What is the diagnosis?

This is a distal radius metaphysis fracture. It is dorsally displaced and angulated making it a Colle’s fracture. Critically it does not involve the articular surface. These are very common, accounting for over 1/6th of all fractures in the emergency department [1].

What is the mechanism of injury?

These injuries are commonly associated with the fall on an outstretched hand or FOOSH. This position is often with the forearm pronated and wrist extended.

• Pearl: In patients under 65 who had Colle’s fractures, bone mineral density was found to be lower than expected [2]. In younger patients it is usually a much higher impact injury that causes a Colle’s fracture. 

What physical exam findings are expected?

Wrist pain, swelling and possible deformity. 

• Pearl: Be sure to do a neurovascular exam as there can be injuries to the median nerve. This can result in palmar paresthesias on examination. 

Which imaging modalities can be used?

X-ray is the answer here! Be sure to get you PA and lateral. The lateral is used to observe the dorsal angulation. This can lead to the “classic dinner fork” deformity. CT scan can be used if there is concern for intra articular injury or for surgical planning. This does not need to be routinely performed unless requested by orthopedics. 

What complications and other injuries can occur?

Always check the ulna styloid for a fracture. If there is an ulnar injury, this suggests injury to the TFCC (Triangular fibrocartilage complex) or distal radioulnar junction (DRUJ) instability. You can use the TFCC compression test and the piano key test to help assess for these instabilities. 

• Pearl: TFCC compression test is done by axial loading patients wrist and then deviating wrist to ulnar side- clicking or pain is a positive test [3]. Piano key test for DRUJ instability: Wrist is held in pronation and volar pressure is applied to distal ulna- positive if pain or instability compared to contralateral side [3].

There can be injury to the median nerve, compartment syndrome, vascular injury and injury to carpal bones as well.

What is the management in the ED?

Always treat your patient’s pain! A hematoma block is a great choice for pain management, in particular before reducing the fracture.

It is important to determine stability as this will dictate whether a patient needs urgent orthopedics follow up. Indications for complex reductions include: 

• Intra Articular involvement

• Greater than 5 mm of radial shortening

• Greater than 20 degrees of angulation

Reduction should be done in the emergency department with recreation of the injury. Flex the patient’s elbow and then place their wrist in extension. Then apply longitudinal traction and volar pressure. Finally place the patient in a sugar tong splint. Get post reduction XRs and if the reduction is stable discharge with ortho follow up.

• Pearl: Wrist should be splinted in flexion of about 15 degrees with ulnar deviation [3].

When do you consult Orthopedics?

Unstable fractures, fractures that cannot be reduced, open fractures, neurovascular compromise and compartment syndrome.