A 14 year old presents to your ED after a fall on an outstretched hand during a basketball game. He is complaining of left wrist pain. He is tender diffusely over the distal radius and ulna with associated soft tissue swelling, but is neurovascularly intact throughout the left upper extremity with no pain above or below the wrist. He denies snuffbox tenderness, or wrist pain with axial loading of the thumb. You obtain the following radiographs. Click each question below for the answer.
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1] How would you describe this fracture to your orthopedic colleagues?
There are two major abnormalities here, one involving the distal radius, and one involving the distal ulna. There is a comminuted distal radius fracture at the metaphysis that extends to the physis, and is approximately 25% displaced dorsally with minimal angulation. There is also an ulnar styloid fracture with probable physeal injury here as well.
2] What are the important features you need to include when describing fractures to your colleagues?
There are a few important features you should be able to tell your colleagues, and that will be important for your orthopedic specialist to know. There are various mnemonics out there that try to help you remember what to look for and describe. I am not a big believer in mnemonics, as I find people often have trouble remembering the mnemonic itself, much less what it aims to help you describe or remember. So here is what you need to talk about when describing a fracture:
- What is their hand dominance? Consider this with all upper extremity injuries. Much like you start an OB presentation with the G’s and P’s, let your orthopedist know if the patient is Right or Left hand dominant.
- What kind of fracture is it (i.e. transverse, oblique, buckle, etc.). Is the fracture comminuted or not?
- What is the location of the fracture - midshaft, distal, metaphyseal, etc.
- Is the fracture displaced, and if so in what direction? Remember, this refers to the relation of the distal segment with the proximal segment. So in the case above, the distal segment is displaced dorsally. You describe this with a percentage of the distal segment that is displaced.
- Is the fracture angulated? Again, this is described by the direction and angle of the distal segment, and the angle of the distal segment compared to the axis of the proximal segment.
- Is the fracture rotated or impacted?
- Is the fracture open? It is crucial to take any dressings down to identify any signs of an open fracture.
3] What should I document in terms of an exam?
It is important to identify a few things. Obviously, if someone shows up with a deformed limb, make sure to do a full H/P, and identify any other injuries. Once you are focusing on the suspected (or confirmed) fracture, you want to inspect at least the joint above and below the area of injury. Document pain, swelling deformity, and range of motion. You also want to document a good neurovascular exam. Remember, the vascular exam should include skin color, temperature, capillary refill, and pulses. Neurologically, make sure you document motor and sensory function. Also, be sure to document any skin findings over or around the area of injury. Breaks in the skin, bruising, swelling or deformity are all important to note.
4] Why all the fuss? Can’t I just call this a Colles fracture and be done?
I guess you could, but that fails to describe some important information. A Colles fracture is technically a radial fracture about an inch from the radiocarpal joint with dorsal displacement and/or angulation, but just saying a Colles fracture tells you nothing of how displaced, comminuted or not, the neurovascular status, or any other bony involvement. Being as descriptive as possible helps paint the picture for our colleagues. In general, I hear mixed things from my orthopedic colleagues about fracture eponyms. Colles is well known, but do you know a Barton or Rolondo off the top of your head? Know the difference between a Jones and a Pseudo-Jones? These things often are taught and come up on board exams, but at 2 AM describing the fracture as above paints a much better picture and keeps you from calling a Monteggia a Galeazzi.
I would advise that in order to best learn how to interpret plain radiographs, read them yourself, and do so before you read the radiology interpretation. At many EM training programs we have 24 hour radiology coverage, and the tendency is to wait for the radiologist’s interpretation. Try reading it, make a commitment to a read, and see how radiology interprets it. Many places you will eventually practice do not have real time reads for plain films, and your staff and patients will be counting on you to get it right.
Questions, comments, additional thoughts? Feel free to let me know below, or send an email to firstname.lastname@example.org