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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Older adult hip fracture usually follows low-energy fall and indicates osteoporosis
- Classic exam: groin pain, inability to bear weight, shortened externally rotated leg
- Initial imaging: AP pelvis and lateral hip x-rays
- MRI detects occult fracture when x-ray negative but suspicion remains
- Most require early operative management once optimized
Overview
Hip fracture includes femoral neck, intertrochanteric, and subtrochanteric proximal femur fractures. In older adults it causes high mortality, delirium, disability, and loss of independence.
Epidemiology
Risk rises with age, osteoporosis, prior fracture, low BMI, falls, impaired vision, sedatives, alcohol, dementia, stroke, Parkinson disease, and glucocorticoids.
Clinical Features
Symptoms
Hip or groin pain after fall
Inability to bear weight
Pain with any hip movement or log roll
Persistent groin pain despite normal x-ray suggests occult fracture
Preceding syncope/chest pain/neuro symptoms may explain fall
Signs
Shortened externally rotated leg
Groin tenderness and pain with passive ROM
Inability to perform straight-leg raise
Document distal neurovascular status
Delirium/frailty affect perioperative risk
Investigations
First-line
Focused clinical assessmentPattern recognition, red flags, functional impact, and targeted examination
Basic labs when indicatedCBC, CMP, ESR/CRP, CK, urinalysis, or disease-specific testing depending on suspected condition
Initial imaging when indicatedPlain radiographs or MRI/ultrasound based on suspected structural, inflammatory, infectious, or neurologic disease
Second-line
Disease-specific confirmatory testingAutoantibodies, HLA-B27, synovial fluid, nerve conduction studies, DEXA, or cultures as appropriate
MRI/ultrasound/CTUsed for early inflammatory disease, occult fracture, tendon tear, infection, or surgical planning
Screening before immunosuppressionTB, hepatitis, vaccination review, and baseline labs when biologic or high-risk therapy is planned
Specialist
Specialist referralRheumatology, orthopedics, infectious disease, ophthalmology, neurology, or spine surgery depending on red flags and disease severity
1
Initial management
- Address red flags and emergencies first
- Use guideline-directed first-line therapy matched to disease severity
- Educate the patient and set functional goals
- Use analgesia and rehabilitation when appropriate
2
Escalation
- Escalate to specialist-directed therapy if severe, refractory, progressive, or organ-threatening disease
- Use imaging, procedures, immunosuppression, antibiotics, or surgery according to diagnosis
- Monitor response objectively and revise diagnosis if response is atypical
3
Prevention and follow-up
- Manage comorbidities and medication toxicity
- Vaccinate and screen when immunosuppression is used
- Prevent disability, falls, fracture, infection, and functional decline
Complications
- Functional impairment: Pain, weakness, stiffness, deformity, or disability depending on disease
- Diagnostic delay: Missed infection, fracture, inflammatory disease, neurologic compromise, or organ-threatening complication
- Medication toxicity: NSAID, steroid, antibiotic, anticoagulation, opioid, or immunosuppressive adverse effects
- Chronic disease burden: Reduced quality of life, work impairment, deconditioning, and mental health impact
USMLE Step 2 CK Exam Tips
- 1Fall + groin pain + shortened externally rotated leg = hip fracture
- 2Initial imaging = AP pelvis and lateral hip x-rays
- 3Negative x-ray but unable to bear weight = MRI
- 4Femoral neck fracture risks avascular necrosis
- 5Displaced femoral neck fracture in older adult usually needs arthroplasty
- 6Hip fracture is osteoporosis-defining fragility fracture
practicetest your knowledge on hip fractureApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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