An 88-year-old woman falls and presents with a shortened, abducted, externally rotated leg and knee pain. Which injury is most likely?

• A. Non-displaced pelvic fracture
• B. Hip dislocation
• C. Femoral shaft fracture
• D. Femoral neck fracture

Answer: (D)

In older adults, a fall that leaves the leg shortened and externally rotated almost always points to a fracture of the proximal femur, most commonly the femoral neck. The fracture disrupts the alignment of the femur at the hip, and the surrounding muscles pull the leg into external rotation while gravity and the broken neck shorten the limb. This combination—hip pain with a visibly shorter, externally rotated leg—is a classic sign of a femoral neck fracture and signals an orthopedic emergency that needs prompt imaging and treatment.

Why the other possibilities fit less well: a non-displaced pelvic fracture can be painful and tender but doesn’t typically produce a clearly shortened leg with external rotation; the leg alignment remains relatively closer to normal. a femoral shaft fracture would usually cause obvious deformity and swelling in the thigh, often from a higher-energy mechanism. a hip dislocation can cause leg abnormalities too, but its typical patterns differ: posterior dislocation tends to shorten the leg and turn it inward and inward-ward (adducted), while anterior dislocation is rarer and presents with abduction and external rotation but is not the common result of a simple fall in an elderly patient. The combination of age, mechanism, and the leg’s position most strongly indicates a femoral neck fracture.