Helpful Tips for Ruling Out Fractures

Posted on in Clinical, News

Diagnosing potentially sinister pathologies can seem a little daunting and ambiguous.  Thankfully, there are ways to help guide clinical decision making when you are in these situations.  The use of algorithms and diagnostic instruments may be helpful to understand when a referral is needed for further medical assessment.

Screening Tools

Diagnostic instruments are utilized by practitioners to determine if patients need a referral for radiographic imaging.  As clinicians, we have a responsibility to be able to triage our patients, and direct them for further medical assessment when indicated.  Diagnostic instruments are a helpful way for clinicians to recognize and appropriately refer to the right medical professional. There are several rules that are designed for specific body regions. 

Here are a few common instruments that are used by practitioners.

Canadian C-Spine Rules

The Canadian C-Spine Rules (CCR) are a helpful guide for practitioners to detect clinically important cervical spine injuries including fracture, or ligamentous instability.3 The sensitivity of the CCR was 99.4%, which means the decision-making tool is very beneficial for ruling out fractures.3

Helpful Tips for Ruling Out Fractures

Ottawa Knee Rules

The Ottawa Knee Rules is way determine the need for further radiographic imaging after sustaining an injury to the knee. There is a high degree of sensitivity, 100%.6 Criteria for radiographs include the following:4

  • Age >55
  • isolated tenderness without other bone tenderness
  • tenderness of the fibular head
  • inability to flex the knee to 90 degrees,
  • Inability to bear weight immediately after injury and in the emergency department (4 steps) regardless of limping
Ottawa Knee Rules

Ottawa Ankle and Foot Rules

The Ottawa Ankle and Foot Rules allow clinician to determine the probability of ruling out an ankle or foot fracture. There is a high sensitivity, and therefore helps the clinician determine to rule out a potential fracture. The components of the testing are4,5

  • bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
  • bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
  • bony tenderness at the base of 5th metatarsal
  • bony tenderness at the navicular
  • inability to bear weight both immediately after injury and for 4 steps during the initial evaluation
Ottawa Ankle and Foot Rules

Tuning fork fracture test

Tuning forks are not only just for assessing hearing loss and vibratory sensation.  Tuning forks can be used to help determine if someone has a potential fracture. The tuning fork test is an acceptable method for identifying fractures.1 However, it is important to understand that the findings from this single test alone, isn’t sufficient to rule in or out a fracture.  Many studies have a low power and sample size so it can be difficult to draw conclusions.2 It is essential to use this information as a guide on conjunction with a thorough clinical evaluation.1 Further research is warranted to determine the efficacy of the tuning fork test.

Why is this Important?

There are numerous clinical instruments out there to further assist and guide clinicians when ruling out potential fractures. The ability for clinician to rule out the possibility of fractures allows us to demonstrate our capabilities as autonomous practitioners.  We possess the knowledge and clinical skill be primary care providers of musculoskeletal care for our patients and poise ourselves as a communal presence. However, this information should guide the clinician during the episode of care, rather than being an absolute definitive answer.  Other pertinent information is relevant to appropriately refer patients for further medical assessment. Utilizing these instruments, is a great way to initiate the process and for the betterment of our patients.

Article written by Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT


  1. Moore MB. The use of a tuning fork and stethoscope to identify fractures. Journal of Athletic Training, 2009; 44(3): 272-274.
  2. Mugunthan K, Doust J, Kurz B, and Glasziou. Is there sufficient evidence for tuning fork tests in diagnostic factures? A systematic review. British Medical Journal, 2014; 4. doi:10.1136/bmjopen-2014-005238.
  3. Steill IG, Clement CM, McKnight D, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera, Reardon M, Holroyd B, Lesiuk H, and Wells GA. The Canadian c-spine rule versus the NEXUS low-risk criteria in patient with trauma. The New England Journal of Medicine, 2003,349; 26: 2510-2518.
  4. Steill IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, and Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA, 1994; 271: 827-832.
  5. Beckenkamp PR, Lin C-WC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. British Journal of Sports Medicine 2017; 51(6): 504-510. doi:10.1136/bjsports-2016-096858.
  6. Steill IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, Cacciotti TF, Sivilotti ML. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA, 1996; 275: 611-615.