dr. Arun Sayal and Dr. Matt DeStefano for their expert insights and practical clinical pearls from the EM Cases podcast that informed this column.