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CLINICAL FEATURES AND DIAGNOSIS OF FRACTURESBY
Dr.K.S.N.Chenna Kesava Rao
(1st year pg)
A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINUITY OF THE BONE
CLINICAL FEATURES OF A FRACTURE
PAIN SWELLING DEFORMITY TENDERNESS BONY IRREGULARITY ABNORMAL MOBILITY CREPITUS LOSS OF SKIN LOSS OF FUNCTION DISTAL NEURO-
VASCULAR DEFICITS
PAIN very severe increased with movement
SWELLING
o Haematoma o soft tissue edema o minimal swelling --- with severe fracture
IC fracture neck of femur;
o massive swelling ---- absence of a fracture conditions like – ligament sprains and muscle injuries..
If swelling is increasing we have to suspect compartment syndrome.
Compartment syndrome can be diagnosed early by high index of suspicion .
An excessive pain ,-- not relieved by usual
doses of analgesics, pain with passive
stretch of involved muscle group
DEFORMITY
An obvious deformity-- very specific sign of a fracture or dislocation.
Deformity may be absent --- undisplaced or impacted fractures or hair line fracture
INJURIES WITH CHARECTERSTIC DEFORMITIES
DINNER- FORK DEFORMITY---COLLE’S FRACTURE
GARDEN SPADE DEFORMITY
SMITH,S FRACTUREFLATTENING OF SHOULDER-SHOULDER DISLOCATION
FLEXION,ADDUCTION AND INTERNAL ROTATION OF HIP---POSTERIOR DISLOACTION HIP
ABDUCTION AND EXTERNAL ROTATION OF HIP---ANTERIOR DISLOCATION OF HIP
EXTERNAL ROATATION OF LEG—IC OR IT OR SHAFT FRACTURES OF FEMUR
TENDERNESS pain elicited by direct pressure at fracture site or
by indirect pressure may suggest a fracture.Direct pressure:-A localised tenderness on a
subcutaneous bone, elicited by gently running the back of tip of the thumb may suggest an underlying fracture.
Indirect pressure:-it may possible to elicit pain from a fracture site by applying pressure at a site away from the fracture.
EG:- springing test -----fore arm bones fracture, Axial pressure ------ scaphiod fracture.
BONY IRREGULARITIES It is possible to feel bony elevations and
depressions in fractures of sub-cutaneous bones such as the tibia and ulna. This a definitive sign of fracture.
ABNORMAL MOBILITY AND CREPITUS If one can elicit mobility at sites other
than the joints, or an abnormal range of movement at the joint suggestive of definitive fracture
o one can hear or feel a crepitus while doing this.
LOSS OF SKIN
A fracture is called open (compound) when there is a break in the overlying skin and soft tissue.Thus establishing communication between the fracture and the external environment.
GUSTILO CLASSIFICATION OF OPEN FRACTURES
TYPE 1 CLEAN WOUND LESS THAN 1 CM IN LENGTH
TYPE2 WOUND LARGER THAN 1CM IN LENGTH WITHOUT EXTENSIVE SOFT TISSUE DAMAGE
TYPE3 WOUND ASSOCIATED WITH EXTENSIVE SOFT TISSUE DAMAGE;USUALLY LONGER THAN 5 CMOPEN SEGMENTAL FRACTURESTRAUMATIC FRACTURESGUNSHOT INJURIESFARMYARD INJURIESFRACTURE ASSOCIATED WITH VASCULAR REPAIRFRACTURE MORE THAN 8 HOURS OLD
SUBTYPE 3A
ADEQUATE PERIOSTEAL COVER
SUBTYPE 3B
PRESENCE OF SIGNIFICANT PERIOSTEAL STRIPPING
SUBTYPE 3C
VASCULAR REPAIR REQUIRED TO REVASCULARIZE LEG
LOSS OF FUNCTION Following fracture ,the patient may unable to
use the affected limb. In some rare conditions like impacted IC fracture femur they may walk with the fractured limb.
DISTAL VASCULAR DEFICITS Blood vessels lie in close to the fractured
bones are involved most commonly,the pulses distal to the injury should be examined In every case of fracture or dislocation.
The popliteal artery is the most frequently involved artery in musculo-skeletal injuries.
VASCULAR INJURIES AND SKELETAL TRAUMA
Vessel injured trauma
femoral Fracture lower 1/3 of femur
Popliteal Supracondylar fracture of femur
Posterior tibial Dislocation of knee, fracture tibia
Subclavian Fracture of clavicle
Axillary Fracture dislocation of shoulder
brachial Supracondylar fracture of humerus
DISTAL NERVE DEFICITS Nerves close proximity to the bones are
damaged when those bones are fractured. Most common nerve involved In musculo-
skeletal injuries is the radial nerve.
Nerves may be damaged in one of the following ways
By the agent causing the fracture(eg:-bullet)
By direct pressure by the fracture –ends at the time of fracture or during manipulation
Entrapment in callus at the fracture site
NERVE INJURIES AND SKELETAL TRAUMA
NERVE TRAUMA EFFECT
Axillary nerve Fracture surgical neck of humerus,dislocation of shoulder
Deltiod paralysis
Radial nerve Fracture shaft of humerus
Wrist drop
Median nerve Supracondylar fracture humerus
Ponting index,claw hand(radial)
Ulnar nerve Fracure medial epicondyle humerus,supracondylar fracture humerus
Ulnar claw hand
Sciatic nerve Posterior dislocation of hip
Foot drop
Common peroneal nerve
Fracture neck of fibula,knee dislocation
Foot drop
DIAGNOSIS OF FRACTURES
HISTORY CLINICAL EXAMINATION RADIOLOGICAL EXAMINATION SPECIAL IMAGING
HISTORY MOST OF THE FRACTURES ARE DIAGNOSED ON THE
BASIS OF HISTORY AND CLINICAL EXAMINATION. HISTORY OF THE FALL IS VERY IMPORTANT TO KNOW
THE MECHANISM OF INJURY TO CAUSE A FRACTURE AND TYPE OF FORCE TO ACT ON THE BONE TO CAUSE PARTICULAR FRACTURE.
FALL ON OUT STRECHED HAND MOST COMMONLY FRACTURES DISTAL END OF RADIUS.
TRIVIAL FALL IN OSTEOPOROTIC WOMEN MAY PRODUCE INTRA CASPULAR FRACTURE NECK OF FEMUR.
HISTORY OF FREQUENT FRACTURES SHOULD BE ASKED TO RULL OUT OSTEOGENISIS IMPERFECTA , HISTORY OF SYSTEMIC ILLNESSES SHOULD BE ASKED.
HISTORY OF ANY RADIOTHERAPY TAKEN FOR ANY MALIGNANCIES.
CLINICAL EXAMINATION
CLINICAL EXAMINATION IS VERY IMPORTANT IN EVERY CASE OF A FRACTURE
To decide the x-ray examination is needed or not
To ascertain whether the injury under consideration needs a special view
To avoid making a wrong diagnosis ;by correlating the clinical findings with the radiological findings
To detect complications associated with a fracture like hypovolaemic shock, injury to neuro-vascular bundles and fat embolism.
FOLLOWING POINTS ARE TO BE CONSIDERED IN CLINICAL EXAMINATION OF A PATIENT WITH A FRCATURE
AGE OF THE PATIENT:-
certain fractures are common in a particular age groups
Age group Fractures
At birth Humerus and clavicle
In children Supracondylar fracture of humerus
In adults Fracture shaft of long bones
In elderly Colle’s fractureFracture neck of femur
MECHANISM OF INJURY:-mechanism by which patient sustains the injury often gives an idea about the expected fracture/dislocation.
eg:- Fall on out
stretched hand – colle’s fracture
DASH BOARD INJURY-POSTERIOR DISLOCATION OF HIP
PRESENTING COMPLAINTS:- pain swelling, deformity loss of function. EXAMINATION:-a proper exposure of the
body parts is crucial to an accurate examination.
comparing the effected limb with opposite limb may be use full sometimes in cases of findings are subtle.
joints proximal and distal to the injured bone should always be examined.
EXAMINATION FOR DISTAL NEUROVASCULAR DEFICITS IS ALSO VERY IMPORTANT IN CLINICAL EXAMINATION.
In vascular injuries signs in the limb distal to the fracture are 5 P’s
Pain-cramp like Pulse-absent Pallor Parasthesias Paralysis
ONE SHOULD OBSERVE FOR FOLLOWING SIGNS
swelling, deformity, tenderness, abnormal mobility, bony irregularity and absence of transmitted movements.
RADIOLOGICAL EXAMINATION A RADIOLOGICAL EXAMINATION HELPS IN
1.Diagnosis of fracture dislocation2.Evaluation of displacements3.Studying nature of force causing
fracture4.Helps in planning of treatment
options
BEFORE ASKING FOR X-RAY FOLLOWING POINTS SHOULD BE KEPT IN MIND
RULE OF TWO TWO VIEWS(AP/LAT) TWO JOINTS ONE ABOVE AND ONE
BELOW TWO LIMBS(BOTH THE LIMBS FOR
COMPARISON ESPECIALLY IN CHILDREN) TWO INJURIES TWO OCCASIONS(IN SOME FRACTURES
LIKE SCAPHOID FRACTURE IS VISIBLE IN THE X-RAY AFTER TWO WEEKS)
X-RAY FINDINGS SHOULD BE CORRELATED WITH CLINICAL FINDINGS SO AS TO AVOID ERROR BECAUSE SOME ARTIFACTS WHICH MAY MIMIC A FRACTURE
SOME NORMAL FINDINGSo EPIPHYSEAL LINES o VASCULAR MARKINGS ON BONES o ACCESSORY BONES WHICH ARE OFTEN MAY MIS INTERPRETED
AS FRACTURES.
COMPARISON OF OPPOSITE LIMB HELPS
IN ALLEVIATING ANY DOUBTS.
COMMONLY MISSSED FRACTURES IN POLY TRAUMA
SCAPHIOD , ACROMIO—CLAVICULAR SUBLUXATION, FRACTURE HEAD AND NECK OF RADIUS FRACTURE OF CAPITULUM
SPECIAL VIEWS – DIAGNOSE SOME FRACTURES
SPECIAL VIEWS
VIEW FRACTURE
JUDET VIEW ACETABULAR FRACTURES
OBLIQUE VIEW OF THE WRIST FOR FRACTURE SCAPHIOD
MORTICE VIEW ANKLE INJURIES
SKYLINE VIEW FRACTURE PATELLA
VON ROSEN VIEW CDH
OBLIQUE VIEWS HAND AND FEET
AP AND SKYLINE VIEW
JUDET VIEW
ILIAC VIEW OBTURATOR VIEW
AP AND MORTICE VIEWS OF ANKLE
ROLE OF CT-SCAN IN FRACTURE DIAGNOSIS CT scan is not routinely recommended for the
diagnosis of fractures. Plain radiographs are sufficient for diagnosis of 90% of all fractures.
CT scan provides excellent detail of the fracture pathoanatomy and serve as a critically important aid to preoperative active planning for operative approaches and fixation techniques.
Three dimensional images from multidetector CT scans provide detail of fractures, which enable the surgeon to asses comminution ,depression ,and fracture location more accurately than previously possible.
MRI MRI has higher
sensitivity and specificity to detect occult fractures than CT and bone scans.
MRI also provides additional information regarding the soft tissue injuries.
MRI is more specific and sensitive to detect occult scaphiod fractures and occult IC fractures of femur.
BONE SCAN
A bone scan is sometimes performed to rule out an occult fracture(small fracture not seen on x-ray like stress fractures) or an inflammatory process(such as tumor or infection)
A bone scan is performed by injecting a small amount of radioactive marker into an intravenous line.Three hours later the patient is placed through a scanner and the radioactive marker will be concentrated in any region where there is high bone turnover .
Bone scan is highly sensitive test to pick up tumors, infections or very small fractures, because all these conditions result in high bone turnover.
.
Bone scans how ever, cannot distinguish what a lesion represents, and therefore cannot differentiate between a tumor ,an infection or a fracture
The results of the test reveals ‘hot’ or ‘cold’ spots.
hot spots appear darker on image and denote high area of tracer uptake. Possibly indicating a abnormality.
Cold spot appears light and indicate the bone absorbed less of the tracing element.
Bone scans commonly used for diagnosing stress fractures and some scaphiod fractures( carpel bone fractures) and shin splints
BONE SCAN OF WRIST
BONE SCAN OF WRIST SHOWS HOT SPOTS AT SCAPHOID AND LUNATE REGIONS