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Obtain basic labs and admit the patient for pain control and observation
0%
0/7
Hematoma block followed by closed reduction at the bedside
14%
1/7
Take the patient to the operating room for exploration and open reduction
Obtain radiographs of both wrists
86%
6/7
Right forearm fasciotomy for compartment syndrome
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The patient in the question stem has suffered a right distal radius fracture, which commonly presents following a fall on outstretched hands. Before treating any fracture, no matter how confident one might be on physical exam, it is important to obtain radiographs of the injury. Distal radius fractures (DRF) are the most common orthopedic injury. They occur in a bimodal distribution with younger patients typically having endured a high-energy injury and elderly patients having endured a low-energy trauma, such as a fall from standing, as in this case. There are several eponymns for DRF, all of which are based on the vector of dislocation and joint involving. In this case, we see a Colles' fracture, which is a low-energy, dorsally displaced, extra-articular injury. The radiograph is an important tool for evaluating such fractures. Important measurements include changes in radial height, radial inclination, articular step-off, and volar tilt. Most Colles' fracture can be treated with closed reduction and splint immobilization with prognosis highly dependent on the success of articular reduction and early efforts to regain hand and wrist mobility. Black and Becker report that DRF account for up to one-sixth of all fractures treated. Regarding treatment, they note that DRFs traditionally have been treated with closed manipulation and casting. However, when unstable, casting may not maintain acceptable reduction, necessitating open reduction and internal fixation. Kucek et al. evaluated the interobserver reliability and intraobserver reproducibility of the Universal, AO, Fernandez and Frykman classifications for distal radius fractures and found that none of the classification systems were superior in terms of reliability and reproducibility. They note that the reliability and reproducibility rates of all four classifications were insufficient. Illustration A shows a radiograph of a Colles' fracture, or dorsally-displaced distal radius fracture that does not involve the joint. Incorrect Answers: Answer 1: Admitting the patient for pain control and observation is not the next appropriate step in treatment. Given symptoms of median nerve compression, reduction is necessary. Answer 2: Hematoma block in a non-comminuted, non-spiral or oblique fracture, is usually sufficient for an attempt at closed reduction. Answer 3: Only open fractures or those compromising the neurovascular components unrelieved by closed reduction will be brought to OR urgently. Answer 5: This patient is vascularly intact and there is no indication for fasciotomy at this time.
3.8
(4)
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