What is the diagnosis?

Femoral neck fracture that appears subacute

Image 2. Initial image with label by author

Why is this concerning?

The blood supply to the proximal femoral head is primarily from the medial femoral circumflex artery (MFCA, see Image 3) via retrograde flow. This places the femoral head in a watershed area, which makes it susceptible to malunion and avascular necrosis in the event of a femoral neck fracture.

Image 3. courtesy of Tabitha Ford, MD

What could have prevented this from happening?

Walking on the hip after fracture exacerbated the patient’s condition. Due to high malunion occurrence with non-operative treatment, hip fractures are generally admitted for surgical operation when they initially present. 

• Pearl: Hip fractures are associated with high rates of morbidity and mortality even when treated appropriately. Complication rates are even worse when missed, so keep a high suspicion in falls of the elderly [1].

• Pearl: X-ray has been found to have a 90-98% sensitivity for proximal hip/pelvic fractures. If you have high suspicion and it is not seen on x-ray or CT, an MRI is considered the gold standard [2]. 

When do you consult Orthopaedics?

The patient will need operative repair via a hip replacement in the near future, but this can be either inpatient or outpatient. The timing of this will be guided by institutional protocol and/or discussion with your orthopedic surgeon. If being discharged, the patient should be made strictly non-weightbearing, be able to care for themselves in this setting, and have close follow-up in place.