A 78-year-old client is admitted to the emergency department after falling at home. The client reports severe pain in the right hip and is unable to bear weight. Which assessment finding would be most indicative of a fractured hip?

External rotation and shortening of the affected leg is the classic sign of hip fracture due to muscle pull and bone displacement. Other findings like bruising or tenderness are less specific and can occur with soft tissue injuries.

Core Nursing Explanation Key Concept Analysis: This question assesses the ability to identify the most specific and classic sign of a hip fracture, particularly in an elderly patient after a fall. The pathophysiology involves the fracture disrupting the continuity of the femur, typically at the femoral neck or intertrochanteric region. The powerful muscles surrounding the hip (especially the iliopsoas and gluteal muscles) contract, pulling the distal fragment, leading to a characteristic deformity.

Answer Rationale: Key Point! External rotation and shortening of the affected leg is the hallmark sign of a displaced hip fracture. The shortening occurs because the fractured bone ends override each other. The external rotation (foot pointing outward) is caused by the unopposed pull of the external rotator muscles on the distal fragment. This finding is highly specific for a fracture and is a key part of the physical assessment.

Distractor Analysis:
① Watch out for confusion! Bruising and swelling are common with many injuries, including hip fractures, but they are not specific. They can occur with severe contusions, muscle strains, or other soft tissue trauma and do not definitively indicate a fracture.
② Inability to perform straight leg raises can be due to pain from a fracture, but it is also a non-specific finding. A patient with severe pain from any cause (e.g., bursitis, severe arthritis) may be unable to lift the leg. It is a test for motor function and pain tolerance, not a diagnostic sign for fracture.
④ Tenderness over the greater trochanter is a common finding but is not diagnostic. It can be present in conditions like trochanteric bursitis or a contusion. While a fracture will cause tenderness, the absence of the classic deformity makes this finding less indicative on its own.

Related Concepts: In geriatric nursing, a hip fracture is a sentinel event often linked to osteoporosis and falls. Immediate nursing priorities include pain management, immobilization to prevent further injury and neurovascular compromise, and preparing the patient for likely surgical intervention (e.g., hip pinning or arthroplasty). Post-operative care focuses on preventing complications like deep vein thrombosis (DVT), infection, and pressure ulcers.

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the ED. Mr. Johnson, 78, is on a stretcher. He is holding his right leg, which is noticeably turned outward and appears shorter than the left. He rates his pain as 9/10.

Nursing Intervention Strategy: 1. Assessment: Perform a focused neurovascular assessment (CMS: Circulation, Motor, Sensation) distal to the injury. Check pedal pulses, capillary refill, sensation, and toe movement. Compare to the unaffected side. Document the leg's position (external rotation, shortening). 2. Immediate Care: Do not attempt to "straighten" the leg. Apply a traction splint if ordered/available to stabilize the fracture and reduce pain. Administer prescribed analgesics (often IV opioids). 3. Preparation: Keep the patient NPO (Nothing by mouth) in anticipation of possible surgery. Assist with imaging (X-ray, possibly CT). Provide emotional support and explain all procedures.

Patient Safety and Precautions: Never log-roll or move the patient without adequate support to the leg and hip. Monitor for signs of shock (hypotension, tachycardia) due to potential blood loss into the thigh, which can be significant (1.5-2 liters). Watch for fat embolism syndrome, a rare but serious complication, especially after long bone fractures.

Nursing Procedure & Medication Flow Pre-Operative Care for Hip Fracture: 1. Immobilize the limb (e.g., with pillows, splint). 2. Pain Management: Administer IV morphine or hydromorphone. Monitor respiratory rate and sedation level. 3. IV Fluids: Maintain hydration and blood pressure. 4. Skin Assessment: Check for pressure points, especially on the heel of the unaffected leg. 5. DVT Prophylaxis: Apply sequential compression devices (SCDs) to the unaffected leg. Pharmacologic prophylaxis (e.g., enoxaparin) is typically started post-op.

A Word from Your Senior Nurse "In the chaos of the ED, spotting that classic 'shortened and externally rotated' leg is a game-changer. It immediately tells you this is a major orthopedic injury requiring urgent surgical consultation. Your calm, efficient assessment and pain management in those first minutes make a huge difference for the patient's outcome and experience. Remember, for these frail elderly patients, a hip fracture can be a life-altering event—your compassionate care is just as critical as your clinical skills."