A 70-year-old woman comes to the emergency department at 10 PM after falling in her kitchen 30 minutes ago. She has severe left wrist pain. The patient did not hit her head and reports no other injuries. Medical history is significant for hypertension and osteoporosis. Vital signs are within normal limits. On examination, the left wrist is bruised and swollen and diffusely tender to palpation, but the skin overlying the wrist is intact. The radial pulse is absent, and capillary refill in the fingers is delayed. X-rays of the left wrist are shown in the exhibits. Which of the following is the best next step in management of this patient?

Question

A 70-year-old woman comes to the emergency department at 10 PM after falling in her kitchen 30 minutes ago.  She has severe left wrist pain.  The patient did not hit her head and reports no other injuries.  Medical history is significant for hypertension and osteoporosis.  Vital signs are within normal limits.  On examination, the left wrist is bruised and swollen and diffusely tender to palpation, but the skin overlying the wrist is intact.  The radial pulse is absent, and capillary refill in the fingers is delayed.  X-rays of the left wrist are shown in the exhibits.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d859_e75f_bc81_c3c60a1475cf_MD0003_00 This patient who fell has x-rays showing left distal radius and ulna fractures, with evidence of severe fracture displacement of the distal radius bony fragment proximally and dorsally. Distal radius (ie, Colles) fractures typically occur from a fall on an outstretched hand and are common in the elderly; osteoporosis is a risk factor. A thorough neurovascular examination is essential because severe fracture displacement can compress or injure important neurovascular structures, especially the radial artery and the median nerve (leading to acute carpal tunnel syndrome). In this patient, the displacement has likely stretched and/or kinked the radial artery, which runs along the surface of the radius near the wrist, leading to an absent radial pulse on examination and delayed capillary refill in the fingers. Distal radius (ie, Colles) fractures median nerve Neurovascular compromise (eg, absent radial pulse, diminished median nerve sensation) is an indication for immediate fracture reduction. Therefore, the first step in management in this patient is to restore normal radial artery alignment and perfusion to the hand (which is receiving only partial perfusion through the ulnar artery) through closed reduction of the fracture. Closed reduction often resolves most neurovascular deficits and exacerbation of any neurovascular injuries during the procedure is unlikely. However, if evidence of neurovascular compromise persists after closed reduction, CT angiography and/or emergency orthopedic surgery consultation for possible open reduction and exploration is warranted. (Choice A) Intraarterial thrombolytic therapy is sometimes used to treat acute limb ischemia due to intraarterial embolus (eg, atrial fibrillation) or thrombosis (eg, peripheral arterial disease). However, the primary cause of this patient's radial artery occlusion is likely extrinsic compression from the displaced distal radius fracture. Therefore, fracture reduction, which may be curative for reestablishing normal radial artery alignment and circulation, should be performed prior to any other interventions (eg, CT angiography, thrombolytics). (Choices B and E) Waiting for next-day or outpatient orthopedic evaluation is contraindicated when signs of neurovascular compromise (eg, absent radial pulse, delayed capillary refill) are present. The fracture should be immediately reduced; if normal perfusion is restored, then splinting the wrist is appropriate and consultation with orthopedic surgery is less urgent (rather than emergent if perfusion is still impaired). (Choice C) Distal forearm fractures can cause increased forearm compartment pressures (ie, compartment syndrome), which can impair intracompartmental and/or distal perfusion. However, an absent peripheral pulse is usually a late finding that would be highly unlikely 30 minutes after injury, and other signs of compartment syndrome (eg, tensely swollen forearm, paresthesia) would be present. late finding Educational objective: Distal radius fractures with neurovascular compromise (eg, absent radial pulse, diminished median nerve sensation) should undergo immediate reduction. References: Evidence-based review of distal radius fractures. (http://www.ncbi.nlm.nih.gov/pubmed/29499822) High-energy injuries of the wrist. (http://www.ncbi.nlm.nih.gov/pubmed/26782706)

A 70-Year-Old Woman Comes to the Emergency Department at 10