History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include direct or indirect trauma, age <30 years or >70 years, long-term bisphosphonate use, and seizures (all fractures); bone tumour (pathological fractures); low body mass index, history of recent fall, prior fracture, and long-term corticosteroid use (insufficiency fractures).
pain
Acute fractures usually cause severe pain.
In stress fractures pain may be mild and often has a gradual onset, becoming progressively more severe over time.
Pain in the lower limb reproduced on weight-bearing exercise, such as hopping, jogging, or even walking, can be due to a stress fracture.
Pathological and insufficiency fractures usually cause a sudden onset of pain.
In patients with long bone fractures, compartment syndrome is seen most commonly following fractures of the tibia or forearm. The key clinical findings of compartment syndrome are pain out of proportion to the associated injury and pain on passive movement of the muscles of the involved compartments.[48]
soft-tissue swelling
May be massive but is non-specific. Pathological fractures may present with rapid swelling; however, these fractures are typically low-energy and can also present with minimal swelling.
ecchymosis
May be marked but is non-specific.
expanding haematoma
Indicates vascular injury and significant haemorrhage.
impaired limb function
Usually seen in long bone fractures.
inability to bear weight
Patients with an acute femoral or tibial or tibial-fibular shaft fracture are usually unable to bear weight.
Patients with lower-extremity stress fractures or isolated fibular fractures are usually able to bear weight.
point tenderness
Commonly occurs over the site of the fracture.
deformity
Indicates displaced fracture and/or dislocation.
guarding
The patient may guard against any movement of the affected limb (e.g., during physical examination).
wound overlying site of injury
If associated with underlying fracture, this is an open fracture. However, a wound may not be directly over the fracture site; bone can piston, leading to a wound nearby. A break in the skin at or near the site of injury greatly increases the risk of infection.
signs of vascular injury
Includes: lack of palpable pulse, continued blood loss, or expanding haematoma.[46]
signs of acute compartment syndrome
In patients with long bone fractures, compartment syndrome is seen most commonly following fractures of the tibia or forearm.[48] The classic signs of acute compartment syndrome are loss of distal pulses, pallor, increased pain with passive stretch of tissues distal to the fracture site, paraesthesias, and poikilothermia. Negative predictive value is high, but positive predictive value of these signs separately is low. A high index of suspicion is therefore needed because vascular injury without acute compartment syndrome can also cause pain, pallor, paraesthesias, and loss of distal pulses.[52] See Compartment syndrome of extremities.
hypotension/hypovolaemic shock
Can occur in high-energy trauma, particularly in fracture of the femur.[58] Bruising of the thigh is often noted, and an expanding haematoma indicates severe vascular injury. Distal pulses may be weak or absent.
Other diagnostic factors
uncommon
altered nerve sensation
In proximal humeral shaft fractures, injury to the axillary nerve causes altered sensation over the regimental patch.
In fractures involving the proximal radius, there may be associated injury to the radial or posterior interosseous nerve causing abnormal sensation (including pain) at the dorsum of the thumb and second and third fingers.
An isolated fibular fracture may cause damage to the common peroneal nerve causing paraesthesia down the lateral aspect of the lower leg.
impaired motor function
In proximal humeral shaft fractures, injury to the axillary nerve may cause deltoid (shoulder abduction) and teres minor (subtle external rotation) weakness. Radial nerve palsy (in which the patient is unable to extend their wrist and fingers, resulting in the hand presenting in a position of flexion) may result from mid or distal humeral shaft fractures.
In fractures involving the proximal radius, wrist and thumb extension may be weak due to radial nerve damage.
In isolated proximal fibular fractures, damage to the common peroneal nerve may result in foot drop.
bony crepitus
May be palpable over the site of the fracture.
callus
May be palpable over the site of a healing stress fracture.
reproduction of symptoms in stress fractures of the neck or shaft of the femur
Several examination techniques can be used to help in the diagnosis of a stress fracture of the neck or shaft of the femur.
The fulcrum test, which involves the patient levering the shaft of the femur over the examiner's forearm, which is placed underneath the shaft, may reproduce the symptoms in a stress fracture of the neck or shaft of the femur.
Similarly, internal rotation of the hip often reproduces pain in a patient with a femoral neck stress fracture.
The hop test, which asks patients to hop on one or both legs, will usually produce pain as well.
These findings can be subtle, so it is very important to maintain a high index of suspicion for these injuries.
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