A 72-year-old woman is brought to the emergency department after a fall at home, landing on her left side. She reports severe pain in her left hip and is unable to bear weight. X-rays reveal a displaced femoral neck fracture. What is the most important nursing assessment priority for this patient?

Monitoring neurovascular status is the priority due to high risk of avascular necrosis and compartment syndrome from vascular compromise. Other assessments like pain or patient education are important but secondary to preventing irreversible tissue damage.

Understanding the Priority Assessment in a Displaced Femoral Neck Fracture

When a patient presents with a displaced femoral neck fracture following a fall, the immediate nursing priority extends beyond pain management to the early detection of a limb-threatening complication. The correct answer is to monitor the neurovascular status of the affected extremity. This assessment is critical because the fracture and subsequent swelling can compromise blood flow and nerve function, leading to acute compartment syndrome (ACS), a condition that can cause irreversible tissue damage and limb loss within hours if not recognized and managed promptly ^[1].

While assessing pain is an essential and standard nursing intervention, it is not the most important priority in this specific scenario. The patient's severe pain is an expected finding with a displaced fracture. The priority assessment must rule out a more insidious pathology. The severe pain, especially if it becomes disproportionate to the injury or unresponsive to analgesia, is actually a hallmark clinical sign of developing ACS. Therefore, a comprehensive neurovascular assessment is the only option that proactively screens for this dangerous complication, making it the highest priority ^[1].

The Pathophysiology of the Threat: Compartment Syndrome

To understand why neurovascular monitoring is paramount, consider the anatomy and physiology at play. The muscles and neurovascular structures of the thigh are encased within fascial compartments—tough, inelastic connective tissue sheaths. A displaced femoral neck fracture causes significant bleeding and edema within these closed spaces. As the intra-compartmental pressure rises, it first exceeds capillary perfusion pressure, collapsing the microcirculation. This leads to muscle and nerve ischemia. If the pressure continues to rise and is unrelieved, it can eventually obstruct larger arterial flow. The "6 Ps" of compartment syndrome (pain, paresthesia, pallor, paralysis, pulselessness, poikilothermia) are a late finding; pulselessness is a catastrophic and often irreversible sign. The assessment must detect the earliest indicators, which are severe pain with passive stretch and paresthesia, long before a pulse is lost ^[1].

Breakdown of Assessment Components

A thorough neurovascular check involves a systematic comparison of the affected limb to the unaffected limb and includes the following:

- Pain Assessment (The 6th P): This is not a simple pain scale rating. You must evaluate the quality, location, and severity of the pain. The critical red flag is pain that is disproportionate to the injury and, crucially, pain with passive stretch of the muscles in the affected compartment. For a hip fracture, this would involve gentle, passive flexion and extension of the toes and ankle. An escalating pain level unrelieved by opioids is a classic early warning sign of ACS [1,2].
- Paresthesia: This is an early and reliable sign of nerve ischemia. Assess sensation by asking the patient if they feel numbness or a "pins and needles" sensation. Test light touch sensation in the distribution of the peroneal nerve (the web space between the first and second toes) and the tibial nerve (the sole of the foot). Any decrease in sensation compared to the baseline or the other limb is a significant finding ^[1].
- Pallor and Color: Observe the skin color of the affected leg and foot. Compare it to the unaffected side. A pale or dusky appearance can indicate compromised arterial inflow or venous outflow obstruction.
- Pulses: Palpate the dorsalis pedis and posterior tibial pulses. Document their presence and quality (e.g., strong, weak, Doppler-only). It is vital to remember that the presence of a palpable pulse does not rule out ACS, as capillary and venous pressure is compromised long before arterial pressure.
- Paralysis and Motor Function: Ask the patient to wiggle their toes and perform dorsiflexion and plantarflexion against resistance. Weakness or inability to move the toes is a late and concerning sign suggesting significant nerve or muscle damage.
- Temperature (Poikilothermia): Feel the patient's foot and lower leg. A cool extremity compared to the unaffected side can signal vascular compromise.

Why the Other Options Are Lower Priority

- Option 1 (Assess pain level): This is a component of the neurovascular assessment, not a separate, higher-priority action. Simply noting a pain score of 10/10 without interpreting it in the context of compartment syndrome misses the critical clinical picture ^[1].
- Option 3 (Evaluate understanding of surgery): While a femoral neck fracture often requires surgical intervention (such as internal fixation or arthroplasty) [3,4], a psychosocial and knowledge-based assessment is not the immediate physiological priority in the emergency department. The patient's acute physiological stability takes precedence over preoperative teaching.
- Option 4 (Check ability to perform range of motion): This is contraindicated in the acute phase of a displaced fracture. Active or passive range of motion exercises would cause severe pain, could further displace the fracture, and damage surrounding soft tissues. The limb should be stabilized and immobilized until definitive surgical management is performed [3,4].

The foundational principle here is the nursing process: assessment comes first, and within assessment, the "ABCs" (airway, breathing, circulation) and their related threats (like neurovascular compromise) are the priority. A displaced femoral neck fracture presents a high risk for vascular and neurological injury, making serial neurovascular assessments the most critical nursing action to prevent permanent disability ^[1].