A 68-year-old patient with a suspected hip fracture is brought to the emergency department after a fall. Which assessment finding would be most indicative of a displaced femoral neck fracture?

External rotation and shortening of the affected leg is the classic sign of a displaced femoral neck fracture, indicating bone displacement and muscle pull. Other findings like pain with motion or swelling are less specific for this type of fracture.

Core Nursing Explanation Key Concept Analysis: This question assesses your ability to identify the classic clinical sign of a specific orthopedic injury—a displaced femoral neck fracture. The key is understanding the pathophysiological mechanism: when the femoral neck breaks and the fragments shift (displace), the powerful muscles attached to the proximal femur (like the iliopsoas and external rotators) pull the leg into a characteristic, deformed position. This is a definitive sign of displacement, unlike more general signs of injury.

Answer Rationale: Key Point! The correct answer is External rotation and shortening of the affected leg. This is a pathognomonic finding for a displaced femoral neck fracture. The shortening occurs because the fracture allows the femoral shaft to ride upward. The external rotation is caused by the unopposed pull of the external rotator muscles (like the piriformis) on the distal fragment after the fracture disrupts the bone's structural integrity. This combination is highly specific for this diagnosis.

Distractor Analysis:
1. Watch out for confusion! Pain that increases with passive range of motion is a common finding with many musculoskeletal injuries (sprains, strains, other fractures) and inflammatory conditions. It is not specific to a displaced femoral neck fracture.
2. Inability to bear weight is a significant finding that indicates a serious injury, but it is not diagnostic. A patient with a severe hip contusion, nondisplaced fracture, or other lower extremity injury may also be unable to bear weight.
4. Swelling and bruising around the hip joint are expected signs of trauma and soft tissue injury. They are nonspecific and can occur with many types of hip trauma, including contusions or less severe fractures. They do not indicate bone displacement.

Related Concepts: This assessment finding directly informs immediate nursing actions: maintaining limb alignment, avoiding further rotation or movement, and preparing for likely surgical intervention (like hemiarthroplasty or internal fixation). It also highlights the importance of a thorough neurovascular assessment distal to the injury to rule out compartment syndrome or vascular compromise. Concept Summary

Concept	Description	Clinical Significance
Femoral Neck Fracture	A break in the narrow section of bone connecting the femoral head to the shaft.	Common in older adults with osteoporosis; high risk of avascular necrosis (AVN) of the femoral head.
Displaced vs. Nondisplaced	Displaced: bone ends are shifted out of alignment. Nondisplaced: bone is cracked but aligned.	Displacement dictates treatment. Nondisplaced may be treated conservatively; displaced almost always requires surgery.
Classic Deformity	Affected leg is shortened and externally rotated.	A definitive physical exam finding that strongly suggests a displaced fracture.
Neurovascular Assessment	Check pulses (dorsalis pedis, posterior tibial), capillary refill, sensation, and movement distal to the injury.	Critical nursing priority to detect complications like compartment syndrome or vascular injury.

Side-by-Side Comparison!

Finding	Displaced Femoral Neck Fracture	Hip Dislocation (Posterior)	Hip Contusion/Strain
Leg Position	Shortened, Externally Rotated	Shortened, Internally Rotated and adducted	Normal position
Weight-Bearing	Unable	Unable	May be possible with pain
Specificity	Pathognomonic for this fracture type	Pathognomonic for posterior dislocation	Nonspecific

Anatomy, Physiology & Pharmacology Points

• Anatomy: The femoral neck is a common fracture site due to its relative weakness, especially in osteoporotic bone. The medial circumflex femoral artery, which supplies the femoral head, is often damaged in displaced fractures, leading to avascular necrosis (AVN).
• Physiology (Muscle Pull): The iliopsoas muscle flexes the hip, and the external rotators (e.g., piriformis, obturator internus) externally rotate it. When the femoral neck breaks, these muscles pull the distal fragment, causing the classic deformity.
• Pharmacology: Immediate pain management (IV opioids like morphine, NSAIDs) is crucial. Pre-op antibiotics (e.g., cefazolin) are given to prevent surgical site infection. Post-op, anticoagulants (e.g., enoxaparin) are used for DVT (Deep Vein Thrombosis) prophylaxis.

Memory Tips

• Mnemonic: "Short and Out" for a displaced femoral neck fracture: the leg is Shortened and turned Out (externally rotated).
• Visualize: Imagine the broken thigh bone allowing the leg to roll outward and slide upward toward the hip.
• Associate: Hip Dislocation = leg is shortened and turned In (internally rotated). Fracture = turned Out.

High-Frequency NCLEX Topics This is a Core topic for NCLEX-RN. You must know: 1. The classic signs of common fractures (e.g., Colles' fracture = "dinner fork" deformity). 2. Priority nursing assessments for any trauma/fracture: Neurovascular status (the 6 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia). 3. Patient safety and mobility precautions to prevent further injury. Watch Out for Question Variations!

• From Sign to Intervention: "The nurse observes external rotation and shortening of a patient's leg after a fall. What is the nurse's priority action?" (Answer: Immobilize the limb in the position found and perform a neurovascular assessment).
• From Assessment to Complication: "A patient with a femoral neck fracture is postoperative day 1. For which complication should the nurse monitor most closely?" (Answer: Fat embolism syndrome or Deep vein thrombosis (DVT)).
• Population Focus: "An 85-year-old patient with osteoporosis sustains a hip fracture. Which finding is most concerning for avascular necrosis?" (This ties the initial injury to its long-term complication).

Nursing Clinical Practice Guide Clinical Scenario: You are the triage nurse in the Emergency Department (ED). Mr. Johnson, an 82-year-old man with a history of osteoporosis, is brought in by ambulance after slipping on ice at home. He reports severe right hip pain.

Nursing Intervention Strategy:

1. Immediate Assessment (ABCs first, then focused): Once airway, breathing, and circulation are stable, perform a focused musculoskeletal assessment. Observe limb positioning without moving the patient. Finding a shortened and externally rotated right leg is a red flag.
2. Priority Action - Immobilize: Do not attempt to "straighten" the leg. Place pillows alongside the leg to support it in its current position. Anticipate orders for traction (e.g., Buck's traction) to reduce muscle spasm and pain pre-operatively.
3. Comprehensive Neurovascular Checks: This is non-negotiable. Assess the 6 P's in the affected foot every 15-30 minutes initially. Document pulses, capillary refill (Normal Value: < 3 seconds), sensation, temperature, color, and movement.
4. Pain Management: Administer IV analgesics as ordered. Use a pain scale to assess effectiveness. Pain from a displaced fracture is often severe and requires opioid analgesia.
5. Pre-operative Preparation: This patient will likely need surgery (hemiarthroplasty or internal fixation). Nursing responsibilities include NPO (Nothing by Mouth) status, informed consent, IV access, lab draws (CBC, electrolytes, coagulation studies), and administering pre-operative antibiotics.

Patient Safety and Precautions:

• Contraindication: Never perform active or passive range of motion on a suspected fractured extremity. This can cause further displacement, bleeding, and neurovascular damage.
• Medication Caution: Use caution with opioids in the elderly due to increased risk of respiratory depression, confusion, and falls. Monitor sedation levels closely.
• Key Monitoring: Besides neurovascular status, monitor for signs of hypovolemic shock (tachycardia, hypotension) from blood loss at the fracture site, which can be significant.

Nursing Procedure & Medication Flow Procedure: Applying Buck's Traction (Skin Traction)

1. Explain the procedure to the patient (reduces muscle spasm, relieves pain).
2. Clean and dry the skin on the affected leg. Apply benzoin tincture to protect the skin and improve adhesive strip adherence.
3. Apply foam-backed traction straps longitudinally along the medial and lateral aspects of the leg, avoiding bony prominences and the peroneal nerve (near the fibular head).
4. Secure with elastic bandages, wrapping from distal to proximal. Ensure wraps are snug but not tight enough to impair circulation.
5. Attach the spreader bar and weights (usually 5-10 lbs) as ordered. Ensure weights hang freely, not touching the bed or floor.
6. Elevate the foot of the bed to provide counter-traction.
7. Reassess neurovascular status immediately after application and frequently thereafter.

Medication: Enoxaparin (Lovenox) for DVT Prophylaxis

• Action: Low molecular weight heparin; inhibits Factor Xa.
• Dose/Route: Typically 40 mg subcutaneously (SQ) once daily. For patients with renal impairment, dose may be reduced.
• Administration: Inject SQ into the abdomen, at least 2 inches from the umbilicus. Do not aspirate or massage the site. Rotate sites.
• Monitoring: Monitor for signs of bleeding (bruising, hematuria, melena). No routine lab monitoring (like aPTT) is required for prophylactic doses.

A Word from Your Senior Nurse "Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In a case like this, your keen observation of that 'shortened and externally rotated leg' is the first critical piece of data that sets the entire treatment plan in motion. In clinical practice, you'll learn that patients with this injury are in tremendous pain and are terrified. Your calm, competent assessment and explanation can make all the difference. When studying for your boards, don't just memorize the deformity — connect it to the 'why' (muscle pull, risk of AVN) and the 'what next' (immobilize, neuro checks, prep for surgery). That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse who can think on your feet in the ED!"