A 58-year-old homeless man is being evaluated for wrist pain after an injury. He was found lying on the sidewalk by a local shopkeeper, who then called for an ambulance. He does not remember the details of the injury. The patient reports no other focal pain but says that he hurts "all over." On examination in the emergency department, he appears intoxicated and distractible. He has scattered contusions and abrasions in various stages of healing. There is diffuse swelling at the distal forearm with significant tenderness. The patient is uncooperative with further examination of the upper extremity due to pain. X-ray is shown in the image below. Which of the following is the most likely mechanism of injury?

Question

A 58-year-old homeless man is being evaluated for wrist pain after an injury.  He was found lying on the sidewalk by a local shopkeeper, who then called for an ambulance.  He does not remember the details of the injury.  The patient reports no other focal pain but says that he hurts "all over."  On examination in the emergency department, he appears intoxicated and distractible.  He has scattered contusions and abrasions in various stages of healing.  There is diffuse swelling at the distal forearm with significant tenderness.  The patient is uncooperative with further examination of the upper extremity due to pain.  X-ray is shown in the image below.  Which of the following is the most likely mechanism of injury?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ca_8c8a_8f63_2369b48c84f7_MD0005_00 This patient's x-ray shows a distal radius fracture with shortening and dorsal displacement. This injury, also known as a Colles' fracture, is common in older patients following a fall onto an outstretched hand (FOOSH). Osteoporosis is a major risk factor for Colles' fracture, and patients with this fracture following a ground-level fall should have a bone density measurement to assess for osteoporosis. radius fracture Patients with FOOSH-related trauma should be screened for additional injuries. In particular, at least half of patients with a Colles' fracture will have a concurrent ulnar styloid fracture. Other associated injuries include scaphoid fracture, wrist sprain, supracondylar humerus fracture, and a variety of potential injuries to the elbow and shoulder. Patients with Colles' fracture are also at risk for acute carpal tunnel syndrome. Acute management of Colles' fracture is dependent on the displacement and angulation of the fracture as well as any additional injuries. Most can be managed with conservative measures such as sugar tong splinting, with or without closed reduction. More severe injuries, especially those with significant displacement or angulation >15-20 degrees may require urgent orthopedic consultation for possible surgical intervention. (Choice A) A direct blow to the wrist is a common cause of carpal bone fractures. Some Colles'; fractures may be caused by a direct blow, but FOOSH injury is more common. (Choice B) A fall with the wrist in flexion may lead to hyperflexion in addition to a ventrally displaced distal radius fracture (Smith's fracture). These fractures have a higher risk of complications and usually require orthopedic consultation. (Choice C) Fractures of the 4th and 5th metacarpals are frequently caused by punching with a closed fist (boxer's fracture). Proximal radius fracture is significantly less common in this type of injury. (Choice D) Twisting or torsional injury to the hand may cause metacarpal fractures or a spiral fracture of the radius. Educational objective: Distal radius (Colles') fracture is common following a fall onto an outstretched hand. Patients with this injury frequently have additional injuries, including ulnar styloid fracture, scaphoid fracture, and acute carpal tunnel syndrome. References: Emergency department management of Colles-type fractures: a prospective cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/19682015)

A 58-Year-Old Homeless Man Is Being Evaluated for Wrist Pain