# A 72-year-old patient with osteoporosis fell at home and is suspected of having a hip fracture. Which assessment finding would be MOST indicative of an intracapsular femoral neck fracture?

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## 문제

A 72-year-old patient with osteoporosis fell at home and is suspected of having a hip fracture. Which assessment finding would be MOST indicative of an intracapsular femoral neck fracture?

## 보기

1. External rotation and shortening of the affected leg with severe pain
2. Internal rotation and lengthening of the affected leg with moderate pain
3. Minimal deformity with the ability to bear weight and walk short distances **✔ 정답**
4. Complete inability to move the hip joint with visible bone protrusion

**정답: 3**

## 해설

Intracapsular femoral neck fractures often present with minimal deformity and ability to bear weight, unlike extracapsular fractures. This subtle presentation is most indicative, while other options describe more severe findings typical of extracapsular fractures.

## 심화 해설

Understanding the Clinical Presentation

The correct answer is 3: Minimal deformity with the ability to bear weight and walk short distances. This presentation is most indicative of an intracapsular femoral neck fracture, specifically an impacted or valgus-impacted type. In the context of an elderly patient with osteoporosis, the fracture fragments can become wedged together upon impact, creating a relatively stable configuration despite the break. This stability allows some patients to retain the ability to ambulate, a phenomenon that often leads to delayed diagnosis because the presentation contradicts the classic image of a displaced fracture.

Pathophysiology and Fracture Classification

To understand why this occurs, it is essential to differentiate between intracapsular and extracapsular fractures. An intracapsular femoral neck fracture occurs within the hip joint capsule. The key anatomical and physiological consequence is the risk to the blood supply of the femoral head, primarily from the medial femoral circumflex artery. Disruption of this delicate vascular network is the primary driver of avascular necrosis (AVN), a devastating complication where bone tissue dies due to lack of blood flow [2, 3]. The degree of fracture displacement is the most critical factor determining this risk.

A valgus-impacted femoral neck fracture, as described in the provided research, is a subtype where the femoral head is driven into the neck in a stable, compressed position [4]. Because the fracture fragments are impacted, there is minimal to no visible deformity. The leg typically does not appear shortened or significantly rotated, and the inherent stability can paradoxically permit weight-bearing. This contrasts sharply with a displaced intracapsular fracture or an extracapsular intertrochanteric fracture, which present with classic and severe deformity.

Analyzing the Incorrect Options

- Option 1 describes a leg that is externally rotated and shortened. This is the classic presentation of a displaced femoral neck fracture or, more commonly, an extracapsular intertrochanteric fracture. The unopposed pull of the iliopsoas muscle on the lesser trochanter and the external rotators causes this characteristic deformity. The severe pain aligns with significant displacement and soft tissue injury.

- Option 2 describes internal rotation and lengthening, a rare finding in hip fractures. This pattern is not typical for any common hip fracture type and is more suggestive of a posterior hip dislocation, a different orthopedic emergency.

- Option 4 describes a complete inability to move the joint with visible bone protrusion. This is indicative of an open fracture, a surgical emergency. While a femoral neck fracture can be severely displaced, it is almost never an open injury due to its deep location within the joint capsule and surrounding musculature. Visible bone protrusion would be exceptionally rare.

Clinical Significance and Complication Risk

The ability to bear weight in an impacted fracture is a deceptive clinical finding. Even in these stable patterns, the vascular insult to the femoral head has already occurred. The research on femoral neck fractures consistently highlights that the primary complication is avascular necrosis (AVN), which can lead to bone tissue death, femoral head collapse, and severe joint dysfunction requiring arthroplasty [2, 3]. A study on valgus-impacted fractures notes that even with modern fixation techniques, complications such as femoral neck shortening and screw sliding can occur, underscoring that these are not benign injuries simply because the initial deformity is minimal [4]. The management of even non-displaced or impacted Garden I and II fractures typically involves surgical fixation to prevent displacement and to optimize the biological environment for healing, as the risk of AVN remains a primary concern [1, 3].References (research sources)

- [4]Improving Outcomes with Sequential Fixation Using Long-Threaded Screws for Valgus-Impacted Femoral Neck Fractures.Research articleKoh JH, Sakong S, Cho WT, Lim S, Song HK. (2024) · DOI: 10.3390/medicina61010040

## 임상 시나리오

Clinical Pearl: The Deceptive Ambulatory Hip Fracture

In elderly patients with osteoporosis, an **impacted intracapsular femoral neck fracture** can present a deceptive clinical picture. The fracture fragments are wedged together into a stable, compressed position (valgus impaction). This stability allows some patients to **bear weight and even walk short distances** with minimal visible deformity. This presentation often leads to a delayed diagnosis, as it contradicts the classic expectation of a displaced, non-weight-bearing fracture.

⚠️
**High-Risk Pitfall:** Do not rule out a hip fracture because a patient can ambulate. Maintain a high index of suspicion for any elderly patient with hip pain after a fall, even with normal or near-normal initial X-rays. An MRI or CT scan may be necessary to identify the occult fracture.

Key Assessment Differentiation

- **Impacted Intracapsular:** Minimal deformity, possible weight-bearing, groin pain. The limb may appear normally aligned.

- **Displaced Intracapsular:** Moderate shortening and external rotation. Inability to bear weight.

- **Extracapsular (Intertrochanteric):** Significant shortening and marked external rotation. Severe ecchymosis and swelling are common. Inability to bear weight.

Urgency & Complication Focus

The primary concern with intracapsular fractures is disruption of the **medial femoral circumflex artery**, leading to **avascular necrosis (AVN)** of the femoral head. The risk of AVN is directly related to the degree of fracture displacement. Prompt diagnosis and surgical fixation (or arthroplasty) are critical to preserving the joint and preventing this devastating complication.

## 핵심 개념

- **Intracapsular Femoral Neck Fracture (관절낭내 대퇴경부 골절)** — A fracture occurring in the narrow neck area (femoral neck) just below the femoral head, inside the hip joint capsule. Because this is where the blood vessels supplying the femoral head pass through, the risk of avascular necrosis is very high.
- **Extracapsular Fracture (관절낭외 골절)** — Fractures occurring outside the hip joint capsule, in the intertrochanteric or subtrochanteric region of the femur. Due to the rich blood supply, the healing prognosis is good, but muscle traction forces cause marked external rotation and shortening deformity.
- **Avascular Necrosis (AVN) of Femoral Head (대퇴골두 무혈성 괴사)** — A condition where bone tissue of the femoral head dies due to blocked blood supply. It is a major complication of intracapsular femoral neck fractures, requiring early detection and appropriate surgery (fixation or replacement).
- **Log Roll Test (통나무 굴리기 검사)** — Test performed when a hip fracture is suspected. The patient is laid flat, and the nurse holds both knees and ankles together, slowly rotating them inward and outward. If pain is provoked in the hip area, it is a positive response suggesting the possibility of a fracture.
- **Intertrochanteric Fracture (전자간 골절)** — The most common type of extracapsular fracture occurring between the greater and lesser trochanters of the femur. It is common in the elderly and is accompanied by severe pain and inability to bear weight along with external rotation and shortening deformity.

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