Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left hip pain following a mechanical fall. Reports inability to bear weight on the left lower extremity. Pain is localized to the left groin/hip region, exacerbated by movement. No history of loss of consciousness, chest pain, or palpitations. Denies numbness or tingling in the distal extremity.
Clinical Examination Findings
Left lower extremity demonstrates external rotation and shortening. Significant tenderness to palpation over the left greater trochanter and groin. Range of motion of the left hip is severely limited by pain. Neurovascular status: Distal pulses (dorsalis pedis and posterior tibial) are palpable and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes. No motor deficits noted in the distal foot.
Treatment Protocol
Diagnosis: Intertrochanteric fracture, left hip, closed (ICD-10: S72.142A). Plan: Admit for orthopedic surgical stabilization (Cephalomedullary nail fixation). Maintain strict non-weight bearing status on the left lower extremity. Initiate DVT prophylaxis per protocol. Pain management with scheduled analgesics. Pre-operative clearance and optimization of comorbidities.