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Dr Mohammed Hutaif
Dr Mohammed Hutaif
العربية

Basic Sciences
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22 min read

The diagnosis of fractures and principles of treatment

How to diagnose a fracture 25

History 25

 

Clinical examination 26

 

Radiological and other visualisation techniques 29

 

Diagnostic pitfalls 30

 

Treatment of fractures 31

Resuscitation and fluid replacement 32

 

Complications of transfusion 36

 

Persisting circulatory impairment 37

 

Head injuries 38

 

Glasgow Coma Scale 39

 

Trauma complications 40

 

Trauma scoring 40

 

General principles of treatment 41

 

Damage control orthopaedics 44

 

Mangled Extremity Severity Score 51

 

Suspected child abuse 53

 

 

How to diagnose a fracture

 

 

 

1 History

 

In taking the history of a patient who may have a fracture, the following points may prove to be helpful, especially when there has been a traumatic incident.

 

1 What activity was being pursued at the time of the incident (e.g. taking part in a sport, driving a car, working at a height, etc.)?

 

2 What was the nature of the incident (e.g. a kick, a fall, a twisting injury, etc.)?

 

3 What was the magnitude of the applied forces? For example if a patient was injured in a fall, it is helpful to know how far he fell, if his fall was broken, the nature of the surface on which he landed, and how he landed; trivial violence may lead one to suspect a pathological fracture: severe violence makes the exclusion of multiple injuries particularly important.

 

4 What was the point of impact and the direction of the applied forces? In reducing a fracture, one of the principle methods employed is to reduplicate the causal forces in a reverse direction. If a fracture occurs close to the point of impact, additional remotely situated fractures must be excluded.

 

5 Is there any significance to be attached to the incident itself? For example, if there was a fall, was it precipitated by some underlying medical condition, such as a hypotensive attack, which requires separate investigation?

 

6 Where is the site of any pain, and what is its severity?

 

7 Is there loss of functional activity? For example, walking is seldom possible after any fracture of the femur or tibia; inability to weight bear after an accident is of great significance.

 

8 What is the patient’s age? Note that while a young person may sustain bruising or a sprain following moderate trauma, an incident of comparative magnitude in an older patient may result in a fracture.

 

 

Diagnosis

 

In some cases the diagnosis of fracture is unmistakable, e.g. when there is gross deformity of the central portion of a long bone or when the fracture is visible as in certain compound injuries. In the majority of other cases, a fracture is suspected from the history and clinical examination, and confirmed by radiography of the region.

 

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2 Inspection (a) Begin by inspecting the limb most carefully, comparing one side with the other. Look for any asymmetry of contour, suggesting an underlying fracture which has displaced or angled.

 

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3 Inspection (b) Look for any persisting asymmetry of posture of the limb, for example, persisting external rotation of the leg is a common feature in disimpacted fractures of the femoral neck.

 

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4 Inspection (c) Look for local bruising of the skin suggesting a point of impact which may direct your attention locally or to a more distant level. For example, bruising over the knee from dashboard impact should direct your attention to the underlying patella, and also to the femoral shaft and hip.

 

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5 Inspection (d) Look for other tell-tale skin damage. For example (A) grazing, with or without ingraining of dirt in the wound, or friction burns, suggests an impact followed by rubbing of the skin against a resistant surface. (B) Lacerations suggest impact against a hard edge, tearing by a bone end, or splitting by compression against a hard surface.

 

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6 Inspection (e) Note the presence of: (C) skin stretch marks, (D) band patterning of the skin, suggestive of both stretching and compression of the skin in a run-over injury, (E) pattern bruising, caused by severe compression which leads the skin to be imprinted with the weave marks of overlying clothing. Any of these abnormalities should lead you to suspect the integrity of the underlying bone.

 

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7 Inspection (f) If the patient is seen shortly after the incident, note any localised swelling of the limb (1). Later, swelling tends to become more diffuse. Note the presence of any haematoma (2). A fracture may strip the skin from its local attachments (degloving injury); the skin comes to float on an underlying collection of blood which is continuous with the fracture haematoma.

 

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8 Inspection (g) Note the colour of the injured limb, and compare it with the other. Slight cyanosis is suggestive of poor peripheral circulation; more marked cyanosis, venous obstruction; and whiteness, disturbance of the arterial supply. Feel the limb, and note the temperature at different levels, again comparing the sides. Check the pulses, and the rapidity of pinking-up after tissue compression.

 

 

 

Dr. Mohammed Hutaif

About the Author: Prof. Dr. Mohammed Hutaif

Vice Dean of the Faculty of Medicine at Sana'a University and a leading consultant in orthopedic and spinal surgery. Learn more about my expertise and achievements.

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