Clinical assessment

There is usually an history of acute trauma to the injured part and this is important to determine whether a fracture is pathological or not. It should also be determined if there is a history of prior problems with the affected part which preceded the acute trauma. If there are any conditions, either local or general which may predispose to the development of fractures, this may also affect patients' recovering rehabilitation.

Figure 22.1. Radial non-union. Plated radius (left) and ulna (right).

Figure 22.2. Malunion of a fractured tibia (left) and fibula (right).

Clinical features are usually:

• Pain is usually of sudden onset and localized to the region of the fracture; however, it may radiate to an area remote from the fracture (e.g. fractured neck of femur). In pathological fractures, there may have been pre-existent mild bone symptoms prior to the sudden onset of severe pain.

• Due to the associated bleeding into the soft tissues secondary to the fracture, swelling can be marked around the fracture site. The soft tissues are distended and in a limb fracture this may present as a fusiform swelling of the affected part of the limb. Bleeding into the subcutaneous region also leads to bruising.

• The fracture area is exquisitely tender and on palpation, abnormal movement and/or crepitus may be detected at the fracture site due to mobility between the fracture ends.

• If the fracture is displaced or angulated, the affected bone and therefore the affected body part will lose their normal anatomical contour. The deformity must be assessed not only in the coronal and sagittal planes, but also by looking for rotational deformity as this must be corrected as the capacity for rotational remodelling is limited.

• Due to the above, there is acute loss of function of the affected part. However, a patient may also present with deformity and swelling but no pain or tenderness because of damage to the peripheral nerves. Under these circumstances, the patient may tolerate the disturbed function and their presentation may be delayed.

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