Wait a Minute, You Auscultated What?

"Didn't notice any crepitus or deformities, Doc, but it sure sounded broken when I auscultated it."

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The Emergency Department was a little busy that day, so I suppose it was no surprise that I was almost out the door before the ED physician who took my handoff report caught up to me, grabbed my arm and blurted, "Wait a minute, you auscultated what?"

Thus arose my first opportunity to pass along something I learned from an orthopedic surgeon in a long-ago PHTLS course: using the lost art of auscultatory percussion to evaluate suspected long bone fractures.

The use of the technique to diagnose long bone fractures traces its origins to the infancy of diagnostic imaging, when X-ray machines were crude and CT scans were unheard of. However, since we have neither at our disposal, we may still find the technique useful, if for no other reason than to show an ED physician that our assessment is strong, and that we can do a more elegant assessment than the crude and painful "three-point long bone check" taught in so many EMT courses. These are the people we're calling for treatment orders, after all.

When the patient is screaming in pain and one leg is several inches shorter than the other, or an arm has an extra joint, diagnosing a long bone fracture is easy. However, how do we make the call when the signs are more ambiguous, or absent? I can remember a number of femur fractures I've treated that were not significantly deformed, particularly in patients with neuromuscular weakness, and in one memorable case, a stripper wearing leather pants so tight they may as well have been painted on.

To perform auscultatory percussion, simply percuss a bony prominence at one end of a long bone while auscultating over the other end. Intact bone conducts sound very well, and will produce a distinct, low-frequency "thump" with percussion. Compare to the uninjured side and note the relative decrease or absence of sound conduction in the fractured limb. To evaluate the femur and hip, percuss the patella while auscultating over the symphysis pubis. To evaluate the humerus and shoulder, auscultate the manubrium and percuss the elbow.

Give it a try sometime. The results may surprise you.