Endgames Picture Quiz

A 72 old woman with a painful leg after a fall

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h585 (Published 25 February 2015) Cite this as: BMJ 2015;350:h585
  1. K C Eseonu, specialty trauma and orthopaedic registrar1,
  2. M Rafferty, specialty trauma and orthopaedic registrar2,
  3. S Al-Nammari, senior clinical fellow 2
  1. 1Department of Orthopaedics, John Radcliffe Hospital, Oxford OX3 9DU, Oxford, UK
  2. 2Wexham Park Hospital, Heatherwood and Wexham Park NHS Trust, Slough, UK
  1. Correspondence to: K Eseonu 724 Fulham Road, London SW6 5SF, UK Kelechi.eseonu{at}doctors.org.uk

A 72 year old woman presented to the emergency department after tripping over uneven carpet at home. She had pain in her right groin and was unable to weight bear but had no other injuries. The fall had been a true mechanical one, with no preceding dizziness, chest pain, or palpitations. Her medical history included hypertension, and she had undergone a left (contralateral) total hip replacement four years earlier. Her only regular drug was ramipril. She lived alone, was independent in activities of daily living, and could walk short distances in the community unsupported. She had no ophthalmological disease or other visual impairment.

On examination, her right leg was shortened and externally rotated. She could not straight raise the leg and any attempted movement was painful. Figure 1 shows an anteroposterior radiograph of her right hip.


  • 1. On the basis of the history, what is the most likely diagnosis?

  • 2. What is the radiographic diagnosis and how would you classify this injury?

  • 3. How would you manage this patient acutely?

  • 4. How would you manage this patient definitively?

  • 5. What are the risks of treatment?


1. On the basis of the history, what is the most likely diagnosis?

Short answer

The most likely diagnosis is a proximal femoral fracture.

Long answer

The most likely diagnosis is a fracture of the proximal femur. Radiographic assessment is needed to differentiate between a fracture of the femoral neck or one of the proximal femoral diaphysis, and if located at the neck of the femur, to differentiate between intracapsular and extracapsular fractures. Differential diagnoses include fracture of the pubic rami, pelvic fracture, other fractures of the lower limb and axial skeleton, and soft tissue injury. Anterior dislocation of the hip would also present with an externally rotated (but abducted) limb; however, this is more commonly associated with high energy trauma such as a fall from a height or a road …

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