Management of Acute on Chronic Hip Pain

Initial Diagnostic Approach

The American College of Radiology recommends obtaining standard radiographs immediately, including an anteroposterior (AP) view of the pelvis with 15 degrees of internal hip rotation and a cross-table lateral view of the symptomatic hip, to identify hip fractures and other pathology 1, 3
Radiographs can be performed portably and rapidly, reducing morbidity by avoiding unnecessary patient movement, and are essential for comparing with the contralateral side and detecting concomitant pelvic fractures 1
If clinical suspicion for occult fracture persists after negative radiographs, proceed directly to MRI without IV contrast, as MRI has nearly 100% sensitivity for proximal femoral fractures 2, 4

Assess for vascular compromise immediately, as a blue, purple, or pale extremity requires emergency activation, and evaluate for severe bleeding and open fractures requiring urgent attention 6
Implement immobilization in the position found to reduce pain and prevent further injury, and apply ice packs to decrease pain and swelling in the acute period 6
Use a multimodal analgesic regimen including regular intravenous acetaminophen, NSAIDs, and opioids as needed, and reassess pain levels regularly using the Numeric Rating Scale (NRS) for communicative patients 6

Surgical delay beyond 12 hours significantly increases 30-day mortality risk in patients over 50 years with hip fractures, and obtain noncontrast CT when further characterization of fracture alignment is needed for surgical decision-making 1, 7
If soft tissue injury is suspected, order MRI hip without contrast to evaluate for tendon, muscle, or ligament injury as the source of acute pain, as MRI detects 100% of proximal hamstring avulsions versus only 58.3% with ultrasound 8

Increasing pain despite appropriate analgesia may indicate fracture displacement or instability requiring surgical intervention, and neurological symptoms, signs of compartment syndrome, or signs of infection require immediate attention 6
These complications are associated with increased costs, complication rates, hospital length-of-stay, and mortality 1, 4