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Diagnosing Fractures (Broken
Bones)
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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is worth until he or she has all the medical records, bills and wage loss
analysis in hand. However, by calling
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explaining the specific circumstances of your accident and injuries, one
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