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M1) Wrist pain after fall
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with arm pain.
- Review the DDx considerations in a patient with arm pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with arm pain.
History
An 80-year-old female presents to the primary care physician following a fall from slipping on a rug onto her outstretched right hand and extended right wrist. She reports immediate severe pain and difficulty moving her right wrist. There was no loss of consciousness or other injuries reported. She has a past medical history significant for osteoporosis.
Physical Exam
Vital Signs: BP 140/90 mmHg, HR 80 beats/min, RR 16 breaths/min, Temp 98.6°F, SpO2 97% on room air.
Musculoskeletal Exam: Deformity of the right wrist with dorsal angulation ("dinner fork deformity"). The right wrist is tender to palpation with significant swelling. There is decreased range of motion due to pain. The radial pulse is intact, and there is normal capillary refill in the fingers. Sensation to light touch is intact.
Labs
None
Provisional Diagnosis
Select the Dx you believe is most appropriate
Given the history of a fall onto an outstretched hand, significant pain, “dinner fork” deformity, and known osteoporosis, the most likely diagnosis is a Colles' fracture.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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This patient with a suspected fracture without signs of neurovascular compromise requires routine, but expedited workup.
First Imaging Study
What is the first imaging study you will order?
The most appropriate initial imaging modality for a suspected Colles' fracture is a wrist X-ray. This can help confirm the diagnosis and evaluate the presence, extent, and orientation of the fracture. This information helps in planning the treatment strategy, whether that be conservative management, closed reduction, or surgical intervention.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Wrist X-ray
Which bone is fractured?
The fracture is in the radius bone. A Colles' fracture specifically refers to a fracture of the distal radius, often with dorsal displacement and angulation.
Is the fracture intra-articular or extra-articular?
This fracture is extra-articular as it does not involve the joint surface.
What is the direction of the fracture displacement?
There is significant posterior displacement of the fracture. This is a common feature of Colles' fractures, often leading to a "dinner fork" deformity.
Is there evidence of any additional fractures?
There are no additional fractures identified in the x-ray of the wrist.
Is there evidence of osteoarthritis in the wrist?
Yes, there is moderate triscaphe and severe thumb carpometacarpal (CMC) osteoarthritis noted in the x-ray.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is needed. This patient’s fracture is well visualized on the initial x-rays. Advanced imaging modalities such as CT are usually not necessary unless there are specific concerns about the fracture complexity that might change management.
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What is your Diagnosis now that you have seen the imaging results?
The working diagnosis is a Right Colles' Fracture. The characteristic features of a Colles' fracture include a fracture of the distal radius with dorsal (posterior) displacement and angulation. A Smith's fracture is the reverse of a Colles' fracture, with volar (anterior) displacement. A Scaphoid fracture would involve a different bone in the wrist. An Ulnar styloid fracture would also involve a different bone, and this patient's x-ray does not show a fracture of the ulna.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires routine workup and management.
Assessment and Plan
Please provide your assessment and plan for this patient
This is an 80-year-old female who sustained a distal radius fracture (Colle’s fracture) after a mechanical ground level fall at home. Due to the significant dorsal displacement and angulation, orthopedic surgery will be consulted for consideration of possible operative management. In the interim, the patient should be administered analgesics, undergo immobilization of the wrist. Physical therapy should be engaged following appropriate management.
Lessons Learned:
- Colle’s fractures are distal radius fractures with dorsal displacement of the distal radius. The mechanism is generally a fall on an outstretched hand with the wrist extended.
- Risk factors include older age and osteoporosis.
- Radiographs are sufficient for diagnosis.
- Uncomplicated distal radial fractures can be managed conservatively with cast immobilization as outpatient. However, in the case that the fracture has unstable features, such as significant dorsal angulation or radial shortening, an orthopedic consultation is recommended.
Socioeconomic Factors: Given her age and wrist osteoarthritis, this fracture could significantly impact her quality of life and ability to perform daily activities. Occupational therapy may also be beneficial to help her adapt her activities of daily living to accommodate her wrist fracture. This patient should also undergo a home assessment for fall risk.
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