Full Clinical Case: Colles' Fracture

Patient Presentation

History of Present Illness

Physical Examination

The classic "dinner fork deformity" occurs because the distal radial fragment is displaced dorsally and proximally, creating a visible step when viewed from the side.

Diagnostic Tests

1. Plain X-Ray Wrist (PA and Lateral Views) - PRIMARY INVESTIGATION

• Transverse fracture of the distal radial metaphysis, approximately 1.8 cm from the articular surface
• Shortening of the radius (radial shortening ~4 mm)
• Loss of radial inclination (normal: 22-23 degrees; reduced to ~14 degrees)
• Negative ulnar variance (ulna appearing relatively longer)
• Associated fracture of the ulnar styloid (present in ~60% of cases)
• No intraarticular extension on this view

• Dorsal angulation of the distal radial articular surface: ~18 degrees (normal volar tilt is +11 degrees; the fragment has reversed to -18 degrees of dorsal tilt)
• Dorsal displacement and comminution of the dorsal cortex
• Classic "dinner fork" profile

• Dorsal angulation of the plane of the distal radius
• Distal fragment displaced proximally and dorsally
• Radial displacement of the carpus
• Ulnar styloid fracture

2. CT Wrist (Ordered After X-Ray Review)

• Extra-articular distal radius fracture confirmed; no intraarticular step-off
• Dorsal comminution of the cortex
• No radioulnar joint instability
• Ulnar styloid fracture confirmed - at the base (Type II, may affect TFCC stability)
• No carpal fractures

Per Tintinalli's: "If the fracture has significant intra-articular extension, or comminution, or if distal radioulnar joint instability is suspected, CT may provide important additional information for diagnosis and treatment."

3. Neurovascular Check (Clinical Test - Pre and Post Reduction)

4. Blood Tests

Diagnosis

Management

Step 1 - Analgesia (Immediate)

• Morphine 2.5 mg IV titrated (reduced dose for eGFR 68)
• Elevate the limb; apply ice pack wrapped in cloth

Step 2 - Closed Reduction (Performed in ED)

• Dorsal angulation >neutral position (18 degrees dorsally angulated)
• Radial shortening (4 mm)
• Active patient in dominant hand

Per Rosen's EM: "The hematoma block remains an easy and effective method of anesthesia and may be performed by placing a 22-gauge needle in the dorsum of the distal radius, withdrawing until a fracture hematoma is encountered and then instilling 5 to 10 mL of 1% or 2% lidocaine."

1. Finger traps applied to the index and middle fingers; countertraction via a cuff around the upper arm
2. Traction applied for 5-10 minutes to relax forearm musculature and disengage the fracture
3. The distal fragment is pushed distally and volarly (palmarly) while the forearm is stabilised
4. Anatomic volar tilt is restored; goal is at least 0 degrees (neutral) or positive volar tilt

• Dorsal angulation corrected to +4 degrees of volar tilt (restored to neutral/slightly volar)
• Radial length restored; ulnar variance now positive
• Acceptable reduction achieved

Step 3 - Immobilisation

• First slab: from elbow to wrist (dorsal/volar)
• Second slab: extends from elbow to axilla over the first slab
• Wrist held in slight flexion and ulnar deviation
• Fingers free to move

Per Pfenninger & Fowler's: "If extra-articular and nondisplaced, it can be treated with a double sugar-tong splint for 3 to 5 days followed by a short-arm cast for 4 to 6 weeks."

Prescription

EMERGENCY DEPARTMENT PRESCRIPTION
Patient: Amelia Hartley | DOB: 12/03/1958 | MRN: 7842310
Allergies: Penicillin (rash)
Date: 12/07/2026

1. Paracetamol (Acetaminophen) 1 g PO every 6 hours
   (Regular analgesia - first line)

2. Ibuprofen 400 mg PO TDS with food for 5 days
   [NOTE: Use with caution given eGFR 68 - short course only;
   monitor renal function; omit if GI upset develops]

3. Codeine Phosphate 30 mg PO every 4-6 hours PRN
   (Breakthrough pain - max 240 mg/24 hrs; avoid if drowsy)

4. Omeprazole 20 mg PO OD
   (Gastroprotection while on NSAID)

5. Baclofen 5 mg PO TDS PRN
   (Muscle spasm relief if needed)

---
Osteoporosis / Fragility Fracture Management:
6. Continue: Alendronate 70 mg PO weekly (existing prescription)
   [Note: Ensure taken on empty stomach with full glass of water;
   remain upright for 30 mins]

7. Colecalciferol (Vitamin D3) 1000 IU PO OD
   (Supplement - Vitamin D level 42 nmol/L; target >75 nmol/L)

8. Calcium Carbonate 1000 mg PO BD
   (Bone health - ongoing)

---
Thromboprophylaxis:
9. Aspirin 75 mg PO OD for duration of immobilisation
   (DVT prophylaxis; may upgrade to LMWH if mobility severely
   reduced or if surgical fixation is required)

Prescriber: Dr. C. Rahman (ED Registrar)
Date: 12/07/2026

Follow-Up Plan

Indications for Surgery (Not Met in This Case, But Would Apply If:)

• Dorsal angulation > 20 degrees post-reduction
• Radial shortening > 5 mm
• Articular step-off > 2 mm (intraarticular fracture)
• Severely comminuted, unstable fracture
• Open fracture
• Neurovascular compromise not resolving
• Dominant hand in high-demand active patient with inadequate reduction

Complications to Monitor

Per Tintinalli's EM: "A wide range of complications occur in 6% to 80% of cases... The most common complication is immediate or delayed carpal tunnel syndrome... Factors associated with long-term disability or instability include dorsal angulation ≥20 degrees and ≥5 mm of radial shortening."

Discharge Education

1. Keep the splint dry at all times.
2. Elevate the arm above heart level to reduce swelling (use a pillow when lying down).
3. Move all fingers actively several times per hour to prevent stiffness.
4. Return immediately if: increasing pain under the cast, numbness or tingling in fingers, skin colour changes (white/blue), inability to move fingers, fever, or splint feels too tight.
5. Do not drive or lift anything with the right arm until cleared by the orthopaedic surgeon.
6. Review osteoporosis management with your GP to prevent future fragility fractures.