CLINICAL EVALUATION AND TESTING

Use of Auscultation and Percussion to Evaluate a Suspected Fracture Kimberly D. Johnston, MS, ATC • High Point University; Russell T. Baker, MS, ATC and Jayme G. Baker, DPT, ATC, PT • California Baptist University

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linical examination of a suspected fracture is often limited to observation (i.e., localized swelling and/or ecchymosis) and palpation (i.e., point tenderness and/ or crepitus), which can be unreliable when fracture signs are not obvious.1-5 Referral for further clinical evaluation of a possible fracture typically involves radiographic examinaKey Points tion, which may not be sensitive enough to The Auscultatory Percussion Test is a detect subtle patholsimple and highly accurate method for ogy. 2-6 A missed fracidentification of fractures. ture is most likely to be The Auscultatory Percussion Test is painless associated with a subtle presentation that is diffor the patient, and it provides immediate feedback about the likelihood that a ficult to differentiate fracture exists. from soft-tissue pathology.3,7 The Auscultatory The bones most often assessed by the Percussion Test (APT) Auscultatory Percussion Test are the tibia, involves assessment fibula, clavicle, femur, humerus, and ulna. of the transmission of sound through the bone structure, which can be performed without the imposition of stress that could elicit pain.1 A fracture or callus formation that may not be visible on a radiograph may be detected through performance of the APT, which can provide an athletic trainer or therapist with more information for accurate clinical decision-making.1,2,8,9 The purpose of this report is to describe the history, development, and

evidence relating to use of the APT in clinical practice.

Development of Auscultation and Percussion Auscultation was first used in general medicine to assess pulmonary function and to diagnose respiratory diseases.10 The first description of the use of auscultation to hear crepitus associated with a fracture was reported in 1823.11 Camman and Clark12 reported diminished sound conduction in patients with fractures in the 1840s, and the first description of using auscultation with percussion was reported in 1846 for diagnosis of hip fractures.13 Limited descriptions of the technique were included in reports by Stimson in 191714 and Stewart in 1921.15 In 1932, Lippman14 suggested that the combination of auscultation with percussion could be effective for identification of fractures, confirmation of proper fracture reduction, and determination of progress in achievement of bone union associated with fracture healing. Colwill and Berg1 published a study on the effectiveness of the procedure for identification of upper and lower extremity fractures in the 1950s, but the next mention of the diagnostic technique in the literature did not appear until Peltier16 published a historical review in 1977. Bache and Cross17 © 2013 Human Kinetics - IJATT 18(3), pp. 1-6

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and Misurya et al.9 were the first to report the use of a vibrating tuning fork as an alternative to a finger tap in the 1980s. As more sophisticated diagnostic imaging techniques have become readily available, utilization of auscultation and percussion as a means to diagnose fractures disappeared from the literature.7,18

fracture site (Figure 1).17,20 Sound waves at the 128-Hz frequency have a long duration that is easily heard and that is not readily transmitted across a fracture line. A higher frequency tuning fork produces greater kinetic energy, which has the potential to overcome an obstruction to transmission of sound waves.9 The sound produced by either the percussive technique or the application of a vibrating tuning fork is compared bilaterally at the same anatomic sites.1,17,22 The clinician listens to the resulting sound for approximately 6 to 8 seconds.20 A positive test is defined by a difference in the sound conducted through the injured bone to that which is conducted through the uninjured bone,10,17,20 whereas a negative test is defined by equal sound conduction bilaterally. 17,18,21,22 The altered sound conduction may be characterized by reduced volume or differing pitch1,7,10,14,20-24 or a complete absence of sound conduction through the injured bone.20,24 Lippman14 has suggested that a discontinuity in bone structure changes the frequency of vibration that are conducted through the bone, thereby resulting in less resonance and decreased volume.

Clinical Utilization of the Auscultatory Percussion Test The APT is most commonly used for detection of a fracture in the tibia, fibula, femur, clavicle, humerus, or ulna.8,14 The site for auscultation may be separated by one, two, or more joints from the site of percussion.1,14 The passage of sound through normal joints does not alter sound quality or decrease sound volume (Table 1).14 The injured extremity is placed in a similar position to that of the uninjured extremity for testing.7,17,19 The auscultation is performed by placing the bell of an adult stethoscope over a bony prominence that is proximal to the suspected fracture site (Figure 1),17,20,21 but a pediatric stethoscope may be used as an alternative for close conformity to an irregular bony surface. 9,14 The percussive force is typically applied to a distal bony prominence by the clinician’s free hand, which should be strong enough to produce a distinctly audible sound but light enough to avoid inducement of pain.10,14 An alternative APT method involves the application of a vibrating 128-Hz tuning fork to the bone surface at a site that is distal to the suspected

Research Evidence The findings of numerous studies support the clinical value of the APT for fracture diagnosis (Table 2). Most of the studies have been focused on identification of hip and pelvis fractures. Few studies have assessed the

Table 1. Summary of Common APT Application Locations FX Examined

Stethoscope Placement

Percussion Location

Pelvis

Anterior Superior Iliac

Femur & Hip

Symphysis Pubis1,4,13,14,18,19 or ASIS5,10

Patella4,5,10,13,14,18,19 or Medial Femoral Condyle5,13

Femoral Shaft

Greater Trochanter5

Patella5

Femoral Neck

Anterior Superior Iliac Spine5

Patella5

Pubic Rami

Symphysis Pubis5

Patella5

Tibia

Tibial Tuberosity1,4,5

Medial Malleolus1,4,5

Fibula

Fibular Head4,16

Distal tip of Lateral Malleolus16

Clavicle

Manubrium1,4,10,17

Olecranon1,17 or Acromion1,4,10

Humerus

Manubrium1,17 or Acromion4,10

Olecranon1,4,10,17

Radius

Olecranon1

Radial Styloid Process1

Ulna

Olecranon1,4

Ulnar Styloid Process1,4

Phalange in Hand

Metacarpalphalangeal Joint16

Tip of Phalange16

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Spine1

Patella1

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Figure 1  Placement of the stethoscope bell (fibular head) and tuning fork (distal fibula) to examine the fibula with the APT.

diagnostic accuracy of the APT for upper extremity fractures and none have compared percussion to the use of a 128-MHz tuning fork. Case studies reported by File et al.7 and Borgerding et al.19 have advocated use of the APT for identification of femoral neck fractures. In both case studies, patients had hip pain after a fall and initial radiographs were interpreted as negative, and one also involved a CT scan that was interpreted as negative on the day of injury.19 The APT was positive in both cases, and the existence of a fracture was ultimately confirmed in both cases by additional diagnostic imaging.7,19 Adams and Yarnold22 assessed APT diagnostic accuracy for patients who sought care for hip trauma at an emergency department. Interrater agreement

Table 2. Summary of Research Utilizing APT to Examine Fractures Author

Subjects

FX Location

Technique

Outcomes*

Patient 1: 85-yr-old woman with a history of traumatic injury after a fall; Patient 2: 95-yr-old man that had suffered a fall.

Femoral neck FXs

Percussion

Patient 1: Initial radiographs were negative, APT indicated fracture confirmed by radiograph (Garden III) 5 days after initial radiograph; Patient 2: APT indicated fracture, radiograph was negative, but CT scan confirmed fracture (Garden II).

Borgerding et al.19

68-yr-old female referred to physical therapy 8 days after a fall.

Femoral neck FXs

Percussion

Initial radiographs and CT scan on day of injury were negative for fracture; APT indicated fracture on 5th visit (19 days after initial visit); radiographs that day confirmed non-displaced sub-capital fracture.

Adams & Yarnold22

41 consecutive patients presenting to ED following hip trauma.

Intertrochanteric, Lesser trochanteric, Femoral neck, Acetabular, and pelvic FXs

Percussion

The APT was performed by two physicians prior to performing a clinical exam or knowing the diagnosis. Overall, in the patients with a “+” APT, a FX was present in 93.8% of cases (the false positive occurred in a patient with Paget’s disease); four false negatives occurred and involved either an impacted or avulsion FX.

Adams et al.21

96 consecutive patients presenting to an ED with a chief complaint of shoulder trauma.

Humeral & Clavicle FXs; also used in cases of GH dislocations, AC separations, RC tears, Shoulder sprains, Labral tears, and contusions

Percussion

The APT was performed by two physicians prior to performing a clinical exam or knowing the diagnosis. A false-positive error did not occur in any of the 96 cases, but a 15% false-negative error did occur. APT correctly identified all Clavicle FXs (N = 9) with inter-rater accuracy of 0.86; Identified 16 of 20 Humeral fractures with interrater accuracy of 0.9 (missed impacted FX, comminuted FX with associated avulsion FX, and two cases of head fractures not transecting bony pathway); identified 40 of 47 patients with some type of radiographic abnormality.

File et

al.7

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Table 2. (continued) Author

Subjects

FX Location

Technique

Outcomes*

Colwill & Berg1

50 normal patients & 50 consecutive patients with fractures.

Clavicle, Humerus, Radius, Ulna, Pelvic, Femoral, Tibia, and Fibula FXs

Percussion

APT correctly identified 44 of 50 fractures; false negatives involved impacted femoral head FX, a pelvic FX due to adequate cortical contact of a ramus; and three ankle FXs due to fragmented pieces; no false positives occurred.

Tiru et al.18

290 patients (54 males, 236 females, mean age of 72 ± 6.8 years) with post-traumatic hip pain who were unable to ambulate and had initial normal radiographs.

Femoral Neck FXs

Percussion

Sensitivity = 0.96; Specificity = 0.86; + Predictive Value = 0.98; – Predictive Value = 0.75; + Likelihood Ratio = 6.73; – Likelihood Ratio = 0.75.

Misurya et al.9

50 patients examined at a fracture clinic.

Femoral neck, Femoral shaft, and Tibia FXs

128Hz Tuning Fork and a pediatric stethoscope

Each case was examined clinically and then the APT was performed. The results of the clinical exam and the results of the APT were compared with radiological findings. The APT was correct in 94% of cases, while clinical exam was correct in only 88% of cases. The APT wrongly diagnosed a posterior hip dislocation as a fracture (decreased sound conduction) and missed two impacted fractures (one at femoral neck and one femoral shaft). Clinical exam missed fractures to the femoral shaft (N = 2), femoral neck (N = 3), and tibial shaft (N = 1).

Bache & Cross17

100 consecutive patients (18 male, 82 female, average age of 78.6 years) examined in an accident unit.

Femoral Neck FXs

128Hz Tuning Fork

Clinical exam performed first, followed by the APT, and then substantive diagnosis made with radiograph. Clinical exam correctly identified FX in 85.7% of cases; APT correctly identified FX in 91.1% of cases; combined examination identified FX in 94.6% of cases.

Moore20

37 patients (19 males, 18 females, age range of 7 to 60 years) who had the test performed within 7 days of injury.

Fibula, Phalanges (Foot & Hand), Ulna, 5th Metatarsal, Metacarpals, Clavicle, Tibia, Humerus, & Radius FXs

128Hz Tuning Fork

Sensitivity = 0.83; Specificity = 0.80 (0.92*); + Likelihood Ratio = 4.2 (10.4*); – Likelihood Ratio = 0.21 (0.18*); Diagnostic Accuracy = 81% (89%*).

Femoral Neck FXs

128Hz Tuning Fork; used an electronic stethoscope

Jawad et al.2

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20 patients (14 women, 6 men, between the ages of 79 and 85) reporting to a hospital with post-traumatic hip pain and normal radiographs.

*APT statistics with stethoscope placed over area of swelling Sensitivity = 0.78; Specificity = 0.82; Diagnostic Accuracy = 80%; + Likelihood Ratio = 4.3.

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for two emergency room physicians was 90.2% for 41 cases (84.2% for the patients who had a fracture of the proximal femur or pelvis and 95.4% for those without a fracture). When the physicians agreed (i.e., both considered the APT positive or negative for 37 of 41 cases), a correct classification resulted for 89.2% of the patients.22 Tiru et al.18 focused on diagnosis of occult femoral neck fractures in patients who reported post-traumatic hip pain. The patients were unable to ambulate following injury and initial radiographs were interpreted to be negative. The APT was performed, which was followed by further diagnostic imaging (e.g., repeat radiography, MRI, CT scan). The APT result was reported to have sensitivity of 0.96 and specificity of 0.86 for occult femoral neck fractures.18 Studies have also assessed the value of the APT with use of a 128-Hz tuning fork for diagnosis of fractures. Misurya et al.9 reported that the APT was more accurate than traditional clinical examination for identification of fractures to the femoral neck, femoral shaft, and tibia. The APT result was correct for 94% of cases (100% for tibia fracture cases), whereas clinical diagnosis based on traditional methods was correct for 88%.9 Bache and Cross17 also studied the effectiveness of the tuning fork method for diagnosis of femoral neck fractures. Fractures were correctly identified for 91% of cases, whereas a traditional clinical examination resulted in correct results for 86% of cases. Combining the tuning fork APT with other findings derived from a complete examination resulted in a correct diagnosis for 95% of cases.17 Jawad et al.2 also used a 128-Hz tuning fork and further modified the APT by using an electronic stethoscope. Patients with post-traumatic hip pain and normal radiographs were referred for an objective analysis of recorded APT sound, and the patient was subsequently referred for MRI. Comparison of the APT results with the gold standard MRI results demonstrated sensitivity of 0.78, specificity of 0.82, and overall diagnostic accuracy of 80%.2 Adams et al.21 assessed the diagnostic accuracy of APT results in patients who presented to a hospital emergency department following shoulder trauma. The patients presented a variety of conditions (e.g., fractures, dislocations, sprains, contusions). The APT results did not produce a single false-positive error, but did have a false-negative rate of 15% among positive cases (primarily due to failure to yield a positive test result for cases with acromio-clavicular separations, international journal of Athletic Therapy & training

which may have been due to minimal disruption of sound conductance). The APT was deemed useful for identification of gleno-humeral dislocation, as well as subsequent successful reduction.21 Colwill and Berg1 assessed the diagnostic accuracy of the APT for fractures of both the upper and lower extremities. False-negative results (i.e., missed fractures) only occurred when patients had fractures that maintained cortical contact (e.g., an impacted fracture of femoral neck) or fractures that involved small bone fragments (e.g., an avulsion fracture of tibial malleolus). Greatest accuracy was found for fractures involving the fibula (100%), clavicle (100%), and femur (94%). The APT appears to be least useful for bones that do not have relatively superficial surfaces at both the distal and proximal ends (e.g., tarsal and carpal bones) and fractures that do not interrupt sound conductance through a largely intact bone structure (e.g., avulsion fractures). Moore20 used a 128-MHz tuning fork to identify fractures in both the upper and lower extremities. The tuning fork APT was highly accurate for detection of transverse fractures but not for diagnosis of avulsion or buckle fractures. Moore20 reported sensitivity of 0.83, specificity of 0.80, a positive likelihood ratio of 4.2, a negative likelihood ratio of 0.21, and diagnostic accuracy of 81%. Swelling appeared to negatively impact the accuracy of the APT, so the test was modified by placing the tuning fork away from the site of swelling and placing the stethoscope directly over the swollen tissues. This alteration in the clinical test procedure improved specificity (0.92), the positive likelihood ratio (10.4), the negative likelihood ratio (0.18), and diagnostic accuracy (89%).20 Although there is strong evidence to support use of the APT, fractures that leave a substantial amount of the bone intact (i.e., impacted fractures and avulsion fractures) may produce a high rate of falsenegative results.9,17,20,21 For example, an impacted fracture of the femur could maintain a high degree of cortical contact that allows for normal sound conduction,1,8,9,21,22 and an avulsion fracture may be separated from the bone structure that conducts sound.1,20 Additionally, bilateral fractures may produce comparable sounds,9,17,21,22 or the existence of a fracture at an untested location could produce a false-negative result.9,17 Bony anomalies (e.g., Paget’s Disease, tumors),21 obesity,9,17 or the presence of metal plates or intramedullary hardware8 may alter sound transmission. may 2013  5

Summary The APT is easy to perform, painless for the patient, and provides immediate diagnostic information.1,9,14,18,20,24 The high level of APT accuracy could reduce the number of unnecessary radiographs2 and the number of missed fractures. 14,20,22 The APT is useful for assessment of numerous bones and fracture types20 and may be particularly useful for identification of a fracture with a subtle presentation similar to that of a soft tissue injury.7,18,19 The APT has been shown to be more accurate than a traditional physical examination for detection of certain types of fractures,9,17 and the combination of APT results with other clinical findings provides diagnostic accuracy that is superior to the use of either approach in isolation for detection of long bone fractures.9,17,18 Thus, the physical examination of an athlete who is suspected to have a fracture should include performance of the APT to maximize diagnostic accuracy.9,18,20,22 

References 1. Colwill JC, Berg EH. Auscultation as an important aid to the diagnosis of fractures. Surg Gynecol Obstet. 1958;106(6):713-714. 2. Jawad Z, Odumala A, Jones M. Objective sound wave amplitude measurement generated by a tuning fork: an analysis of its use as a diagnostic tool in suspected femoral neck fractures. Injury. 2012;43(6):835-837. 3. Leddy JJ, Smolinski RJ, Lawrence J, Snyder JL, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 1998;26(2):158-165. 4. Shetty S, Sidharthan S, Jacob J, Ramesh B. ‘Clinical scaphoid fracture’: Is it time to abolish this phrase. Ann R Coll Surg Engl. 2011;93(2):146148. 5. Cruickshank J, Meakin A, Breadmore R, Mitchell D, Pincus S, Hughes T, Bently B, Harris M, Vo A. Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures. Emerg Med Australas. 2007;19(3)223-228. 6. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier;2008. 7. File P, Wood JP, Kreplick LW. Diagnosis of hip fracture by the auscultatory percussion technique. Am J Emerg Med. 1998;16(2):173-176. 8. Siffert RS, Kaufman JJ. Acoustic assessment of fracture healing: capabilities and limitations of “a lost art”. Am J Orthop. 1996;25(9):614-618.

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9. Misurya RK, Khare A, Mallick A, Sural A, Vishwakarma GK. Use of tuning fork in diagnostic auscultation of fractures. Injury. 1987;18(1):63-64. 10. Peltier LF. The diagnosis or fractures of the hip and femur by auscultatory percussion. Clin Orthop Relat Res.1977;123:9-11. 11. Lisfranc J. Application of the stethoscope to the diagnosis of fractures. N Engl J Med. 1824; 13:220-221. 12. Camman GP, Clark A. A new mode of ascertaining the dimensions form and condition of internal organs by percussion. NY J Med Surg. 1840;3:62-96. 13. Bowditch HI. The Young Stethoscopist, or the Student’s Aid to Auscultation. New York: J. and H. Langley., 1846, and reprinted by William D. Tickner and Co.; 1946. 14. Lippmann RK. The use of auscultatory percussion for the examination of fractures. J Bone Joint Surg Am. 1932;14(1):118-126. 15. Stewart FT. Manual of Surgery for Students and Physicians. 5th ed. Philadelphia, PA: Blakiston’s Son and Co.;1921. 16. Nokes LDM. The use of low-frequency vibration measurement in orthopaedics. Proc Inst Mech Eng H. 1999;213(3):271-290. 17. Bache JB, Cross AB. The Barford test: a useful diagnostic sign in fractures of the femoral neck. Practitioner. 1984;228(1389):305-308. 18. Tiru M, Goh SH, Low BY. Use of percussion as a screening tool in the diagnosis of occult hip fractures. Singapore Med J. 2002;43(9):467-469. 19. Borgerding LJ, Kikillus PJ, Boissonnault WG. Use of the patellar-pubic percussion test in the diagnosis and management of a patient with a non-displaced hip fracture. J Man Manip Ther. 2007;15(4):E78-E84. 20. Moore MN. The use of a tuning fork and stethoscope to identify fractures. JAT. 2009;44(3):272-274. 21. Adams SL, Yarnold PR, Matthews JJ. Clinical use of the olecranonmanubrium percussion sign in shoulder trauma. Ann Emerg Med. 1988;17(5):484-487. 22. Adams SL, Yarnold PR. Clinical use of the patellar-pubic percussion sign in hip trauma. Am J Emerg Med. 1997;15(2):173-175. 23. Carter MC. A reliable sign of fractures of the hip or pelvis. N Engl J Med. 1981;305(20):1220. 24. Mirels H. Diagnosis of fractures using sound conduction in bone. S Afr Med J. 1986;69(7):410.

Kimberly Johnston is the certified athletic trainer responsible for Women’s Soccer and Women’s Lacrosse for the High Point University Athletics Department in High Point, NC. Russell Baker is an assistant professor in the Department of Kinesiology at California Baptist University in Riverside, CA. He is also a doctoral student at the University of Idaho in the Doctor of Athletic Training program. Jayme Baker works at West Coast Spine Restoration Center and serves as an adjunct professor with the Department of Kinesiology at California Baptist University in Riverside, CA. Scott Cheatham, PT, DPT, OCS, ATC, CSCS, California State University Dominguez Hills, is the report editor for this article.

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