Clinical

Clinical features
features of
of
fractures
fractures
By Eman A. Salem

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 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.

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

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 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

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 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

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

X-ray
At least two views must be obtained

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 injuriessevere 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: Frx. rib or sternum ass. with injury to
lung or heart.
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
plexus or vessels at base of neck. Neurological and
vascular examination are essential

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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. Difficult to diagnose: Bone ends are largely cartilaginous and
don’t show up in X-Ray. It helps to X-Ray both limbs and compare the
appearance on both sides.
2. 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. Periosteum is thicker than adult bones that’s
why frx. displacement is more controlled. Cellular
activity is increased (frx. heals faster).
4. Non-union is very unusual
5. More capacity to reshape frx. Deformity more
modeling and remodeling.
6. 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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