CHAPTER XV DIAGNOSIS OF FRACTURES AND DISLOCATIONS OF THE UPPER LIMB The application of X-rays to surgery has greatly simplified the diagnosis of injuries of the skeleton... <Callout type="tip" title="Tip">Always compare both sides when examining a limb for fractures or dislocations.</Callout> In every case, therefore, in which injury of bones is suspected, an examination under the fluorescent screen, or, which is far more useful, the taking of one or more skiagrams, should be insisted upon. This examination should be made as soon as possible... <Callout type="warning" title="Warning">Oversights can lead to missed fractures and serious complications.</Callout> Without the use of X-rays a certain number of fractures are sure to be overlooked, and in every case the information obtained is of the greatest service to the surgeon. In the large majority of cases the patient is able to point out the seat of injury; but this is not always the case... <Callout type="important" title="Important">Always examine all parts of an injured limb and all limbs of a seriously injured person.</Callout> For if not, when one fracture or dislocation has been detected, similar injuries or sprains and contusions may be overlooked and the results be very serious. Comparative measurement of the limbs.— It will be well to notice here the best measurements... <Callout type="risk" title="Risk">Inadequate examination can result in misdiagnosis and poor treatment outcomes.</Callout> First measure from the inner end of the clavicle to the tip of the acromion : this measurement is not increased by any injury; it may be shortened by fracture of the clavicle with over-riding of the fragments, by bending of the bone (greenstick fracture), or by dislocation of its outer end. Next, measure from the tip of the acromion to the outer epicondyle (epicondylus lateralis) of the humerus... <Callout type="beginner" title="Beginner">For a greenstick fracture, look for an unsymmetrical, exaggerated anterior curve in the clavicle.</Callout> The patient should be seated in a chair, and the surgeon, standing behind him, should place the forefinger of each hand on the suprasternal notch of the sternum... <Callout type="gear" title="Gear">A tape measure is essential for accurate limb measurements during examination.</Callout> If the line of the clavicle is interrupted, or if crepitus can be felt in it, there is a fracture. This is most common in the middle third, with considerable deformity; it may occur close to the inner end, with slight deformity, or at the outer end between the conoid and trapezoid ligaments, without any deformity... <Callout type="risk" title="Risk">Failure to use a tape measure can lead to inaccurate diagnosis.</Callout> An unsymmetrical, exaggerated anterior curve is due to a greenstick fracture of the clavicle; the bone will be tender. Rickets causes a similar curve, but it is symmetrical... <Callout type="tip" title="Tip">Use a ruler or some such body to measure the shoulder when examining for dislocation.</Callout> The surgeon, standing in front of the patient, should place his hand flat upon the outer part of the patient's shoulder, with his thumb resting on the acromion; if he feels the upper end of the humerus beneath the deltoid muscle, projecting beyond the acromial arch, the head of the bone is in the glenoid cavity—there is no dislocation. If the resistance is not felt, but the hand sinks in deeper than the acromion towards the glenoid fossa, the shoulder is dislocated... <Callout type="important" title="Important">Always check for bilateral dislocations when examining a patient.</Callout> Dislocations of the shoulder.— In all dislocations the anterior fold of the axilla is depressed and... <Callout type="risk" title="Risk">Failure to detect a subclavicular or subspinous dislocation can lead to improper treatment.</Callout> If in reduction of the dislocation, crepitus is obtained, and the head of the bone easily slips out of place again, and the surgeon is able to assure himself that there is no fracture of the humerus or of the coracoid or acromion process, he should diagnose a fracture of the glenoid cavity. This injury is never met with apart from dislocation of the joint, except as the result of gunshot wounds... <Callout type="tip" title="Tip">Use the patient's age to help determine the nature of shoulder injuries.</Callout> If the patient is under 20 years of age, and a projection of the upper end of the humerus is found in front just below the coracoid process, and rotation of the arm causes a soft kind of crepitus, and yet the humerus is entire... <Callout type="risk" title="Risk">Misdiagnosis can lead to improper treatment and long-term complications.</Callout> If there is a point of great tenderness on the greater tuberosity, and the patient is unable to abduct the arm with the palm of the hand to the front, whilst he is able to do so if the arm is rotated either in or out, there is complete or partial separation of the tendon of the supraspinatus muscle from its attachment to the greater tuberosity... <Callout type="important" title="Important">Always check for dislocation of the biceps tendon when examining the elbow.</Callout> Fractures and dislocations of the elbow.— The varieties of fracture and dislocation about the elbow-joint are numerous, and their diagnosis is extremely important, for, unless all displacement is corrected, the function of the joint may be permanently interfered with. The fractures are commonly the result of direct violence... <Callout type="warning" title="Warning">Ignoring subtle signs can lead to missed diagnoses.</Callout> By comparing the relative position of these three bony prominences is first to be ascertained. When the joint is flexed the olecranon sinks below the epicondyles; when the elbow is extended it lies in front with them... <Callout type="risk" title="Risk">Failure to detect a dislocated ulna can lead to complications.</Callout> The distance between the two condyles can be measured by calipers ; any increase in it immediately after an injury must be due to fracture of the humerus. Then notice whether the elbow is rigid or movable—rigidity is the common result of dislocation, whereas in a fracture movement is possible but almost always causes a good deal of pain... <Callout type="tip" title="Tip">Use calipers for precise measurement when examining the elbow joint.</Callout> By this examination the following injuries can be recognized: 1. When the olecranon projects too far behind both condyles of the humerus and the sigmoid notch can be felt, there is dislocation of the ulna backwards... <Callout type="important" title="Important">Always ensure thorough examination to avoid missing critical injuries.</Callout> The two bones of the forearm may be dislocated inwards or outwards; in either case one of the epicondyles of the humerus will be very prominent, and a bone of the forearm will project on the opposite side of the joint... <Callout type="risk" title="Risk">Incomplete examination can lead to improper treatment.</Callout> If the prominence of the olecranon at the back of the joint is lost and
Key Takeaways
- Always use X-rays or comparative measurements for accurate diagnosis.
- Examine all parts of an injured limb to avoid missing other injuries.
- Use specific techniques like comparing sides and measuring accurately.
Practical Tips
- Always compare both sides when examining a patient's limbs for fractures or dislocations.
- Use X-rays whenever possible for more accurate diagnosis, especially in cases where the injury is not obvious.
- Ensure thorough examination by checking all parts of the limb and using specific techniques like measuring accurately.
Warnings & Risks
- Oversights can lead to missed fractures and serious complications.
- Failure to detect dislocated bones or subtle signs can result in improper treatment.
- Ignoring critical injuries during examination can have long-term consequences for the patient.
Modern Application
While X-rays are now standard, many of the physical examination techniques described still apply. Understanding how to accurately diagnose and treat fractures and dislocations is crucial for modern survival preparedness, especially in remote or resource-limited settings where imaging may not be available.
Frequently Asked Questions
Q: How can I ensure I don't miss critical injuries during an examination?
Always compare both sides of the patient's limbs, examine all parts thoroughly, and use specific techniques like measuring accurately. Missing any part of the examination can lead to overlooked injuries.
Q: What should I do if X-rays are not available?
Use comparative measurements and physical examination techniques as described in this chapter. While less precise than X-rays, these methods can still provide valuable information for diagnosis.
Q: How can I prevent misdiagnosis during an elbow injury examination?
Ensure you check the relative position of bony prominences, measure accurately with calipers, and look for signs like rigidity or pain. Missing subtle signs can lead to improper treatment and long-term complications.