Page 132 - JSOM Winter 2017

An Ongoing Series

Use of a Tuning Fork for Fracture Evaluation

An Introduction for Education and Exposure

Michael R. Hetzler, 18D (Ret), NRP, ATP

ABSTRACT
Radiographs, bones scans, and even ultrasound may be rare Discussion
in the austere or acute environment for the evaluation of sus-
pected musculoskeletal fractures. Having an easy, simple, and Before discussing the methodology, it is important to review
confident means of objective evaluation used in conjunction the pathophysiology and healing of fractures to better under-
with the patient presentation, history, and physical findings stand findings when using TFTs in the evaluation of traumatic
may provide a more efficient and economical means of treat- or stress fractures. Remembering that all bone types—long,
ment. This introduction and review of selected literature are short, flat, irregular, and sesamoid—develop and strengthen
meant to provide a fuller understanding and consideration for due to the forces acting on them (Wolff law) will provide a
the methods of using a tuning fork in fracture assessment. better understanding of the dynamic causes of growth, injury,
and healing.
Keywords; tuning fork; fractures; austere; operational medi-
cine; primitive medicine Stress fractures are an overuse injury of the bone; they occur
through continuous, repetitive activity and can more often be
seen in bone with less density and maturity. The bone is mi-
Introduction croscopically damaged through impact and repetitive injury.
It is hypothesized that oxygen debt occurs through constant
Limitations to care occur naturally and frequently in the re- perfusion and reperfusion in repair, which is further exacer-
mote environment. Loss of power in disaster areas, a lack of bated by vascular complications and breakdown, and then
access to clinical testing in rural areas, and the expense, cost, a stress fracture occurs. Common sites for stress fractures
2
and delay of advanced diagnostics are all limitations on care. include the tibia, metatarsals, and fibula. A patient may ex-
When fractures are suspected in these scenarios, care may be perience an insidious onset of activity-related pain and minor
augmented by simple and easy methods by using a tuning fork swelling at the site and demonstrate an antalgic gait. Stress
for immediate findings in evaluation. fractures also occur in stages, which can often complicate
signs, symptoms, findings, and diagnoses. Treatment is pri-
3
The use of a tuning fork in the evaluation of skeletal frac- marily through activity modification, rest, and protection of
tures has been exercised for more than 70 years, and although the injury with a boot while still allowing mobility to reduce
conclusive findings in accuracy are still not yet quantified and muscle atrophy. 4
qualified, the research to date provides confidence in its aug-
mentation to evaluation and treatment. This report is meant to Traumatic fractures are more distinct and occur through un-
profile the two primary methods of using tuning forks in the natural forces acting on the skeletal system that directly cause
assessment of suspected fractures in the austere or acute en- a break in the continuity of bone. Types of long bone fractures
vironment and to provide further information and references include the complete transection, comminuted fracture, avul-
in the evaluation of its use. The literature considered varies in sion, and greenstick, depending on the mechanism of injury.
age, credibility, and perspective but is informative in the use
and limitations of the tuning fork test (TFT). There are two primary methods of tuning fork use in the
evaluation of fractures that have sustained the test of time:
Additionally, there has been recent, renewed interest in the the auscultation method, which consists of comparing the in-
TFT by physical therapists for the identification of stress frac- terpretation of sound between proximal and distal points of
tures in athletes and military recruits in the acute setting to bones and comparing them bilaterally between uninjured and
make more informed decisions for treatment and care. TFT for injured limbs, and the direct contact method, which requires
fracture evaluation has also been specifically identified for use the direct stimulation of a suspected fracture site by vibration
in the austere or acute settings. 1 of an activated tuning fork to elicit a pain response.
Address correspondence to michael.hetzler@JSOMonline.org
Mr Hetzler is a retired 18D.

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