New-Onset Groin Pain in an Elderly Woman

Answer: Femoral neck fracture

The radiograph (Figure 1) shows osteoarthritis, but the MRI T1 sequence shows the black sinuous line that typically represents a femoral neck fracture.¹

Differential Diagnosis

Hip osteoarthritis, commonly described as “wear and tear,” is a complex degradation process of cartilage and subchondral bone resulting in narrowing of joint space and subsequent worsening range of motion, stiffness, and pain upon awakening. Treatment involves a combination of physiotherapy, NSAIDs, and cortisone injection.²

Trochanteric pain syndrome is a common cause of lateral hip pain. Pain is typical over the area of the greater trochanter of the femur and is worsened by sleeping on the affected side and sitting for long periods of time.³ Women between 40 and 60 years of age are most commonly affected. Treatment typically consists of NSAIDs and physical therapy, but steroid injections have also proven to be effective.⁴

Meralgia paresthetica is an entrapment of the lateral cutaneous nerve, which originates in the lumbar plexus from L1 through L4 and acts primarily as a sensory nerve. Entrapment can have idiopathic causes, such as obesity or tight-fitting belts, or iatrogenic causes, such as lumbar surgeries. The entrapment may cause anterolateral thigh pain, numbness, and paresthesia. Treatment involves NSAIDs, physiotherapy, ultrasound-guided injections, and (rarely) surgery with nerve resection.³

Discussion

Hip fractures are common in elderly patients. Each year, approximately 300,000 elderly (aged ≥ 65 years) patients are hospitalized in the United States because of hip fractures, at a treatment cost of $17 billion dollars per year in 2002.^5,6 This makes recognition of hip fractures prudent. Most hip fractures in the elderly are secondary to low-energy falls.⁷ After such a fall, most patients present with new-onset groin pain and say they have pain with weight-bearing.

Clinicians should have a high index of suspicion for a femoral neck fracture in elderly patients with new-onset groin pain after a fall. Patients with a suspected hip fracture should have radiograph imaging performed to include anterior-posterior views of the pelvis and a cross-table lateral view. If radiographs prove inconclusive but there is a high index of suspicion, MRI is the imaging modality of choice. Patients who have been diagnosed with a hip fracture should have an emergent evaluation by an orthopedic surgeon.

Patient Outcome and Follow-Up

The patient was sent to the emergency department for emergent placement of a cephalomedullary nail for her right hip. She tolerated the surgery well and has completed rehabilitation for her fracture.  She is back to walking her dogs on a regular basis.

References

1. Collin D, Geijer M, Göthlin JH. Computed tomography compared to magnetic resonance imaging in occult or suspect hip fractures. A retrospective study in 44 patients. Eur Radiol. 2016;26(11):3932-3938. doi.10.1007/s00330-015-4189-y  

2. Sinusas K. Osteoarthritis: diagnosis and treatment. Am Fam Physician. 2012;85(1):49-56. https://www.aafp.org/pubs/afp/issues/2012/0101/p49.html

3. Chamberlain R. Hip pain in adults: evaluation and differential diagnosis. Am Fam Physician. 2021;103(2):81-89. https://www.aafp.org/afp/2021/0115/p81.html

4. Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011;19(6):359-367. doi:10.5435/00124635-201106000-00006

5. Hip fractures among older adults. Centers for Disease Control and Prevention. September 20, 2016. Accessed May 30, 2022. www.cdc.gov/falls/hip-fractures.html

6. Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-1460. doi:10.1016/j.injury.2018.04.015

7. Florschutz AV, Langford JR, Haidukewych GJ, Koval KJ. Femoral neck fractures: current management. J Orthop Trauma. 2015;29(3):121-129. doi:10.1097/bot.0000000000000291