Hip Fracture in the Elderly — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 79-year-old left-hand-dominant woman is brought to the emergency department after a mechanical fall from standing in her assisted living facility. She has a history of type 2 diabetes, atrial fibrillation on warfarin, moderate dementia (MMSE 18/30), and a prior right total knee arthroplasty. She reports left hip pain and is unable to bear weight. On examination, the left lower extremity is shortened and externally rotated. She has intact distal pulses and sensation. Skin is intact with no open wounds.
AP pelvis and cross-table lateral radiographs reveal a displaced left femoral neck fracture (Garden IV). The femoral head appears to have maintained its normal contour without evidence of avascular necrosis. The acetabulum is concentrically congruent without significant arthritic changes. Her contralateral hip is normal. Labs show an INR of 2.4, hemoglobin of 10.8, and creatinine of 1.1.
After medical optimization including INR reversal with 4-factor PCC, you performed a cemented bipolar hemiarthroplasty through a posterior approach within 24 hours of admission. Intraoperative findings confirmed a displaced femoral neck fracture with no significant acetabular cartilage damage. Post-operatively, she was made weight-bearing as tolerated and began working with physical therapy on post-operative day one.
What Examiners Look For
- Data gathering: Present the whole patient — functional status, ambulatory capacity, cognitive baseline, and anticoagulation status are as important as the fracture pattern.
- Diagnosis: Garden classification on the AP pelvis and why it matters for treatment decision-making. Can you identify this on the film?
- Treatment plan: Articulate why hemiarthroplasty over ORIF or total hip — patient age, displacement, cognitive status, and activity level all factor in.
- Indications: Why cemented versus cementless? Why bipolar versus unipolar? What would have pushed you toward a total hip arthroplasty?
- Complications: What is your threshold for transfusion? How do you manage the anticoagulated patient perioperatively? What is your DVT prophylaxis protocol?
- Ethics: Time-to-surgery discussion — what is the evidence for surgical timing within 24-48 hours, and how do you balance medical optimization against delay?
- Outcomes: What is the expected 1-year mortality for an elderly patient with a hip fracture? How does cognitive status affect outcomes?
Common Pitfalls
- Jumping straight to implant choice without discussing the patient's functional baseline and cognitive status.
- Not addressing anticoagulation reversal strategy — examiners expect a clear, protocol-driven answer.
- Forgetting the medical co-management discussion — hip fractures are a geriatric emergency, not just a surgical problem.
- Blaming the patient for falls or poor compliance — this is a systems issue and an ethics flag.
- Not knowing mortality statistics — approximately 20-30% one-year mortality is well-established data you should cite confidently.
Key Classifications
Related Scenarios
Free — takes 3 minutes