In taking the history of a patient who may have a fracture, the following points may prove to be helpful, especially when there has been a traumatic incident.
1. What activity was being pursued at the time of the incident (e.g. taking part in a sport, driving a car, working at a height, etc.)?
2. What was the nature of the incident (e.g. a kick, a fall, a twisting injury, etc.)?
3. What was the magnitude of the applied forces? For example, if a patient was injured in a fall, it is helpful to know how far they fell, if the fall was broken, the nature of the surface on which they landed, and how they landed. Trivial violence may lead one to suspect a pathological fracture; severe violence makes the exclusion of multiple injuries particularly important.
4. What was the point of impact and the direction of the applied forces? In reducing a fracture, one of the principal methods employed is to reduplicate the causal forces in a reverse direction. If a fracture occurs close to the point of impact, additional remotely situated fractures must be excluded.
5. Is there any significance to be attached to the incident itself? For example, if there was a fall, was it precipitated by some underlying medical condition, such as a hypotensive attack, which requires separate investigation?
6. Where is the site of any pain, and what is its severity?
7. Is there loss of functional activity? For example, walking is seldom possible alter any fracture of the femur or tibia: inability to weight bear after an accident is of great significance.
8. What is the patient's age? Note that while a young person may sustain bruising or a sprain following moderate trauma, an incident of comparative magnitude in an older patient may resull in a fracture.
Diagnosis In some cases the diagnosis of fracture is unmistakable, e.g. when there is gross deformity of the central portion of a long bone or when the fracture is visible, as in certain compound injuries, hi the majority of other cases, a fracture is suspected front the history and clinical examination, and confirmed by radiography of the region.
2. Inspection (a): Begin by inspecting the limb most carefully, comparing one side with the other. Look for any asymmetry of contour. suggesting an underlying fracture which has displaced or angled.
3. Inspection (b): Look for any persisting asymmetry of posture of the limb. e.g. persisting external rotation of the leg is a common feature in disimpacted fractures of the femoral neck.
4. Inspection (c): Look for local bruising of the skin suggesting a point of impact which may direct your attention locally or to a more distant level. For example, bruising over the knee from dashboard impact should direct your attention to the underlying patella, and also to the femoral shaft and hip.
5. Inspection (d): Look for other tell-tale skin damage. For example (A) grazing, with or without ingraining of dirt in the wound, or friction burns, suggests an impact followed by rubbing of the skin against a resistant surface. (B) Lacerations suggest impact against a hard edge, tearing by a bone end, or splitting by compression against a hard surface.
6. Inspection (e): Note the presence of: (C) skin stretch marks. (D) band patterning of the skin, suggestive of both stretching and compression of the skin in a run-over injury. (E) pattern bruising, caused by severe compression which leads the skin to be imprinted with the weave marks of overlying clothing. Any of these abnormalities should lead you to suspect the integrity of the underlying bone.
7. Inspection (f): If the patient is seen shortly after the incident, note any localised swelling of the limb (I). Later, swelling tends to become more diffuse. Note the presence of any haematoma (2). A fracture may strip the skin from its local attachments (dcgloving injury): the skin comes to float on an underlying collection of blood which is continuous with the fracture haematoma.
8. Inspection (g): Note the colour of the injured limb, and compare it with the other. Slight cyanosis is suggestive of poor peripheral circulation: more marked cyanosis suggests venous obstruction; and whiteness may indicate disturbance of the arterial supply. Feel the limb and note the temperature at different levels, again comparing the sides. Check the pulses and the rapidity of pinking-up after tissue compression.
9. Tenderness (a): Look for tenderness over the bone suspected of being fractured. Tenderness is invariably elicited over a fracture (I >. but tenderness will also be found over any traumatiscd area, even though there is no underlying fracture (2). The important distinguishing feature is that in the case of a fracture tenderness will be elicited when the bone is palpated on any aspect (3).
10. Tenderness (b): In eliciting tenderness, once a tender area has been located the part should be palpated at the same level from another direction. For example, in many sprained wrists tenderness will be elicited in the anatomical snuff-box - but not over the dorsal and palmar aspects of the scaphoid, which are tender if a fracture is present.
11. Palpation: The sharp edge of a fracture may be palpable. Note also the presence of localised oedema. This is a particularly useful sign over hairline and stress fractures. The development of oedema may however take some hours to reach detectable proportions.
12. Other signs: If the fracture is mobile, moving the part may produce angulation or crepitus from the bone ends rubbing together. In addition, the patient will experience severe pain from such movement. These signs may be inadvertently observed during routine examination of the patient, hut should not be sought unless the patient is unconscious and the diagnosis is in doubt.
13. Radiographic examination: In every case of suspected fracture, radiographic examination of the area is mandatory. Radiographs of the part will generally give a clear indication of the presence of a fracture and provide a sound basis for planning treatment. In the case where there is some clinical doubt, radiographs will reassure patient and surgeon and avert any later medicolegal criticism.
Radiographers in the United Kingdom receive thorough training in the techniques for the satisfactory visualisation of any suspect area, but it is essential that they in turn are given clear guidance as to the area under suspicion. The request form must be quite specific, otherwise mistakes may occur. At its simplest, the request must state both the area to be visualised and the bone suspected of being fractured. It is desirable to include tile joints above and below the fracture. It need hardly be stressed that a thorough clinical examination should precede the completion of the radiographic request if repetition and the taking of unnecessary films are to be avoided.
The following table lists some of the commonest errors made in the filling in of request forms.
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