Always take a careful history. Most fractures are the result of some characteristic injury, so enquire carefully about the force which caused an injured limb. For example: If a patient landed on his heels from a height, he may have fractured his calcaneus, and also perhaps his spine. If he fell on his outstretched hand, he may have any of the injuries to his upper limb listed in Section 74.1. If a very small force was able to break his bone, it may have been weakened by some other disease so that the fracture is pathological. If he is a child, he may have fallen because he is feeling ill. CAUTION! Osteomyelitis and septic arthritis are the most important differential diagnoses. if you take a careful history you will not miss them.
Always take a careful history. Most fractures are the result of some characteristic injury, so enquire carefully about the force which caused an injured limb. For example:
If a patient landed on his heels from a height, he may have fractured his calcaneus, and also perhaps his spine.
If he fell on his outstretched hand, he may have any of the injuries to his upper limb listed in Section 74.1.
If a very small force was able to break his bone, it may have been weakened by some other disease so that the fracture is pathological.
If he is a child, he may have fallen because he is feeling ill.
CAUTION! Osteomyelitis and septic arthritis are the most important differential diagnoses. if you take a careful history you will not miss them.
Many methods of examination are the same for an injured patient as for an orthopaedic one, so modify those in the list below appropriately.
The important signs of a fracture are: (1) tenderness and abnormal mobility at the fracture site, and (2) an abnormal X–ray. Sometimes you may be able to feel crepitus—the grating feeling as bone ends move over one another. It is acutely painful so don’t examine for it unless it is necessary. If you expect to feel it and don’t feel it, there may be soft tissue between the fragments.
LOOK Remove the patient’s clothes and look for abnormal attitudes, contour, and shortening. if displacement is gross, one glance will tell you he has a fracture or a dislocation—deformity, shortening, rotation, or overlap will be obvious. You can diagnose most dislocations merely by looking at them.
Are both limbs the same? Compare one side carefully with the other. One joint may look larger than the other, either because it is swollen, or because the muscles round it are wasted. If necessary, measure shortening with a tape measure (77-3).
FEEL Ask the patient to point to exactly where the pain is. Often, his whole joint is acutely tender; if it is not, feel carefully for the place of maximum tenderness, particularly if you suspect a fracture of his wrist or ankle. You will then know which bone to X–ray. Tenderness to gentle pressure is a more useful sign than tenderness to deep pressure.
If a bone is tender, assume it is broken (or he has osteomyelitis) until an X–ray shows it is normal, or until you are quite sure he has not got osteomyelitis—see Section 7.3. If a ligament is acutely tender, it may be ruptured.
Feel the patient’s bones carefully, for example, are the three bony points of his elbow (72-2) in their normal places?
If you suspect infection, test for warmth. Test for this first, because your other examinations may increase it. (1) Use the back of your hand to compare the abnormal side with the normal one. Or, (2) move the palm of your hand down the patient’s limb. It usually gets progressively colder, if it gets warmer anywhere, the warm part may be abnormally vascular, usually because of infection.
MOVE Ask the patient to move his injured limb, as much as he can himself. This is active movement.
If he can use his arm actively, or walk on his injured leg without a limp, he has no serious injury. Many important injuries are missed, or unnecessarily overtreated, because nobody asks a patient to do this.
If he cannot move his limb actively, gently move it passively for him in all directions, as far as you can without hurting him. Record the movement that is possible from the neutral position for each joint as shown in Fig. 69-1.
Most surgeons evolve their own particular routines, which they vary as necessary. Later we describe a detailed routine for the knee. Work out your own for the other joints.
Finally record your findings, and don’t forget to include the soft tissue injuries. A patient’s X–ray films are not a sufficient record of his injury.
(1) If a patient is severely injured, save his life first; treat any airway obstruction (52.1), haemorrhage, or shock (53.2) before you treat his fractures.
(2) Splint him where he lies when you first see him (51.2); this will minimize soft tissue damage and avoid converting a closed fracture into an open one.
(3) Look for signs of nerve (55.8) and vessel injury (55.3) and record your findings.
(4) Handle his injured part as little as you can.
(5) If he has an obvious fracture, make sure that this is his only injury—it may be the least of his injuries. Don’t let him die from a tension pneumothorax (65.5) while you are treating a fracture of his forearm!
(6) Don’t be deceived by the absence of deformity and disability; sometimes he can continue to use his fractured limb.
(7) Take X–rays in 2 planes and examine them yourself.
(8) Reduce the fracture as soon as you can, don’t wait for the swelling to go down, except sometimes in the ankle (82.4).
(9) If he has continuous severe pain, suspect circulatory impairment and treat it immediately (70.4).
(10) When you split a cast, divide the plaster and the padding right down to his skin.
(11) If you put him into traction, be sure to check this frequently (70.9).
(12) All joints that are not immobilized by the fracture must be kept moving (69.10).
(13) Remember that open fractures are contaminated wounds, so toilet them and use delayed primary closure (69.7).
(14) Aim to restore function. if a patient’s arm is injured, try to restore the proper use of his hand; shortening and some misalignment are often acceptable. If his leg is injured, try to restore painless stable weight bearing; prevent misalignment; maintaining length is desirable, but a little shortening is acceptable.
(15) Finally, remember to treat him as a whole person; don’t only treat his injured limb.