Hand Surgery Source

Fracture Crepitus, Deformity, Motion and Tenderness

Test, Exam and Signs

Historical Overview

Ancient bonesetters have known for centuries that broken bones are painful to touch.  Pain in response to touch or palpation of the fracture is accurately called fracture tenderness.  The bonesetters also recognized that palpating the bone for the area of maximal tenderness would allow them to determine the fracture site quite accurately.  Further they knew the limb containing the fracture (broken bone) was manipulated false motion in the limb on related to a joint could be detected because of motion at the fracture site.  In addition motion at the fracture site also called crepitus, the Latin word for rattling or creaking at the site of injury could be detected when fractures were manipulated3.

Description

  • Palpation of a fracture that causes pain is accurately called fracture tenderness and is a very sensitive sign of a broken  (fractured) bone.
  • Crepitus is a gritting or crunching sensation at the fracture caused by manipulating an unstable fracture where each part of the bone is moving separately because of the fracture.
  • Fracture deformity may occur due to an unstable and/or displaced break in the bone causing the bone to loss its normal anatomical alignment and shape. When a fracture heals in a abnormal displaced or angulated shape, a malunion of the bone occurs and can deform the limb. Fractures of the growth plate can disrupt growth and produce limb deformity as a child grows.
  • False motion may occur at an unstable fracture rather than at a joint when a fractured bone is manipulated.

Pathophysiology

  • Crepitus and fracture deformity may arise from Colles’ fracture, distal radius growth plate fracture or scaphoid fracture.
  • Distal radius fractures are usually the result of a fall on an outstretched hand (FOOSH).
  • Scaphoid fractures represent 50–80% of all carpal bone fractures in young people.1

Instructions

  1. Palpate to elicit crepitus; take care so that there is no further damage to bony fragments and the surrounding soft tissue
  2. Evaluate for mechanical blocks to flexion and extension
  3. Check for tenderness and ask the patient about the severity and duration of pain
  4. Do not try to assess fractures for false motion without anesthesia.

Variations

  • Evaluate the nerve of the injured extremity before and after manipulative reduction.2

Related Signs and Tests

  • Tinel’s sign
  • Radial pulse
  • Sensory exam by nerve

Diagnostic Performance Characteristics

  • The fracture crepitus should be gently assessed with fracture tendermess to improve reliable location of potential fractures which can then be verified with routine X-rays. 
Presentation Photos and Related Diagrams
  • Gently palpating fracture site for tenderness at arrow. Note finger ecchymosis from fracture bleeding.
    Gently palpating fracture site for tenderness at arrow. Note finger ecchymosis from fracture bleeding.
  • Checking finger sensation in recently reduced and splinted Colle's fracture patient.
    Checking finger sensation in recently reduced and splinted Colle's fracture patient.
  • Applying passive finger extension to stretch the deep forearm flexors which will cause severe forearm flexor tenderness if a compartment syndrome is present and the flexor muscles are ischemic.
    Applying passive finger extension to stretch the deep forearm flexors which will cause severe forearm flexor tenderness if a compartment syndrome is present and the flexor muscles are ischemic.
  • Checking finger range of motion - extension
    Checking finger range of motion - extension
  • Checking finger range of motion - flexion
    Checking finger range of motion - flexion
Definition of Positive Result
  • A positive (abnormal) result occurs when the examiner observes fracture tenderness, fracture crepitus, false motion at a potential fracture site, gross limb deformity or mechanical blocks to flexion or extension while examining potentially injured parts of he skeleton.
Definition of Negative Result
  • A negative (normal) result occurs when the examiner no fracture tenderness, no fracture crepitus, no false motion at a potential fracture site, no gross limb deformity and normal joint flexion or extension while examining potentially injured parts of he skeleton.  
Comments and Pearls
  • Any bony tenderness should be considered a potential fracture until proven otherwise. 
  • Fracture crepitus will only occur in unstable fractures where the broken parts of the bone are disconnected from each other and the surrounding soft tissues to such a degree that the ends rub against each other. Palpation to elicit crepitus should be done carefully; it is possible to cause further damage to bony fragments and the surrounding soft tissue.  Crepitus is a gritting sensation upon palpation. The absence of crepitus does not necessarily indicate the absence of a fracture.  Interposition of a piece of soft tissue between the fragments, if the ends of the bones are too far apart from each other or if the bones are impacted there can be a fracture without crepitus.
  • Deformity and false motion suggest more severe high energy fractures.
Video
Examination of patient with a recently reduced Colle's Fracture
References
  1. Alshryda S, Shah A, Odak S, et al. Acute fractures of the scaphoid bone: Systematic review and meta-analysis. Surgeon 2012;10(4): 218-29. PMID: 22595773
  2. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012
  3.  Brorson, Stig.  Management of Fractures of the Humerus in Ancient Egypt, Greece, and Rome: An Historical Review. Clin Orthop Relat Res. 2009 Jul; 467(7): 1907–1914.  PMCID: PMC2690737