Clinical features of fractures

By Eman A. Salem

History
Usually includes a history of injury; Followed by inability to use the joint Fracture is not always at the sight of injury. ptn age and mech. Of injury are important Trivial truma path. Fracture Pain, bruising, and swelling are common symptoms.
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 Fracture VS. Soft tissue injury Deformity more suggestive of a FX. Green stick FX. and elderly with impacted FX. of femoral neck may experience little or no pain, or loss of function. Enquire about sympt. of associated injury: numbness, loss of movement, skin pallor, cyanosis, blood in urine, abdominal pain, difficulty with breathing and transient loss of consciousness.

History cont.
Ask about previous or other musculoskeletal abnormality Finally take general medical history.

Examination
Unless purely local injury priority must be given to deal with the general effects of truma In any case X-ray diagnosis is more reliable 1. Examine the most obviously injured part 2. Check for arterial damage 3. Test for nerve injury 4. Look for injury in distant parts

Look for
Swelling Bruising Deformity If skin is intact or not (open VS simple) Posture of distal extremities and color of the skin signs of nerve or vessel damage

Feel
Palpate for localized tenderness In high energy injuries, always examine spin and pelvis Vascular and peripheral nerve abnormalities should be tested for both before and after treatment

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Move
Crepitus and abnormal movement tested only in unconscious patients Ask if patient can move the joint distal to the injury

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Imaging
X-ray is mandatory

Rule of twos:

1.

X-ray At least two views must be obtained

Two views fracture or dislocation may not be seen in a single

2. Two joints include joints above and below FX.

They may be dislocated or fractured

3. Two limbs in children X-ray of uninjured limb are needed for

comparison, because immature epiphysis may confuse the diagnosis

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4. Two occasions

some fractures are difficult to detect soon after injury, another X-ray a week or two latter may show the lesion. example Undisplaced frx. of distal end of clavicle

5. Two injuriessevere force causes injury at more than one

level

CT and MRI

display Frx. patterns in difficult sites such as vertebral column and acetabulum, and calcaneum

Secondary injuries should always be assumed to have occurred unless proven other wise

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1.Thoracic injury:
lung or heart.

Frx. rib or sternum ass. with injury to

2. Spinal cord injury:

neurological ex. Is essential to check for spinal cord or nerve root injury and to obtain a base line for latter comparison

3. Pelvic and abdominal injury: ass. with visceral

injury inquire about urinary function and look for blood in
urethral meatus

4. Pectoral girdle injury: may damage brachial

vascular examination are essential

plexus or vessels at base of neck. Neurological and

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Testing for fracture union

Its impossible to tell when joining occurs Imp. to know: 1. Signs of healing 2. When bone can withstand normal loading

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Signs of healing
1. Absences of pain during daily activities 2. Absences of tenderness at Frx. site 3. Absences of pain on stressing the Frx. 4. Absences of mobility at Frx. Site 5. X-ray signs of callus formation, bone bridging, and finally trabeculation
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Fractures in children
1.
2.

Difficult to diagnose: Bone ends are largely cartilaginous and

dont show up in X-Ray. It helps to X-Ray both limbs and compare the appearance on both sides.

Children bones are less brittle and more liable to plastic deformation. Higher incidence of incomplete fx.
Buckling of the cortex and the green stick frx. are rare in adults.

3.
4. 5. 6.

Periosteum is thicker than adult bones thats why frx. displacement is more controlled. Cellular
activity is increased (frx. heals faster).

Non-union is very unusual More capacity to reshape frx. Deformity more

modeling and remodeling.

Injury to the physis damage to growth plate can have serious consequences.

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Injuries of the Physis

10% of frx. involve injury to the physis (growth plate) If a frx. transverses the cellular (reproductive) layer of the plate premature ossification of injured part and cessation of growth or bone deformity.
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Classification of physeal injuries

Salter and Harris: 5 types
Type 1: transverse frx. Through the hypertrophic or calcified zone of the plate. Even if frx. Is severely displaced, growing physis is not injured and the growth disturbance is uncommon. Type 2: towards the edge the fracture deviates away from the physis and splits of a fractional piece of metaphyseal bone; growth not affected.

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 Type 3: frx. partly along the physis and then veering off through the epiphysis into the joint space. It damages the reproductive zone and results in growth disturbance. Type 4: frx. splits the epiphysis but continues through the physis into metaphysis. Partly liable to displacement and consequent misfit between separated parts of the physis and results in asymmetrical growth. Type 5: a longitudinal compression injury of the physis. No visible fx., growth plate is crushed causing growth arrest.

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 Physeal frx. falls and traction injury. Mostly in RTA and during sports or playground activities. Boys > Girls Any injury in child followed by pain and tenderness near the joint should arouse suspicion. X-ray is essential.

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 X-ray: physeal frx. are difficult to diagnose in younger children. Compare X-ray with the normal side. A 2nd X-ray after 4-5 days is essential.

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Factors that increase suspicion of physeal injury

1. Widening of physeal gap. 2. Incongruity of the joint. 3. Tilting of the epiphyseal axis.

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Thank You

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