4. Physical Examination
• Primary Survey:
A. Can talk fluently, no stridor, spontaneous movement of
neck, no C-spine tenderness
B. Equal breath sound on both lungs, trachea in midline,
Chest compression test positive on Rt. side
C. BP 135/88 mmHg, PR 90 bpm, no external bleeding
D. E4V5M6, pupil 3 mm RTLBE
E. no seen external wound
5. Physical Examination
• Head to toe examination:
vital sign : BT 37.2 ๐C, BP 135/88 mmHg, PR 90 bpm, RR 20/min
General appearance : good consciousness, talkative, not pale,
no jaundice
HEENT : not pale conjunctivae, anicteric sclerae
Heart : normalS1S2, no murmur
Lung : no bruising seen, no external wound, normal chest
expansion, clear on both lungs
Abdomen : no abdominal distension, hyperactive bowel sound,
soft, not tender, no guarding, no rebound
tenderness
6. Physical Examination
• Head to toe examination:
Extremities : Rt. Wrist swelling and tender, Dinner fork
deformity, capillary refill < 2 secs, radial and ulnar
pulse can be palpated (as figure)
Neuro : no wrist drop or finger drop, limit active ROM due to
pain, sensory intact all, DTR 2+ all
8. Physical Examination
• Secondary Survey
A. No food and drug allergy
M. Current medication : Amlodipine (5) 1x2 oral pc
Atenolol (100) 1x1 oral pc
P. U/D of HT, no history of surgery, no history of trauma
in this area before, no history of drinking and
smoking, no family history of hematologic disease
L. NPO time 8.00 am.
E. ตกบันได ล้มเอง เจ็บข้อมือขวา
11. Problem list
• Close fracture of Rt. Distal radius (extra-articular)
with dorsal displacement and volar angulation in
old aged Thai male (Colles’ fracture on Rt. wrist)
• Underlying disease of hypertension
12. Management
• Successful outcomes correlate with
– accuracy of articular reduction
– restoration of anatomic relationships
– early efforts to regain motion of wrist and fingers
• Non-operative management
– closed reduction and cast immobilization
• indications
– extra-articular - Radial inclination change <5 °
– <5mm radial shortening
– dorsal angulation <5° or within 20° of contralateral
distal radius
21. Distal Radius fracture
• Most common orthopaedic injury with a bimodal distribution
– younger patients - high energy
– older patients - low energy / falls
• 50% intra-articular
• Osteoporosis
– high incidence of distal radius fractures in women >50
– predictor of subsequent fractures
• DEXA scan is recommended in woman with a distal
radius fracture
24. Colles’ fracture
• One of the most common distal radius fractures is a Colles
fracture
• Abraham Colles (1884)
Fracture distal radius 2.5 cm from wrist with the dorsal
displacement and volar angulation of distal bony fragment. It
is extra-articular fracture. Usually occurs with osteoporotic
patiens who fall in outstretched hand position
25. Colles’ fracture
• Cause
- Osteoporosis : fall from standing in outstreched hand
position (low energy trauma)
- young people : car accident (high energy trauma)
• Mechanism of injury
The proximal row of the carpus (particularly
the lunate and scaphoid) transfer energy to the distal radius,
both in the dorsal direction and along the long axis of the
radius.
26. • Physical examination
– immediate pain, tenderness, bruising, and swelling.
– Dinner fork deformity usually seen in displaced fracture
– R/O median nerve and radial nerve injury
• Investigation : film wrist in AP, lateral view
Colles’ fracture
28. Colles’ fracture
What to see also?
- degree of volar angulation
- degree and direction of
displacement
- location of the medial
fracture line: does it involve
the radioulnar joint
- presence of intra-articular
fractures
- any other fracture ex.
ulnar styloid, carpal bones
Fracture of distal radius with dorsal
displacement and volar angulation
29. Colles’ fracture
•Treatment
• Successful outcomes correlate with
- accuracy of articular reduction
- restoration of anatomic relationships
- early efforts to regain motion of wrist and fingers
Non-operative treatment
closed reduction and cast immobilization
• indications
- extra-articular
- <5mm radial shortening
-dorsal angulation <5° or within 20° of contralateral
distal radius
30. Colles’ fracture
• What should concern in close reduction?
- Dorsal and radial displacement
- shortening of radius
- loss of normal 10° volar tilt in lateral view
• How to do close reduction under regional anesthesia?
1. Disimpaction
2. Traction
3. Volar flexion with ulnar deviation
เมื่อดึงกระดูกเข้าที่จะพบว่าข้อมือผู้ป่วยอยู่ในท่า volar flexion 15-20O ,
ulnar deviation and pronation จากนั้น on short arm cast ให้ผู้ป่วย
ได้งอศอกและกามือได้เต็มที่ และ on arm sling ไว้ในท่าระดับข้อมืออยู่เหนือระดับหัวใจ
หมายเหตุ : ถ้าข้อมือบวมมาก อาจใส่ radial slab หรือ Charnley slab เพื่อป้องกัน
การบวมที่เกิดขึ้นได้หากใช้ cast
32. Colles’ fracture
• Complication
In early :
- edema
- EPL rupture
- CTS (median n. entrapment)
prevent by avoiding immobilization in excessive
wrist flexion
treat with acute carpal tunnel release for:
- progressive paresthesias
- paresthesias do not respond to reduction
and last > 24-48 hours
In lately :
- malunion : inadequate reduction or redisplacement
- prolong stiffness
36. Colles’ fracture
• Complications
- malunion/nonunion
- stiffness and decreased grip strength
- pin complications (infections, fracture through
pin site)
• Others
- Pain control
- elevation (holding their arm up above their heart)
- keep cast dry
- early mobilize to prevent stiffness
resume Light activities 1 to 2 months after the cast is removed
or within 1 to 2 months after surgery.
resume Vigorous activities 3 and 6 months after the injury