Fracture's tenderness on palpation: don't let it fool you

Pain during physical examination of a healing upper extremity fracture. Gonzalez, A. I., Kortlever, J. T. P., Crijns, T. J., Ring, D., Reichel, L. M., & Vagner, G. A. (2020) Level of Evidence: 2c Follow recommendation: 👍 👍 👍 Type of study: Prognostic Topic: Fracture tenderness - Healing This is a prospective study assessing the correlation between clients ability to cope with pain in daily life and tenderness on palpation of a hand or wrist fracture. A total of 117 participants were included. Of these participants 33% had a distal radius fracture, 21% had a metacarpal fracture, (18%) and phalanx fracture (the remaining 34% had other upper limb fractures). All of the participants included, presented with fractures which were unlikely to present complications or prolonged healing times (e.g. displaced). Clients ability to cope with pain in daily life was assessed through the Pain Self-Efficacy Questionnaire - Two-Item Short Form (PSEQ-2) (scroll to the bottom of the link to find this handy questionnaire), and the PROMIS CATs for physical function, depression, and pain interference (score it yourself or use it for your clients - Try the PROMIS CAT Demo>>). Tenderness on palpation at the fracture site was scored on a 0 to 10 numerical rating scale. Participants were assessed 3 to 6 weeks post injury. On average, participants were over 48 years old. The results showed that participants presenting with greater pain interference and lower self efficacy, presented with greater tenderness on palpation at the fracture site. This study did not objectively assess fracture's union because there is currently no gold standard that can measure this outcome. It is possible that delayed union affected participants' pain and as a results this affected their ability to cope with pain (this is a limitation of the study). This last option is however unlikely due to the type of fractures assessed, which usually heal fast without complications. Clinical Take Home Message: Based on what we know today, hand therapists may not decide on extending or reducing a fracture's immobilisation period based on tenderness on palpation of the fracture site. It appears that clients presenting with limited coping strategies report greater pain with fracture palpation. Traditional fracture healing times may be a better guide, compared to pain, in deciding how long a fracture should be immobilised. URL: You can ask the authors for the full text through Research Gate Available through EBSCO Health Databases for PNZ members. Abstract The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.


by Dr Nico Magni

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