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