History taking and Examination in Orthopedic Trauma

After you completed your primary and secondary surveys on your patient. Now you can focus on the fractures and start by History taking and Examination of the fracture sites in trauma patients

History

• History in trauma is the same as orthopedic history but there is some extra points that you should think of which explained here

History of presenting complaint

• In fractures patient usually present with a history of trauma followed by pain, swelling and inability to use the injured limb but sometimes patient present with deformity which is very suggestive of fracture
• Fracture not always at the site of trauma, it might be in different locations depending upon the size and direction of the applied force.
• Knowing mechanism of injury (how the fracture happened) is key in expecting the fractures locations and severity, so always ask for it.
• Ask for the reason for the fall or the accident: mostly mechanical trip, some complain of chest pain or dyspnea or they aware they blacked out before falling (common causes: urinary or respiratory infections, postural hypotension, transient loss of consciousness, MI, PE)
• If a fracture occurs with mild trauma, suspect a pathological lesion.
• If there was any pain before the fall at the affected region, suspect pathological fracture or stress fracture
• Pain, bruising and swelling are common symptoms  but  they  do  not  distinguish  a  fracture  from  a soft-tissue injury. Deformity is much more suggestive of a fracture or dislocation.
• Consequences of the fall: head injury, how they got help,

Systematic review

• Cardiovascular:  chest pain, syncope, palpitations, SOB
• Respiratory: sputum, cough, hemoptysis, wheeze
• Gastrointestinal: vomiting, abdominal pain, per rectum blood/mucus
• Genitourinary: blood in urine, dysuria
• Neurological: vertigo/dizziness, headache, limb weakness, paresthesia/sensory deficit

Past medical history

• Chronic disease (respiratory, cardiac, GI, ..)
• PMH is important & Required before anesthesia

Social history

• Occupation (physically demanding job => you have to consider management that make them handle their job), living situation (who supports them), smoking, drinking

Drug history

• Full drug history and allergies is important if the patient need surgery

Examination

• Examination in orthopedic trauma same as orthopedics in general but here we will explain some extra points to look for
• In orthopedics we use the examination sequence: look , feel , move
• Use a systematic approach to trauma patients:
  1. Start with examining the obvious injuries.
  2. Always test for vessel and nerve injuries.
  3. Look for other injuries in the same region and in distant parts and examine them as well.
• Cardiopulmonary, gastrointestinal and neurological examination should be also undertaken along with the musculoskeletal examination and injury specific examinations

Look

• Look equals inspection in internal medicine
• Most importantly you need to look at the injured skin, if it is severely lacerated and bone communicates with the external environment then it is an open fracture and requires antibiotic cover and management accordingly ; but if the skin is intact then you assess if there is a fracture either by feeling the bone or by x ray examination
• Swelling, bruising maybe obvious and they are not specific for fractures because it could be a fracture or just a soft tissue injury
• Deformity is specific for fractures 
• Note also the extremity distal to the wound (color and posture) to have an idea of the damage occurred (vessel, nerve)

Feel

• Feel equals palpation in internal medicine
• Tenderness: the injured bone is tender to pressure, there is direct pressure and indirect pressure that result in pain
• Direct pressure is when you apply pressure near the fracture site, and the site of maximal tenderness is the fracture site
• Indirect pressure: applying pressure at site away from fracture result in pain at fracture site (e.g. axial pressure on long bone will elicit pain at the fracture anywhere on the long bone, pinching the forearm bones at any site away from fracture result in pain at the fracture site)
• Sometimes you can feel the fracture edges and bony depressions when you palpate the long bones, but x ray examination is always superior
• Some fractures would be missed if not specifically looked for (e.g. scaphoid fracture when feeling in the anatomical snuffbox)
• Some fractures are always associated with another fractures or ligament injuries so when you see one look for the other (e.g. an isolated fracture of the proximal fibula associated with fracture or ligament injury of the ankle)
• You also feel for temperature of the extremity distal to the fracture and you feel the pulses if they intact or not
• Also feel the distal pulses (distal to the fracture) to assess for vascular injury
• Do neurological examination to look for nerve injuries

Move

• Crepitus  and  abnormal  movement  may  be  present when moving fractured bones but moving the injured bones is painful and x ray is available so use x rays
• Movement is used mostly to assess the joints distal to the injury
• We have fine crepitus and that is associated with osteoarthritis and we have coarse crepitus which is associated with fractures

Differential diagnosis

• Fracture
• Ligament injury 
• Tendon injury 
• Muscle injury
• Soft tissue injury

Course Menu

This article is apart from Orthopedic Trauma Basic Principles Course, This course covers these topics: