# A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his right side. He reports severe pain in his right hip and is unable to bear weight. Which assessment finding would be most indicative of a hip fracture?

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## 문제

A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his right side. He reports severe pain in his right hip and is unable to bear weight. Which assessment finding would be most indicative of a hip fracture?

## 보기

1. Bruising and swelling around the hip joint
2. Numbness and tingling in the affected leg
3. External rotation and shortening of the affected leg **✔ 정답**
4. Inability to perform straight leg raises

**정답: 3**

## 해설

External rotation and shortening of the affected leg are classic, pathognomonic signs of hip fracture due to muscle pull and bone displacement. Other findings like bruising, numbness, or inability to perform straight leg raises are less specific and can occur with other hip injuries.

## 심화 해설

Classic Presentation of Hip Fracture

The assessment finding most indicative of a hip fracture in this scenario is external rotation and shortening of the affected leg. This is a classic, pathognomonic sign resulting from the unopposed pull of muscles on the fractured bone segments. Specifically, when a femoral neck or intertrochanteric fracture occurs, the iliopsoas muscle flexes and externally rotates the proximal fragment, while the distal fragment is pulled proximally (shortening) by the adductor muscles. This creates the characteristic deformity visible even before imaging is obtained. While the provided reference material focuses on femoral head fractures (Pipkin fractures) as high-energy injuries requiring rapid reduction, the underlying principle of early recognition of a fracture based on clinical presentation is universally critical. The reference emphasizes that early recognition and rapid, stable reduction are essential to prevent complications such as avascular necrosis and post-traumatic arthritis [1]. In a displaced femoral head or neck fracture, the disruption of the bony architecture and the force of the musculature reliably produce this externally rotated and shortened limb position, making it the most specific clinical indicator among the options.

Why Other Findings Are Less Specific

- **Bruising and swelling around the hip joint:** This is a nonspecific sign of soft tissue trauma and can occur with any significant contusion, muscle tear, or ligamentous injury, not exclusively a fracture. It indicates injury but lacks the specificity of a structural deformity.

- **Numbness and tingling in the affected leg:** While a fracture fragment could theoretically impinge on a nerve, this finding is more directly associated with neurovascular compromise or a primary nerve injury. It is not a primary or classic indicator of a hip fracture itself.

- **Inability to perform straight leg raises:** This finding indicates significant pain, muscle inhibition, or disruption of the extensor mechanism. While common with a hip fracture, it is also present in severe soft tissue injuries, making it less specific than the visible structural deformity of external rotation and shortening.

The immediate identification of a shortened, externally rotated leg directs the clinical team toward a provisional diagnosis of a displaced hip fracture, prompting urgent diagnostic imaging and consultation, aligning with the referenced principle that rapid management is crucial for preserving the native hip joint and ensuring a better functional outcome [1].

References (research sources)

- [1]Functional Outcome and Hip Survival Rate in Traumatic Femoral Head Fractures.Research articlePrangenberg C, Loy T, Zellner AA, Roos J, Scheidt S, Roder L, Ben Amar S, Welle K. (2026) · DOI: 10.3390/jcm15124741

## 임상 시나리오

Recognizing the Classic Hip Fracture DeformityThe limb position is the key clinical indicator
A pathognomonic sign for a hip fracture is the leg presenting in external rotation and shortening. This occurs because the iliopsoas muscle flexes and externally rotates the proximal fragment, while adductors pull the distal fragment upward.

This classic deformity is visible on inspection before imaging. It is most specific to displaced fractures of the femoral neck or intertrochanteric region. Early recognition is critical to initiate rapid reduction and prevent avascular necrosis.

CautionDo not rely on bruising, swelling, or inability to straight-leg raise as primary indicators. These are nonspecific and can occur with soft tissue injury alone. Always check for the externally rotated, shortened position.

## 핵심 개념

- **Pathognomonic Sign** — A sign whose presence means a particular disease is present beyond any doubt.
- **External Rotation Deformity** — The classic outward turning of the leg seen in hip fractures, caused by the unopposed pull of the iliopsoas muscle on the proximal fragment.
- **Femoral Neck Fracture** — A fracture occurring just below the femoral head, at risk for disrupting blood supply and causing avascular necrosis.
- **Iliopsoas Muscle** — A major hip flexor that, when unopposed in a hip fracture, flexes and externally rotates the proximal bone fragment.
- **Avascular Necrosis** — Death of bone tissue due to a lack of blood supply, a critical complication of displaced femoral neck fractures.

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