571 - If It Walks and Talks Like a Fracture

Case Diagnosis: Femoral Neck Fracture

Case Description: A 72-year-old male presented to the Emergency Department complaining of severe left hip pain after a mechanical fall, aggravated by ambulation and weight-bearing. Initial X-ray imaging was unremarkable, and the patient was discharged with outpatient orthopedic follow-up. Given the persistence of his hip pain, orthopedic clinicians obtained a CT-scan demonstrating left hip arthritis. The patient was then referred to the physiatry clinic for intra-articular steroid injection. Upon physiatry evaluation, nearly two months following the initial injury, the patient endorsed continued severe hip pain and ambulated with an antalgic gait favoring his left leg. Given these findings, MRI was obtained which revealed a non-displaced femoral neck fracture. He underwent successful surgical fixation of the fracture with significant functional improvement.

Discussions: Femoral neck fractures are associated with a high level of patient morbidity and mortality. In elderly patients, non-displaced femoral neck fractures are commonly treated with internal fixation, while displaced fractures are treated with arthroplasty. Operative fixation of non-displaced fractures is important to prevent future displacement. Femoral neck fractures are most often diagnosed successfully with radiographs, particularly anteroposterior views of the hip and pelvis, and lateral views of the hip. However, approximately 5% of nondisplaced femoral neck fractures are missed on initial radiographs and require the use of CT or MRI for identification. For this reason, advanced imaging modalities should be considered when symptoms are severe, persistent, or out-of-proportion to alternative diagnoses.

Conclusions: This case illustrates a unique instance of femoral neck fracture unidentified by both X-ray and CT imaging. In this instance, had an MRI not been obtained, he may have received inappropriate treatment or endured additional complications. It is, therefore, necessary for the physiatrist to lean on clinical judgement when faced with symptoms incongruent with imaging.