CLINICAL FEATURES AND DIAGNOSIS OF FRACTURES

BY 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 NEUROVASCULAR 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 ² 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 SHOULDERSHOULDER DISLOCATION

FLEXION,ADDUCTION AND INTERNAL ROTATION OF HIP--POSTERIOR DISLOACTION HIP

ABDUCTION AND EXTERNAL ROTATION OF HIP---ANTERIOR DISLOCATION OF HIP

EXTERNAL ROATATION OF LEG³IC 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 TYPE2 TYPE3 CLEAN WOUND LESS THAN 1 CM IN LENGTH WOUND LARGER THAN 1CM IN LENGTH WITHOUT EXTENSIVE SOFT TISSUE DAMAGE 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 ADEQUATE PERIOSTEAL COVER PRESENCE OF SIGNIFICANT PERIOSTEAL STRIPPING VASCULAR REPAIR REQUIRED TO REVASCULARIZE LEG

SUBTYPE 3A SUBTYPE 3B SUBTYPE 3C

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 femoral Popliteal Posterior tibial Subclavian Axillary brachial trauma Fracture lower 1/3 of femur Supracondylar fracture of femur Dislocation of knee, fracture tibia Fracture of clavicle Fracture dislocation of shoulder 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 musculoskeletal 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 ²ends at the time of fracture or during manipulation Entrapment in callus at the fracture site

NERVE INJURIES AND SKELETAL TRAUMA
NERVE Axillary nerve TRAUMA Fracture surgical neck of humerus,dislocation of shoulder Fracture shaft of humerus Supracondylar fracture humerus EFFECT Deltiod paralysis

Radial nerve Median nerve Ulnar nerve

Wrist drop Ponting index,claw hand(radial)

Fracure medial Ulnar claw hand epicondyle humerus,supracondyl ar fracture humerus Posterior dislocation of hip Fracture neck of fibula,knee dislocation Foot drop Foot drop

Sciatic nerve Common peroneal nerve

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 At birth In children In adults In elderly

Fractures Humerus and clavicle Supracondylar fracture of humerus Fracture shaft of long bones 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/dislocati on. eg:Fall on out stretched hand ² 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

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 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 , ACROMIO³CLAVICULAR SUBLUXATION, FRACTURE HEAD AND NECK OF RADIUS FRACTURE OF CAPITULUM SPECIAL VIEWS ² DIAGNOSE SOME FRACTURES

SPECIAL VIEWS
VIEW JUDET VIEW OBLIQUE VIEW OF THE WRIST MORTICE VIEW SKYLINE VIEW VON ROSEN VIEW OBLIQUE VIEWS FRACTURE ACETABULAR FRACTURES FOR FRACTURE SCAPHIOD ANKLE INJURIES FRACTURE PATELLA CDH 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 xray 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

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