The Unwitnessed Fall and the Hip Series
An 81-year-old woman is brought from a nursing home after an unwitnessed fall. She has right hip pain, cannot bear weight, and her right leg appears shortened and externally rotated. She is confused and cannot give a reliable history. Her skin is intact over the hip, but she has a stage 2 pressure injury over the sacrum. The order is for an AP pelvis and a lateral right hip. She is in moderate pain and moans when moved. There is no family member present. The nursing home aide says she 'sometimes gets combative.'
1. What patient-care and safety considerations guide this exam before you position her?
Read the worked answer
Several overlapping issues:
- Suspected hip fracture: Shortening and external rotation with inability to bear weight strongly suggest a proximal femur fracture. Movement must be minimized and gentle; do not force internal rotation or extreme abduction for a 'textbook' lateral if it causes severe pain.
- Pain management and consent: She cannot consent reliably. Proceed under the ordering provider's authority, but pause to explain simply and move slowly. Ask the aide what calms her. Consider whether analgesia has been given.
- Skin integrity: The sacral pressure injury means pressure and shear are harmful. Pad the table, avoid dragging her, and use draw sheets with help.
- Confusion and combative behavior: Risk of falling off the table or injuring herself. Keep the stretcher locked, use rails, and have a second person present if possible. Never leave her unattended.
- Communication: Notify the provider of the presentation and document the limitations and behavior.
The exam should be adapted to her, not the reverse.
2. How would you obtain the lateral hip with minimal movement and pain?
Read the worked answer
Use a technique that respects the suspected fracture:
- Cross-table (horizontal beam) lateral hip with the patient supine: place the detector vertically against the lateral aspect of the hip, direct the beam horizontally through the hip, and center to the femoral neck. This avoids rolling her onto the affected side, which would be painful and risky.
- If she can tolerate slight movement, a frog-leg or groin lateral may be attempted only with caution; with a suspected fracture, the cross-table approach is safer.
- AP pelvis: keep her supine, align the midline, and include the entire pelvis and both hips. Do not rotate her legs forcibly.
- Technique: adequate kVp and mAs for her size, tight collimation, gonadal shielding where it does not obscure the femoral neck, and a short exposure time to reduce motion.
- Support: pad under the affected leg, keep her warm, and move in coordinated steps with help.
Document that a cross-table lateral was used because of suspected fracture and pain.