Diagnosis of fractures

Physical Examination

Most fractures cause swelling, deformity, and pain on attempted movement. Minimally displaced, stress, or impending fractures cause tenderness on palpation and pain on weight bearing or loading of the involved bone. In noncommunicative patients, refusal to move an extremity may be the only sign of a fracture or dislocation. Thorough assessment of the sensory, motor, and circulatory status of the injured extremity is important before starting therapy. After application of a cast, splint, or traction or after manipulation of a fractured extremity, the neurovascular status of the limb should always be reevaluated.

When injury or lack of cooperation makes physical examination unreliable, x-rays are required to detect a fracture. For instance, a hip fracture may make examining the contralateral side difficult. Because coexisting injuries and preexisting abnormal conditions may be present, the physician should obtain x-rays of both hips and the pelvis in any patient with a femoral or pelvic fracture.

In patients with suspected hemarthrosis, joint aspiration is useful. Aspiration of fluid suggests acute effusion secondary to gout, pseudogout, or infection, which can be confirmed by laboratory test. Aspiration of blood confirms an intra-articular injury (eg, fracture or torn ligament or meniscus). Fat globules in the blood, which can be seen easily when the aspirate is viewed in an open container, imply a fracture that allows fat from the marrow cavity to enter the joint.

Diagnostic Tests

X-rays:

Radiographs remain the most important tool for diagnosing and treating fractures. Routine x-ray evaluation of suspected fractures should always include both anteroposterior and lateral views. On a single view, the characteristic displacement, discontinuity in contour, or altered alignment of a fracture may be hidden because of overlap or projection. When standard views are equivocal, as sometimes occurs with minimally displaced spiral fractures, oblique views can be helpful. Fractures may be missed if the x-ray shows too small an area. A patient complaining of thigh and knee pain, for instance, may actually have a hip fracture causing referred pain; unless x-rays of the entire femur are taken, the fracture may be missed.

Computed tomography: 

Although not routinely needed, computed tomography is a useful adjunct to plain x-rays in several circumstances. It allows visualization of occult fractures, particularly in areas difficult to image with x-rays because of overlying bony structures (eg, the cervical spine). Computed tomography helps in determining the extent of articular surface disruption in joint fractures and in assessing suspected pathologic fractures for bone destruction and soft tissue masses.
Magnetic resonance imaging:
In special circumstances, magnetic resonance imaging offers advantages, providing excellent tomography, soft tissue contrast, and spatial resolution using noninvasive and nonionizing radiation technology. Magnetic resonance imaging helps in evaluating pathologic fractures and in diagnosing osteonecrosis and osteomyelitis, both of which can mimic fractures. Often, magnetic resonance imaging can show occult fractures before an x-ray can detect them. Magnetic resonance imaging cannot directly show calcification or bone mineral and thus does not visualize bone structure as well as x-ray or computed tomography.

Bone scan: 

Total-body scanning, using 99mTc-labeled pyrophosphate or similar radioactive analogs, is performed to detect focal injury to bone from any cause. Uptake occurs wherever new bone forms, which can occur in response to infection, arthritis, tumor, or fracture. Occult fractures not yet visible on x-ray can often be detected on bone scan 3 to 5 days after injury. Patients with suspected pathologic fractures require bone scans for evaluation of metastatic and metabolic bone disease, which involve areas other than the fracture site.

Blood tests:

Fractures, especially those of the hip, can result in substantial bleeding into soft tissues. The most widely used clinical test for evaluating blood loss from fractures is hematocrit measurement. A 3 mL/dL drop in hematocrit corresponds to the loss of roughly 500 mL (1 u.) of blood in a normally hydrated patient. Patients with acute bleeding or dehydration may initially have a falsely normal or elevated hematocrit; when intravascular volume is replenished with IV fluids, hematocrit will fall. Since elderly patients are often at high risk for developing myocardial ischemia, their RBC volume should not be allowed to drop below a level that maintains sufficient oxygen-carrying capacity. As a clinical guideline, a hematocrit < 30 mL/dL usually indicates the need for blood transfusion, especially preoperatively. In hip fracture patients, the hematocrit should be monitored for at least 4 days after injury or surgery, since a 4- to 8-mL/dL drop can occur because of continued bleeding or equilibration.

A low or falling hematocrit can also warn of a serious underlying medical condition with important implications in the fracture patient. For instance, gastrointestinal bleeding can be exacerbated by anticoagulants routinely given to immobilized patients for prophylaxis of deep venous thrombosis. Anemia may be the first sign of multiple myeloma or another malignancy that has led to a pathologic fracture.

Serum alkaline phosphatase rises when bone turnover increases. This occurs with normal fracture healing as well as with malignancy and metabolic abnormality (eg, Paget’s disease). Serum calcium rises with some endocrine disturbances (eg, hyperparathyroidism) and with metastatic disease, especially breast carcinoma. When patients with Paget’s disease are on bed rest, excessively rapid bone resorption can also elevate the serum calcium level.

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