Sprain or Fracture? How to Tell at Home and When You Need an X-Ray

Short answer: you cannot reliably tell a sprain from a fracture by swelling, bruising or whether you can move the joint. What predicts a fracture is pain when you press directly on specific points of bone, and being unable to take four steps. Doctors use validated checklists called the Ottawa rules for the ankle, foot and knee. Wrist injuries with tenderness at the base of the thumb, any injury in a child, and any fall in an older adult deserve a lower threshold for an X-ray. Get an X-ray the same day if the limb looks deformed, you cannot bear weight, or there is numbness, a cold limb or a wound over the injury.

Myths that delay the right treatment

• "I can move it, so it isn't broken." Many fractures, including ankle, wrist and finger fractures, still allow movement.
• "The swelling is small." Some serious fractures swell very little at first, and some sprains swell dramatically.
• "It's just a sprain, a massage will set it right." Massage, oil rubbing or tight bandaging by a traditional bone-setter before an X-ray can displace a fracture, and very tight bandages can cut off blood supply.

Ankle and foot: the Ottawa rules

An X-ray of the ankle is needed if there is pain around the ankle bones and any of these:

• Tenderness when pressing the back edge or tip of the bony bump on the outer side of the ankle (lower 6 cm of the fibula).
• Tenderness at the back edge or tip of the bony bump on the inner side of the ankle.
• Inability to take four steps, both straight after the injury and when examined.

A foot X-ray is needed if there is midfoot pain and tenderness at the base of the fifth metatarsal (the bony bump halfway along the outer edge of the foot) or at the navicular bone on the inner midfoot, or if you cannot take four steps. If none apply, a fracture is very unlikely, and the injury can be treated as a sprain; the ankle sprain treatment guide covers recovery.

Knee: the Ottawa knee rules

After a knee injury, an X-ray is advised if any one of these is present: age 55 or over; tenderness only over the kneecap; tenderness over the head of the fibula on the outer side just below the knee; inability to bend the knee to 90 degrees; or inability to take four steps. A knee that swells within hours of a twist, with a normal X-ray, can still have a ligament or meniscus tear, which needs an orthopedic examination rather than just rest.

Wrist and hand: the injury that is most often missed

After a fall on an outstretched hand, press the hollow at the base of the thumb on the back of the wrist (the anatomical snuffbox). Tenderness there suggests a scaphoid fracture, which often does not show on the first X-ray. Because a missed scaphoid fracture can fail to heal and lead to wrist arthritis, it is treated in a splint as a fracture until repeat imaging rules it out. Finger injuries that leave the finger bent, rotated or unable to straighten at the tip also need an X-ray, as tendon and joint injuries in the hand do badly if left. The wrist fracture recovery guide explains treatment when a break is confirmed.

Children and older adults: lower the threshold

In children, ligaments are stronger than the growth plates at the ends of bones, so a "sprain" in a child is often actually a growth plate fracture. Any child who limps for more than a day or will not use an arm should be X-rayed. In adults over about 50, a wrist, hip, shoulder or spine fracture from a simple fall suggests osteoporosis, and the fracture is a warning to check bone health.

First aid that helps

• Protect and rest the injured part; use a splint, a folded newspaper or a sling to keep it still on the way to hospital.
• Ice wrapped in a cloth for 15 to 20 minutes at a time, never directly on skin.
• Elevate the limb above heart level to reduce swelling.
• Remove rings, anklets and bangles early, before swelling makes it impossible.
• Paracetamol for pain. No massage, no oil rubbing, no tight bandage.

Go the same day if

• The limb looks bent, deformed or out of place.
• You cannot bear any weight, or cannot use the hand at all.
• There is a wound near the injury, or bone is visible.
• Fingers or toes are numb, cold, pale or blue.
• Pain is getting worse rather than better, especially under a bandage or plaster.

X-ray and fracture care near Chandapura and Attibele

Raghava Multispeciality Hospital on Sarjapura–Attibele Road has in-house X-ray and 24/7 casualty, about eight minutes from Chandapura circle, with Anekal, Hennagara and Jigani a short drive away. Dr. Nitin N Sunku, orthopedic surgeon, reviews the X-ray and the examination together and decides between a support, a plaster or, when needed, surgical fixation. See the fracture and trauma care in Attibele page for details.

This article is general information and does not replace an examination. Any injury with a head, neck, chest or abdominal component, an open wound over a possible fracture, or a cold, pale or numb limb is an emergency.