Radiology · Year 4 · from Radiology
Case 1: Colles Fracture (Distal Radius Fracture)
Patient Demographics
- Age: 68 years
- Sex: Female
Chief Complaint
Right wrist pain and deformity after fall
Presenting Symptoms
The patient fell onto her outstretched right hand while walking her dog when she tripped on an uneven sidewalk. She experienced immediate severe pain in her right wrist and noticed obvious deformity. She has a history of osteoporosis diagnosed 5 years ago but admits she stopped taking her bisphosphonate medication 2 years ago due to concerns about side effects.
Physical Exam Findings
- Vital Signs: BP 148/84 mmHg, HR 92 bpm, Temp 36.6C
- Right Wrist:
- Obvious "dinner fork" deformity with dorsal angulation
- Significant swelling over the distal radius
- Point tenderness over the dorsal distal radius
- Limited range of motion due to pain
- Intact skin, no open wound
- Neurovascular: Radial pulse intact, capillary refill <2 seconds, sensation intact in median, ulnar, and radial nerve distributions
- Hand Function: Able to flex and extend fingers, pain with wrist movement
Imaging Findings and Interpretation
Wrist Radiographs (PA and Lateral):
Posteroanterior (PA) View:
- Transverse fracture through the distal radius metaphysis, approximately 2.5 cm proximal to the radiocarpal joint
- Radial shortening of 4 mm (compared to ulna)
- Loss of normal radial inclination (normally 22-23 degrees)
- Associated ulnar styloid avulsion fracture
- Radiocarpal joint congruent
Lateral View:
- Dorsal displacement: Distal fragment displaced dorsally
- Dorsal angulation: Loss of normal volar tilt; dorsal angulation of 25 degrees (normal volar tilt 11-12 degrees)
- Apex volar angulation: The apex of the fracture angle points volarly
- No volar cortical comminution visible
- Carpal alignment maintained
Fracture Classification:
- Colles Fracture Pattern: Extra-articular distal radius fracture with dorsal angulation, dorsal displacement, and radial shortening
- AO/OTA Classification: 23-A2.2 (extra-articular, metaphyseal, simple with dorsal displacement)
- Frykman Classification: Type I (extra-articular radius, no ulnar styloid involvement) - though ulnar styloid IS involved, making this Type II
Soft Tissue Assessment:
- Dorsal soft tissue swelling
- No evidence of compartment syndrome clinically
- Fat pad displaced but no suggestion of additional carpal fracture
Diagnosis
Colles fracture (extra-articular distal radius fracture with dorsal angulation) with associated ulnar styloid fracture, likely pathologic through osteoporotic bone (fragility fracture)
Management
- Immediate:
- Closed reduction under hematoma block anesthesia
- Post-reduction goals: Restore radial inclination >15 degrees, volar tilt 0-15 degrees, radial length within 2-3mm of ulna
- Post-Reduction Imaging:
- Repeat radiographs show improved alignment
- Radial inclination: 18 degrees (acceptable)
- Volar tilt: 5 degrees (acceptable)
- Radial length: Within 2 mm of ulna
- Immobilization:
- Sugar tong splint initially for swelling
- Conversion to short arm cast at 1 week follow-up
- Total immobilization: 6 weeks
- Follow-up Imaging:
- Weekly radiographs for first 3 weeks to monitor for displacement
- Final radiographs at 6 weeks before cast removal
- Osteoporosis Management:
- Referral to endocrinology/osteoporosis specialist
- DEXA scan to reassess bone mineral density
- Restart osteoporosis treatment (discussion of bisphosphonate vs. denosumab)
- Calcium and Vitamin D supplementation
- Fall risk assessment and prevention
Radiological Image
Image Description: Lateral radiograph of the wrist demonstrating a classic Colles fracture with dorsal angulation and dorsal displacement of the distal radius fragment. The normal volar tilt is lost, creating the characteristic "dinner fork" deformity seen clinically.
Source: Wikimedia Commons - "Colles fracture" URL: https://commons.wikimedia.org/wiki/File:Colles_fracture.JPG License: Creative Commons Attribution 3.0 Unported