History and visual inspection
Determining the mechanism of injury is the first and most crucial step. It allows not only to suggest a preliminary diagnosis but is also important for the prevention of occupational injuries. For example, a fall on an outstretched hand often leads to a distal radius fracture, while landing on the buttocks from a height threatens a compression fracture of the lumbar vertebrae.
Visual inspection is always performed in comparison with the healthy side. First of all, the position of the patient and their injured limb is evaluated:
- Passive position: typical for paralysis, unconscious state, severe spinal injuries, as well as fractures (e.g., passive external rotation of the leg in a femoral neck fracture).
- Forced position: characteristic of dislocations, acute fractures, ankylosis, and improperly healed bones.
- Active position: the patient independently controls movements.
The physician also assesses the skin (pallor, hyperemia, cold clammy sweat, presence of abrasions and bruising) and the limb axis. Axis deviation can be valgus (valgus — angle is open outward) or varus (varus — angle is open inward). Causes of deformations include fractures, dislocations, ankylosis, and congenital pathologies.
Palpation and auscultation
After the visual assessment, palpation of the injury site is initiated. Palpation helps to identify local tenderness, soft tissue induration, and swelling. In some cases, specific accesses are used: through the oral cavity (if a jaw fracture is suspected) or through the rectum (in case of a coccyx injury).
Important palpation findings:
- Patellar tap sign (ballottement): indicates fluid accumulation in the knee joint (hemarthrosis or synovitis).
- Tissue depressions: palpated in tears of muscles and tendons (e.g., the Achilles tendon in the calcaneal region).
- Step-off deformity: a characteristic diagnostic sign of a clavicle fracture.
- Change in muscle configuration: noticeable during its contraction against the background of a rupture (e.g., of the biceps brachii muscle).
Auscultation is critically important in polytrauma involving the abdomen and chest. The absence of breath sounds may indicate lung injury, pneumothorax, or hemothorax. The absence of bowel sounds indicates post-traumatic peritonitis, and a specific murmur indicates a traumatic aneurysm.
Measurement of movements and limb lengths
Instrumental measurements are used to accurately assess the severity of the injury. The range of motion is assessed using a goniometer, with the axis of the device set strictly at the level of the joint space. First, the patient performs active movements, then the physician checks passive ones. The obtained degrees are compared with the healthy side and the norm. In pathology, there is a restriction of mobility (contracture) or complete immobility of the joint (ankylosis).
Measurement of limb length and circumference is performed using a tape measure. The patient must lie on a firm examination couch, and the limbs are positioned strictly symmetrically.
| Limb | Bone landmarks for measuring total length |
|---|---|
| Upper | From the acromial end of the clavicle to the tip of the III digit |
| Lower | From the anterior superior iliac spine (spina iliaca anterior superior) to the medial malleolus |
Limb shortening indicates a fracture or dislocation. A difference in circumference in symmetrical areas indicates edema, a massive hematoma, or displacement of bone fragments.
Special diagnostic methods
Clinical data must be supported by additional examination methods.
- Radiography: mandatory method. Performed in at least two projections (anteroposterior and lateral). It allows determining fragment displacement in fractures, the position of articular ends in dislocations, and monitoring the quality of reduction and bone fusion.
- Radiopaque methods: arthrography (for examining joints) and angiography (for the vascular bed).
- Computed tomography (CT): provides cross-sectional tissue images, helps find foreign bodies, and details complex organ injuries.
- Functional diagnostics: rheovasography and oscillography are used to assess blood flow, and electromyography to analyze muscle contractility.
It is important to remember that the general condition of the body (metabolic disorders, alcoholism, immune suppression) reduces resistance to trauma and promotes the development of shock and infectious complications.
Briefly: answers to topical questions
What types of limb shortening are distinguished during examination in traumatology?
During examination in traumatology, three main types of limb shortening and one summary clinical change in length are distinguished.
- Absolute (true, anatomical) shortening — caused by a violation or reduction of the anatomical length of the bone itself or segment.
- Relative (articular) shortening — the anatomical length of the bone is preserved, but the limb is shorter due to the displacement of the articular ends; causes may include dislocations or intra-articular fractures.
- Apparent (functional) shortening — the anatomical length of the bones and joint congruence are preserved; it occurs with a fixed pathological position in the joints, for example, in contracture, ankylosis, or rigidity.
- Clinical (total) change in length — combines the above types.
What are the absolute (reliable) clinical signs of a bone fracture?
Absolute (reliable) clinical signs of a bone fracture include two main symptoms.
- Pathological mobility — the presence of atypical "rocking" movements in the fracture area outside the joint (revealed by gentle displacement of the peripheral limb segment while fixing the proximal one).
- Bone fragment crepitus — the appearance of a characteristic crunch of bone fragments rubbing against each other during limb displacement.
Due to high invasiveness, targeted detection of these symptoms should only be resorted to in exceptional cases.
What types of bone fragment displacement are determined during radiography of fractures?
The following main types of bone fragment displacement are distinguished in fractures:
- Lateral displacement (widthwise) (dislocatio ad latus) — fragments diverge sideways relative to the cross-section of the bone.
- Axial displacement (angular) (dislocatio ad axin / dislocatio ad angulum) — the bone axis is disrupted, and an angle is formed between the axes of the fragments.
- Displacement along the length (dislocatio ad longitudinem) — displacement along the long axis of the bone. It can manifest as shortening with overlapping fragments (cum contractione), lengthening with separation (per extensionem), or impaction.
- Rotational displacement (peripheral) (dislocatio ad periferium / periphericum) — rotation of the peripheral fragment around its longitudinal axis.
Which clinical symptoms indicate fluid accumulation (hemarthrosis or synovitis) in the knee joint?
Fluid accumulation in the knee joint in hemarthrosis or synovitis is indicated by the following clinical symptoms:
- Change in joint shape — smoothing of contours, increase in circumference, bulging of the suprapatellar pouch; in synovitis, bulging of pouches around the patella is also described.
- Patellar tap sign (ballottement) — a specific sign for the knee joint in the presence of fluid.
- Fluctuation — indicates fluid accumulation in the joint cavity.
- Restriction of movement — flexion contracture is most characteristic when fluid is present in the joint.
To remember the normal axis of the lower extremity, use the "Top-Medial-First" rule: the straight line passes through the anterior superior iliac spine, the medial (medial edge) of the patella, and the first (I) toe of the foot.
Class and exam questions
What is the difference between valgus and varus deformity?
In valgus deformity (valgus), the angle of curvature opens laterally, whereas in varus (varus), the apex of the angle points outward while the angle itself opens medially.
How to determine the presence of fluid in the knee joint?
The patellar tap test (ballottement) is used. Its detection upon palpation indicates hemarthrosis or post-traumatic synovitis.
Why measure the limb circumference with a tape measure?
The difference in circumference compared to the healthy side helps diagnose edema, internal hematoma, hemorrhage, or bone fragment displacement.
What else to study on this topic
- Mechanisms of injury and their relationship with specific diagnoses (compression fractures, fractures at typical locations)
- Rules for positioning goniometer branches for various joints (shoulder, hip, elbow)
- Determining the level of lower extremity shortening (at the expense of the femur or leg)
- Impact of the general condition of the body on the development of shock and post-traumatic complications
- X-ray control of the effectiveness of reduction and osteosynthesis
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Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"
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