Musculoskeletal and rheumatology · Easy
This case is fictional and exists for study. It describes no real patient.
68 years · female
A 68-year-old female presents to the Emergency Department following a fall onto her outstretched right hand while walking in her garden. She complains of immediate, severe right wrist pain, swelling, and deformity. On examination, there is a visible 'dinner-fork' deformity of the right wrist with marked tenderness localized over the distal radius. Neurovascular examination reveals intact radial and ulnar pulses, prompt capillary refill under 2 seconds, and preserved sensation throughout the median, radial, and ulnar nerve distributions. The skin over the deformity is intact with no open wounds.
Vital signs
- HR
- 84 bpm
- BP
- 132/82 mmHg
- RR
- 16/min
- Temp
- 36.7 °C
- SpO₂
- 98%
Examination findings
- Dinner-fork deformity of the right distal forearm and wrist
- Tenderness over the right distal radius
- Intact distal neurovascular status with normal capillary refill
Investigations
| Haemoglobin | 13.5 g/dL | reference: 12.0-15.5 |
| White Blood Cell Count | 6.8 10^9/L | reference: 4.0-11.0 |
Question 1 of 3
Based on the clinical presentation, what is the most likely diagnosis?
A classic 'dinner-fork' deformity following a fall onto an outstretched hand (FOOSH) in an older adult is characteristic of a Colles' fracture, which is an extra-articular distal radius fracture with dorsal displacement/angulation. Smith's fracture involves volar displacement ('garden-spade' deformity) typically from a fall onto a flexed wrist. Scaphoid fractures present with focal tenderness in the anatomical snuffbox without a classic dinner-fork deformity. Galeazzi fractures consist of a distal radius shaft fracture associated with dislocation of the distal radioulnar joint.
Teaching point: A fall onto an outstretched hand causing a distal radius fracture with dorsal displacement presents with a classic 'dinner-fork' deformity, characteristic of a Colles' fracture.
Question 2 of 3
What is the single most appropriate initial investigation to confirm the diagnosis?
Plain radiographs (anteroposterior and lateral views) of the right wrist are the gold-standard initial investigation for suspected wrist fractures. They confirm the fracture, degree of displacement, angulation, and joint involvement. MRI and CT scans are reserved for complex, intra-articular, or occult fractures where plain X-rays are inconclusive. Ultrasound is not standard for primary bone fracture assessment in acute adult wrist trauma.
Teaching point: Anteroposterior and lateral plain radiographs are the mandatory initial imaging modality for assessing acute suspected fractures of the wrist.
Question 3 of 3
If radiographs confirm a displaced extra-articular distal radius fracture with intact neurovascular status, what is the next best management step?
Displaced, extra-articular distal radius fractures with intact neurovascular status are routinely managed in the Emergency Department with closed reduction (often under local haematoma block or Bier's block) and immobilization in a below-elbow plaster backslab, followed by post-reduction radiographs. Open reduction and internal fixation is indicated if closed reduction fails or for unstable intra-articular fractures. Simple crepe bandaging is insufficient for displaced fractures. Intravenous antibiotics and debridement are required for open fractures, but this patient has intact skin.
Teaching point: Initial definitive management for a displaced closed distal radius fracture is emergency closed reduction and immobilization in a splint or backslab.
Key learning points
- Colles' fracture is an extra-articular distal radius fracture with dorsal angulation and displacement, classically presenting as a 'dinner-fork' deformity after a FOOSH.
- Initial assessment requires mandatory neurovascular checking (pulses, capillary refill, sensation) and skin evaluation to rule out open fractures or nerve compression.
- Standard management of displaced closed fractures involves AP and lateral X-rays followed by closed reduction, immobilizing plaster backslab, and check X-rays.
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