The Art of Auscultating Fractures

I’m doing my AMFR1 (Advanced Medical First Responder) course right now, it’s a 40 hour course (excluding homework and 12hr pre-course readings) that runs over a full two weekends:  4hrs Friday night, then 8hrs Saturday and Sunday.  Our instructor is great.  He’s very patient, knowledgeable, and makes an effort to make sure we learn well.  He’s been able to drill into me protocols and assessments so I can run scenarios more efficiently and he’s helped me build more confidence.  The only tough part is that I have full time school on top of this full time weekend course.  But I’m really enjoying it, plus I can’t say no to a free class!  

Taking the AMFR course reminded me of a very interesting and useful article I read several months ago.  It’s about auscultating fractures.  If you’ve never heard of this before you must be thinking WHAT?!!?  How can you auscultate fractures?  I can understand lungs, and heart which makes sounds…but fractures?  

Yup.  F-R-A-C-T-U-R-E-S.

If you spend a moment to really think about it, it’s not that mind blowing.  Ever tried taking a snooze in class with your ear on the table and you get woken up by your friend tapping on the table with his fingers?  Sounds travel through solid objects very well.  

So now lets bring you away from your nice snooze to a scenario where you have a patient who has a suspected closed fracture, but the signs and symptoms are not obvious.  Since we’re in a pre-hospital setting, there are no CT scanners or X-Rays available, so the best method to use to determine if the patient has a fracture is to auscultate it.  According to Bache and Cross, this technique is accurate 88% of the time.  To do this, you basically locate the long bone in which you suspect the fracture to be, and you place your stethoscope at one end and tap the other end, preferably with a tuning fork.  Say if you suspect a fracture in the humerus, you place your stethoscope on the acromium and tap on the olecranon, if it’s the clavicle, you place your stethoscope at the manubrium and tap on the acromium, for a femur, you place your stethoscope at the anterior superior spine of the ilium (or pubis synthesis) and tap on the patella etc.  When you compare the injured side to the uninjured side, the injured side will be duller, softer, and less resonating due to the disconnect of the bones.

Why is it useful?  Well say your patient above refuses to move or says he cannot move because it hurts a lot, you can determine if there’s a fracture without causing the patient pain (like compression tests), provide medications for the pain, and then move the patient.  You can also write in your run form and tell the doc that “a fracture is suspected via auscultation”, that’ll generate some curiosity from the ER 😉

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I first read about this technique from Kelly Grayson’s article: here.  He’s also the author of En Route: A Paramedic’s Stories of Life, Death, and Everything in Between, a wonderful book to read.

Here are some other articles/journals:
The Use of Auscultatory Percussion For the Examination of Fractures
Use of Tuning Fork in Diagnostic Auscultation of Fractures