Page 133 - JSOM Winter 2017

The auscultation method occurs through a reduction of sound Figure 2 Direct contact method of using an activated tuning
transmission from one point in the bone to another either due fork for a boxer fracture and moving the tuning fork lengthwise
to a lack of continuity of the fracture when sound is evaluated (indicated by x symbols) to identify the point of localized pain, which
in length with a stethoscope, the impedance of the same due provides the positive ulna finding.
to clotting and fibrous tissue after injury, or both. To perform
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the auscultation method, you first evaluate the uninjured side
by placing the conical bell of a stethoscope on the proximal
prominence while an activated tuning fork is held base down
and perpendicular with two fingers on the distal prominence
of the same bone and while auscultating for 6 to 8 seconds.
This procedure is then repeated on the injured side, and find-
ings are objectively evaluated. A positive auscultation test oc-
curs if the sound is decreased in pitch and volume compared
bilaterally, indicating a fracture (Figure 1). 6 bone and the potential for sound conduction, but fractures of
irregular bone may be better determined by the direct contact
Figure 1 The auscultation test is accomplished by placing the method. The direct contact TFT can raise confidence in the
conical bell of stethoscope on the proximal bony prominence and
activating the tuning fork and applying it perpendicular on the distal evidence of fractures by demonstrating and increasing a pain
bony prominence of the same bone and auscultating for sound; this response, but that pain may also be misinterpreted by the pa-
should be performed on the uninjured side first and then compared tient’s subjective pain tolerance. Additionally, positive results
with the injured side for tone and volume. to locate the specific fracture site have been found by moving
the activated tuning fork along the long axis of a long bone for
pain sensitivity and the specific point of fracture.
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Conclusion

TFT in fracture evaluation is not an evidence-based method
to reliably diagnose fractures in the austere environment, and
greater standardization, evaluation, and research need to be
accomplished to provide statistical analysis and quantified
It is important to understand dynamics that can affect variabil- sensitivity and specificity for use in the examination of frac-
ity in the auscultation TFT—this method has been found to tures. The TFT should not be used alone for comprehensive,
be more sensitive for transverse fractures and less specific for clinical diagnosis of bone fractures; other modalities such as
avulsion, buckle, and stress fractures due to greater continuity radiological and ultrasound evaluations should be completed.
of the periosteum associated with these latter fracture types
and therefore an unimpeded conduction of sound in these Clinical evaluation of fractures includes a thorough history,
injuries. A transverse fracture will have less conduction due injury presentation, physical examination, and evaluation for
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to the fully separated fracture site that provides a change in a full diagnosis. In absence of advanced diagnostics or during
presentation. Swelling in the extremity and, in particular, the use in limited environments TFT can provide information and
formation of a healing callus may also decrease the accuracy considerations to supplement evaluation, telemedicine, and
of the auscultation test due to their support of the evaluative therapeutics as means to provide fracture care in field.
sound transmission; callus formation usually occurs around 7
days postinjury.
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Findings
The direct contact method of an activated tuning fork to find • A TFT provides an informative and supplementary eval-
a point of localized pain can also be considered for evaluation uation, not a conclusive diagnosis
of suspected fracture. The tuning fork is held perpendicular • A negative finding of a TFT should always be followed
by the base with two fingers on the point of localized pain; an up with more thorough diagnostics if possible
activated tuning fork provokes an acute and increased level of • TFTs can increase confidence of fracture evaluation in
pain and indicates a positive finding for a fracture (Figure 2). the austere or acute setting if correctly administered and
The pain is elicited by the vibration of the tuning fork irritat- the intricacies of each method are well understood
ing nerve endings that are exposed within the fracture of the • The direct application method may prove the most eval-
periosteum, similar to a grind test. Direct contact may also be uative, but it may produce a broader range of findings
more accurate than the auscultation method, especially when due to patient subjectivity and pain tolerance
testing bones other than long bones, such as a short or irregu- • TFT is more accurate when accomplished before acute
lar bone or those occurring alone such as the sternum. swelling occurs or after a healing callus is formed, and
considerations for epiphyseal plate fractures and joint
The direct contact method also has intricacies; it could be interference should be recalled
more sensitive to evaluate other bone types than long bones, • Reviewed literature is referenced to provide greater user
but it is similarly affected negatively by soft tissue swelling and consideration for TFT use or in conjunction with other
after a healing callus has formed for assessment. However, methods of fracture evaluation 7–12
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good results have still been demonstrated by conducting direct
contact with the point of swelling to elicit point pain. The Disclosure
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auscultation and direct contact method may both determine The author has nothing, including financial relationships, to
types of long bone fractures dependent on the length of the disclose.

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