History Taking for Fracture Case — Question Outline

1. Patient Details

• What is your name?
• How old are you?
• What is your gender / occupation / ethnicity?
• What is your ward / bed number / hospital registration number?

2. Chief Complaint

• "Where do you have pain / swelling / deformity?"
• State: Clinical feature + surface anatomy + duration
  • e.g., "Pain over the right thigh for 2 days"

⚠️ Do NOT write "fracture" as the chief complaint — that is a diagnosis, not a symptom.

3. History of Presenting Illness (HPI)

A. Mechanism of Injury

• How did the injury happen? (fall, road traffic accident, direct blow, twisting?)
• What was the energy of impact?
  • High energy → mechanical/traumatic fracture (young patient, no comorbidity)
  • Low energy → suspect pathological fracture (bone already weakened)
  • Repetitive / routine activity → suspect stress fracture
• What position was the limb in at the time of injury?
• Was there a rotational force? → suggests spiral fracture
• Was there a bending / direct force? → suggests transverse fracture
• Was it a high-speed collision (e.g., MVA, road vs. vehicle)? → suggests comminuted fracture

B. Pain (SOCRATES)

• Site — Where exactly is the pain?
• Onset — When did it start? Sudden or gradual?
• Character — What does it feel like? (sharp, dull, throbbing)
• Radiation — Does it spread anywhere?
• Associated symptoms — Any swelling, deformity, bruising?
• Timing — Constant or intermittent?
• Exacerbating / Relieving factors — What makes it worse or better?
• Severity — Score out of 10

C. Determine the Fracture Characteristics (from history)

• Was there a wound / broken skin over the site? → Open (compound) vs. closed fracture
• Is there visible deformity or shortening of the limb?
• Was there an audible crack at the time of injury?
• Anatomical location — Proximal / midshaft / distal?
• Intra-articular involvement — Is the fracture near or involving a joint?

Example diagnosis formulation: "Right open complete displaced transverse fracture of midshaft femur" or "Left closed comminuted fracture of distal femur with intra-articular involvement of knee joint"

D. Neurovascular Status (ask about associated injuries)

• Any numbness, tingling, or weakness distal to the fracture? (nerve injury)
• Any change in skin colour (pallor, cyanosis) or coldness of the limb? (vascular injury)
• Was there a wound associated? → Assess for open fracture / degloving

4. Associated Symptoms

• Swelling at the site?
• Deformity or abnormal angulation?
• Inability to move the limb / bear weight?
• Any other injuries sustained at the same time? (polytrauma)
• Loss of consciousness at the time of injury?

5. Treatment Received So Far

• Was any first aid or splinting done at the scene?
• Is the patient currently in a POP (plaster of Paris) cast or external fixator? (These are temporary stabilization prior to definitive surgery — ORIF)
• Any analgesia given? What type and dose?
• Was the patient taken to another hospital first?

6. Past Medical History

• Any previous fractures at the same site?
• Any bone diseases — osteoporosis, Paget's disease, bone metastases, osteomalacia? → risk of pathological fracture
• Any metabolic conditions — diabetes, renal failure, liver disease?
• Any malignancy (primary or metastatic)?
• Any prior orthopaedic surgeries or implants?

7. Drug History

• Any steroids (long-term use → osteoporosis)?
• Any NSAIDs? (NSAIDs impair bone healing / non-union risk)
• Any anticoagulants? (important pre-operatively)
• Any bisphosphonates or calcium supplements?
• Any over-the-counter medications or supplements?
• Known drug allergies?

8. Social History

• Smoking — impairs bone healing and wound healing
• Alcohol — risk factor for falls, bone disease, impaired healing
• Occupation — affects rehabilitation planning and return-to-work
• Mobility baseline — was patient independently mobile before the injury? Any walking aids?
• Living situation — lives alone or with family? (important for discharge planning)

9. Family History

• Any family history of osteoporosis, bone tumours, metabolic bone disease?

10. Systems Review

• Cardiovascular: chest pain, palpitations (trauma → haemodynamic compromise)
• Respiratory: shortness of breath (fat embolism after long bone fracture)
• Neurological: any loss of consciousness, confusion?
• Genitourinary: any blood in urine? (pelvic fracture → urethral injury)

Summary Tip from the Article

"The rationale is to understand the mechanism of fracture and to note relevant points in history to arrive at a proximate diagnosis prior to imaging modalities."

• Neurovascular / compartment → Do I need to operate in the next hour or the next day?
• Associated injuries → Is there something more life-threatening than the fracture I can see?
• Pathological fracture / comorbidities → Is the bone already diseased, and will it heal?
• Drug history → Can I safely operate, and is this patient sabotaging their own healing?
• Smoking / alcohol → What is the infection and non-union risk post-operatively?
• Systems review (FES, urethral injury) → What systemic complication should I be anticipating in the next 72 hours?