Hip Pain (OSCE focused)

Candidate Instructions:You are the medical student in the Emergency Department. A 76-year-old patient presents with acute left hip pain after a fall at home. Take a focused history, perform a targeted examination of the hip, and present your findings to the examiner. Do not perform special tests of the knee or spine.

Key Areas to Cover ✅

• 📍 Location: Groin pain suggests hip joint pathology; lateral pain suggests trochanteric bursitis.
• 🕒 Onset: Sudden after trauma (fracture) vs insidious (OA, AVN, inflammatory arthritis).
• 🚶 Function: Weight-bearing ability, mobility aids, impact on ADLs.
• 🩺 Risk factors: Osteoporosis, steroid use, alcohol excess, malignancy.

Examination (look–feel–move) 🔎

• 👀 Look: Leg shortening, external rotation, swelling, bruising.
• 🤲 Feel: Tenderness over groin, trochanter, or buttock.
• 🦵 Move: Active & passive ROM (flexion, abduction, rotation). Pain or restriction indicates pathology.
• ⚠️ Do not attempt movement if acute fracture suspected – say you would stop and get X-ray.

Examiner Prompts 💬

• “What are your top 3 differentials in this case?”
• “Which investigations would you order?”
• “How would you manage this patient in the ED?”

Differential Diagnoses 🧾

Investigations 🔬

• 🩻 X-ray pelvis & hip – AP & lateral views.
• 🩸 Bloods: FBC, U&E, CRP, bone profile, clotting.
• 🧲 MRI: If fracture suspected but X-ray negative.
• 🧪 Other: Consider DEXA if osteoporosis suspected; bone scan if metastatic disease suspected.

Management 🩺

• 🏥 Admit under orthopaedics.
• 🔒 Immobilise + analgesia (paracetamol, opioids, fascia iliaca block).
• 💉 Pre-op optimisation: IV fluids, correct electrolytes, ECG, cross-match blood.
• ⚙️ Surgery: Dynamic hip screw (extracapsular) or hemiarthroplasty/THR (intracapsular).
• 🦴 Secondary prevention: osteoporosis assessment, bisphosphonates, Vit D & Ca.

Mark Scheme (10 points) 📝

Teaching Commentary 📚

In OSCEs, hip pain stations are usually either a NOF fracture in an older adult or a slipped epiphysis in a teenager. Examiners want to see: - Safety: stop if fracture suspected. - Always check ability to weight-bear. - Think widely: OA, bursitis, metastasis. Finishing strong with: “I would request an X-ray and admit under orthopaedics, providing analgesia and pre-op care” always scores well.

🧑‍⚕️ Case Examples - Hip Pain

• Case 1 (Osteoarthritis): 🦴 A 72-year-old woman presents with gradually worsening right hip pain and stiffness, worse in the morning and after walking. X-ray shows joint space narrowing and osteophytes. Diagnosis: Hip osteoarthritis. Teaching point: Common in the elderly; managed with weight reduction, analgesia, physiotherapy, and possible hip replacement.
• Case 2 (Hip Fracture): 🚨 An 80-year-old man falls at home and is unable to bear weight. His right leg is shortened and externally rotated. X-ray confirms an intertrochanteric hip fracture. Diagnosis: Fragility hip fracture. Teaching point: Classic presentation of fracture; requires urgent surgical fixation and osteoporosis management.
• Case 3 (Transient Synovitis): 👦 A 7-year-old boy develops acute hip pain and limp following a recent viral illness. He is afebrile, with normal bloods. Ultrasound shows a small joint effusion. Diagnosis: Transient synovitis of the hip. Teaching point: Benign, self-limiting condition in children; must differentiate from septic arthritis.
• Case 4 (Septic Arthritis): 🦠 A 25-year-old man presents with sudden severe hip pain, fever, and inability to move the leg. CRP and WCC are raised. Ultrasound-guided aspiration reveals pus. Diagnosis: Septic arthritis of the hip. Teaching point: Surgical emergency; requires joint washout and IV antibiotics to prevent joint destruction.
• Case 5 (Avascular Necrosis): ⚠️ A 45-year-old man with a history of long-term steroid use presents with progressive groin and hip pain. MRI shows collapse of the femoral head. Diagnosis: Avascular necrosis of the femoral head. Teaching point: Associated with steroids, alcohol, and trauma; early recognition is key to prevent hip collapse.