CLINICAL FEATURES AND

DIAGNOSIS OF FRACTURES
BY
Dr.K.S.N.Chenna Kesava Rao
(1st year pg)
AFRACTURE 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 FRACTURE FLATTENING OF SHOULDER-
SHOULDER DISLOCATION
 ABDUCTION AND EXTERNAL
FLEXION,ADDUCTION AND ROTATION OF HIP---
INTERNAL ROTATION OF ANTERIOR DISLOCATION OF
HIP---POSTERIOR HIP
DISLOACTION 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 CM
OPEN SEGMENTAL FRACTURES
TRAUMATIC FRACTURES
GUNSHOT INJURIES
FARMYARD INJURIES
FRACTURE ASSOCIATED WITH VASCULAR REPAIR
FRACTURE MORE THAN 8 HOURS OLD
SUBTYPE ADEQUATE PERIOSTEAL COVER
3A
SUBTYPE PRESENCE OF SIGNIFICANT PERIOSTEAL STRIPPING
3B
SUBTYPE VASCULAR REPAIR REQUIRED TO REVASCULARIZE
3C 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 Deltiod paralysis
humerus,dislocation of
shoulder
Radial nerve Fracture shaft of Wrist drop
humerus
Median nerve Supracondylar fracture Ponting index,claw
humerus hand(radial)
Ulnar nerve Fracure medial Ulnar claw hand
epicondyle
humerus,supracondylar
fracture humerus
Sciatic nerve Posterior dislocation of Foot drop
hip
Common peroneal nerve Fracture neck of Foot drop
fibula,knee dislocation
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 fracture
Fracture 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 dislocation
2.Evaluation of displacements
3.Studying nature of force causing fracture
4.Helps in planning of treatment options
 BEFORE ASKINGFOR 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 FINDINGS
o 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