Case history
Case history #1
A 20-year-old man is brought in on a stretcher. He reports severe pain in his right leg and inability to walk after being struck on the shin by a baseball bat. He is in moderate distress due to pain. Examination reveals an ecchymotic and oedematous right shin, with disruption of the normal contour of the underlying tibia. No wound or blistering is noted. There is point tenderness and crepitus to palpation at the mid tibia, and the patient guards any movement of the right lower extremity. Knee and ankle examination is limited by guarding but does not show gross instability. Distal pulses are faint and the right foot is somewhat cool and pale, with decreased sensation to light touch and pinprick.
Case history #2
A 25-year-old woman with anorexia nervosa presents for evaluation of progressively worsening left groin pain. The pain was initially noted with running, but now troubles her even when she walks or is at rest. She has not been seen by a physician for the past 3 years and is taking no medications. Her last menstrual period was 11 months ago. The patient appears emaciated, although this is not fully apparent initially because of her baggy clothing. There is no other abnormality on inspection, and palpation of the hip and lower extremity is non-tender. However, passive internal rotation of the left hip reproduces her pain, as does a fulcrum test. Her gait is slightly antalgic, and she is unable to hop on her left foot due to pain in the groin. A urine pregnancy test is negative. Plain x-rays of the hip and pelvis are read as unremarkable.
Other presentations
Acute long bone fractures are usually associated with sudden onset of moderate to severe pain, swelling, and impaired function. Open fractures are often obvious, but sometimes an apparently minor surface wound belies severe injury below or nearby (bone can piston leading to a wound near the site of injury). A patient with head injury, other distracting injuries, or intoxication may not manifest the classic signs of pain and limb dysfunction. New deformity in a limb implies a fracture and/or dislocation. Blistering of the skin associated with marked oedema also signifies underlying fracture. Stress fractures typically have a gradual, more subtle course, often with no to minimal abnormalities on inspection. Pathological or insufficiency fractures may be the first clue that an underlying process (e.g., cancer, osteoporosis) is present. Patients with dementia may exhibit withdrawal from attempted pressure or motion to the affected area, lack of use of the involved extremity, and non-specific signs such as decreased appetite, new or worsened incontinence, or depression.
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