2.0 ANCC Contact History and Physical Examination of Hip Hours Injuries in Elderly Adults Mohammed Abdullah Hamedan Al Maqbali Hip fracture is the most common injury occurring to elderly hours of one morning, she was found on the fl oor of her people and is associated with restrictions of the activities of room. She stated that she was trying to get out of bed to the patients themselves. The discovery of a hip fracture can use her commode. She fell onto her right hip and began be the beginning of a complex journey of care, from initial to complain of a pain in her knee. At the emergency de- diagnosis, through operational procedures to rehabilitation. partment, a physical examination provided the observa- The patient's history and physical examination form the ba- tion that her right leg was externally rotated with a bruising of her right hip. An x-ray confi rmed a right sis of the diagnosis and monitoring of elderly patients with femoral neck fracture. She did not present any past hip problems and dictate the appropriate treatment strategy medical history. The next morning, Mrs. B had surgery to be implemented. The aim of this study is to discuss the for open reduction and internal fi xation of the fracture. different diagnoses of hip pain in a case study of an elderly woman who initially complained of pain in her right knee following a fall at home. It shows that musculoskeletal History Taking physical examination determined the management of the History taking is important in sorting out the differen- hip fracture that was found to be present. In addition, tial diagnosis in elderly patients. The notes concerning the aim of this article is to review diagnostic tests such as the patient’s medical history should include the chief radiographs and recommend appropriate management and complaint, past medical history, family and social his- treatment of hip fractures in elderly patients. tory, risk factors, usual activity, and any history of pre- sent or previous trauma (Price & Miller, 2010). In their study, Cauley et al. (2008) noted that falls in old women were strongly associated with hip fractures. Introduction Mrs. B had a history of a fall on her right hip. Marks In the elderly population, falls are commonplace and (2010) suggested that around 90% of hip fractures were these may be the cause of disability and physical harm, associated with falls in elderly people. Assessing the including fractures or soft tissue injuries. Hagino et al. mechanism of fall and the environment of the fall loca- (2004) suggested that falls from bed or standing height tion could help with an appropriate diagnosis. However, frequently resulted in a fractured hip. The growth of the Mrs. B complained of pain in her right knee. Kreder and elderly population globally will be refl ected in a signifi - Jerome (2010) suggested that, typically, hip pain radi- cant increase in the number of hip fractures presenting ates down to the anterior aspect of the knee. The exam- over the coming decades (Chevalley et al., 2007 ). iner should ask the patient to describe the primary loca- Approximately 1.5 million cases of hip fracture occur tion of the pain and from where it radiated. Mrs. B worldwide each year and this is projected to reach 2.5 located the pain as being in her right hip, which radi- million by 2025 (Johnell & Kanis, 2006). In the United ated to her knee. The examiner has to differentiate be- States, there were approximately 289,000 cases of hip tween the types of pain such as that present with mono- fracture in 2010 (Stevens & Rudd, 2013). There are arthritis, oligoarthritis, and polyarthritis ( Marks, 2010 ). three main types of hip fracture that can be classifi ed on If the pain was localized only in the hip joint, it would the basis of their location (see Figure 1 ). be monoarthritis, usually caused by infection, trauma, This article aims to explore the physical assessment bleeding diathesis, or infl ammation (Huntley, Gibson, & of hip pain specifically due to a fractured hip. Simpson, 2009). Consequently, it aims to identify the appropriate treat- ment that will diminish morbidity and mortality rates in elderly patients. Mohammed Abdullah Hamedan Al-Maqbali, RN, DNA, BSc (Hons), MSc, Senior Staff Nurse, Al-Buraimi Hospital, Ministry of Health, Sultanate of Oman. Case Study The author and planners have disclosed no potential confl icts of interest, Mrs. B, an 89-year-old woman, lived in a residential fi nancial or otherwise. home and walked with a frame (walker). In the early DOI: 10.1097/NOR.0000000000000033 86 Orthopaedic Nursing • March/April 2014 • Volume 33 • Number 2 © 2014 by National Association of Orthopaedic Nurses Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. OONJ586R3.inddNJ586R3.indd 8866 113/03/143/03/14 66:57:57 PPMM associated with arthropathy and in sickle cell disease it may be related to osteonecrosis of the hip ( Huntley et al., 2009 ). However, there is a need to identify comor- bid conditions such as diabetes mellitus, ischemic heart disease, and obesity (Juhakoski, Tenhonen, Anttonen, Kaupinen, & Arokoski, 2008). Mrs. B reported that she did not have any disease and was not taking any medi- cation, vitamins, or herbs. In addition, she did not have any history of previous falls or surgery and was not allergic to any medication or food. Huang et al. (2012) indicated that the use of medica- tion among the elderly population can place them in greater risk of hip fracture because of changes in body composition, total body water, and hepatic and renal function. Several types of drugs may be associated with falls in the elderly such as cardiovascular drugs such as digoxin and diuretics (de Groot et al., 2013), benzodiaz- epines (van Strien, Koek, van Marum, & Emmelot- Vonk, 2013), antidepressants (Coupland et al., 2013), antiepileptics ( Tsiropoulos et al., 2008), and antipsycho- tropics (Echt, Samelson, Hannan, Dufour, & Berry, 2013). Postoperatively these medications may be con- trolled or doses reduced to lower the risk of future hip fractures. The examiner should ask the patient about his or her F IGURE 1. The regions where hip fractures occur. family history because of the hereditary basis of some diseases such as Marfan’s syndrome, osteoarthritis, As component of the history of symptoms of hip rheumatoid arthritis, and osteoporosis. All of these pain, information concerning the onset of symptoms, could be associated with musculoskeletal disorders severity, and duration are essential in reaching an ap- (Oliver & Silman, 2009). Mrs. B stated that she was un- propriate diagnosis. The source of the pain should be sure of her family history in this respect. identifi ed and an assessment of whether it becomes There are many social factors, associated with mus- worse with movement or improves with rest should be culoskeletal system, which should be considered while made. If the patient suffers pain while at rest, it may be obtaining the medical history. Sun et al. (2011) sug- related to infection, tumors, or infl ammation (Bickley & gested that a history of smoking was related to bone me- Szilaygi, 2010). Huntley et al. (2009) suggested that if tastases. Other factors such as alcohol abuse could be the pain was sharp, stabbing, and aggravated by move- correlated with a higher risk of osteoporotic fractures ment it might be associated with a fracture. The onset of ( Berg et al., 2008 ). Furthermore, nutrition is very im- pain may give the assessor a clue as to the diagnosis. A portant in elderly people because they need healthy gradual onset of pain can be related to an arthritic con- bones. Vondracek and Linnebur (2009) demonstrated dition, whereas a quick onset may be associated with that vitamin D defi ciency could enhance susceptibility fractures, ligamentous or meniscal tears (Siva, to fractures in older people. Velazquez, Mody, & Brasington, 2003). The examiner The history of the patient’s activity levels before the should identify from whether or not there is limited incident should include their ability to walk and use the function, swelling, weakness, stiffness, and palpable stairs and the toilet. This information is important for snapping or clicking noises within the hip (Flannery, an accurate assessment of the patient’s functional Green, Harmon, & Masterson, 2011). capacity. In this regard, Mrs. B lived in a residential If the patient describes the stiffness as diffi cult, pain- home and used to move around by using a walker. ful, or restricted movement, in the musculoskeletal eval- uation, a diagnosis of rheumatoid arthritis and/or osteo- arthritis may be made (Woolf & Pfl eger, 2003). Usually, Physical Examination weakness is a description of the loss of strength or gen- Obtaining the patient’s medical history is important in eral fatigue. The presence of weakness may suggest a guiding the examiner when undertaking the physical ex- joint disorder or peripheral nerve lesion ( Huntley et al., amination. The patient is usually exposed during the 2009 ). Swelling is an important symptom that needs to examination. Therefore, the examiner should ensure be described in both the medical history and the physi- that the patient has an appropriate level of privacy and cal examination. Mrs. B complained of the inability to his or her dignity is maintained. Domb, Brooks, and stand and said she felt the sharp pain only after falling Byrd (2009) suggested that the physical examination from the bed. A swelling was observed in the vicinity of should be systematic and comprehensive to avoid the her right hip. possibility of missing clinical fi ndings. As Mrs. B com- A previous medical history of hip pain is important plained of hip pain, the examiner should have under- as a guide as it may exclude some other differential taken an examination of the hip by carrying out a head- diagnosis.