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Question

A 73-year-old man is brought to the emergency department after his daughter found him on the floor. The patient says that he fell and now his left hip "hurts a lot," but he does not recall any details of the fall. Over the past several days, he has felt short of breath with a cough and intermittent palpitations that he attributed to "coming down with the flu." His other medical problems include hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia His temperature is 37.3 C (99.2 F), blood pressure is 118/76 mm Hg, pulse is 116/min, and respirations are 24/min. Pulse oximetry shows 95% on 2 Umin of oxygen by nasal cannula. Breath sounds are decreased at the right lung base, and crackles are present at the left lung base. The left lower extremity is shortened and externally rotated. Initial laboratory studies, including complete blood count, glucose, and serum chemistries, are normal. The pain improves with a dose of hydromorphone. X-ray findings are shown below.

Which of the following is the best next step in management of this patient?

Options:

A Electrocardiogram, cardiac markers, and chest X-ray

B. Hemiarthroplasty for femoral neck fracture

C. Intravenous crystalloids

D. Lower-extremity skeletal traction

E. Skilled nursing care, with hip surgery after the viral syndrome resolves

Best next step:

(A) Electrocardiogram, cardiac markers, and chest x-ray.

🧠 Key Trigger: Underlying acute illness → Fall and hip fracture
⬇️
Respiratory Symptoms

Pre-existing risk (COPD, age) + potential acute infection
⬇️
Cough + shortness of breath → Likely pulmonary infection (e.g., pneumonia)
⬇️
Inflammatory cytokines ↑
⬇️
Crackles (fluid in alveoli) and decreased breath sounds (consolidation/effusion)
⬇️
Systemic inflammation → Contributes to tachycardia and predisposes to fall

🧠 Palpitations and Tachycardia
Acute illness + hypoxemia (95% O2 on nasal cannula)
⬇️
Possible atrial fibrillation (AF) or increased adrenergic tone
⬇️
Risk for falls due to arrhythmias or poor perfusion

🧠 Fall and Hip Fracture
Trauma from fall (often low-energy in elderly with osteopenia/osteoporosis)
⬇️
Femoral neck fracture
⬇️
🧠 Leg shortened + externally rotated → Pathognomonic for displaced femoral neck fracture

🧠 Pain Management
Fracture → Severe pain
⬇️
Improved with hydromorphone (strong opioid)

Diagnostic Approach to the Current Scenario

(A) ECG, Cardiac Markers, and Chest X-ray

🧠 Justification:

• ECG: Rule out arrhythmias (e.g., AF, ischemia-related palpitations).

• Cardiac markers: Rule out myocardial injury (possible acute coronary syndrome).

• Chest x-ray: Identify pneumonia (crackles, fever, symptoms) or effusion.

⬇️

If cardiac and respiratory issues are identified → Optimize before surgery

Explanation of Other Answers

(B) Immediate Hemiarthroplasty for Femoral Neck Fracture

• Premature without addressing underlying medical issues.
  ⬇️
  🧠 Risks: Perioperative complications due to untreated pneumonia or arrhythmia.

(C) Intravenous Crystalloids

• No signs of significant hypovolemia (normal BP, no clinical dehydration).

(D) Lower-Extremity Skeletal Traction

• Rarely used for femoral neck fractures; surgery is definitive.

(E) Delay Surgery Until "Viral Syndrome" Resolves

• Inappropriate as prolonged immobilization increases complications (e.g., VTE).

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