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HKCEM College Tutorial A woman who fall on her hand AUTHOR DR. TW WONG REVISED BY DR. CLARENCE CHU KWOK KEUNG NOV 2013 Triage ▪ F/ 65 ▪ Fell in market place ▪ BP 150/95 ▪ Pulse 100/min ▪ RR 15/min Triage Category-- Urgent She slipped and fell on her out stretched hand. No other injuries Differential Diagnosis? Fall on outstretched hand ▪ Wrist ▪ colles, scaphoid, lunate dislocation… ▪ Forearm ▪ # rad/ulna; # dislocation e.g. ▪ Elbow ▪ dislocation, #rad head, supracondyle ▪ Arm ▪ #Humerus… ▪ Shoulder ▪ dislocation shoulder, #NOH, # clavicle… ▪ Associated injures: HI, # rib… Now, take a history… History ▪ How ▪ Mechanism of injury ▪ Slip, Trip, Dizzy, Weakness of LL ▪ Precipitating factors ▪ Who-- occupation; hand of dominance ▪ When ▪ Where--home, workplace... ▪ What other associated injuries ▪ past health, medications, allergy Examine this patient Interpret the Xrays How about this Xray? And this? Interpret the Xrays What options are open for this patient? WHAT IS YOUR PREFERRED TREATMENT PLAN? Surgical option External fixator The patient opts for CR + POP How do you proceed? Pain control ▪ Fentanyl/midazolam (shorter acting) ▪ Etomidate 0.1 mg/kg ▪ Fracture hematoma block ▪ Bier’s block ▪ Pethidine/valium (look out for complications) ▪ Entonox Pros Vs Cons Close Reduction of distal radius fracture http://www.youtube.com/watch?v=OyZEghznwG0 POP + immobilisation ▪ What POP ? ▪ Long vs short ▪ Slab vs Complete ▪ What position ? ▪ neutral vs cock-down vs cock-up ▪ ulnar deviation vs neutral ▪ For How Long ? Post CR film Is CR satisfactory? Satisfactory CR? Radial Length 10 mm (8 –18 mm) Palmar tilt = 1-23 (10 ) Correction of all deformities. Discharge Advice ▪ Pain killer ▪ POP care ▪ Exercise ▪ FU Patient should be warned of the risk of re-displacement. Early complications ▪ POP ▪ too tight ▪ too loose ▪ impingement ▪ Circulation ▪ Nerve impingement ▪ Re-displacement of # Re-displacement is likely if… ▪ Persistent comminution ▪ Dorsal angulation not corrected ▪ Radius at ulnar level ▪ Comminution of ulna head ▪ Involvement of DRUJ Late complications ▪ Persistent pain ▪ Delayed rupture of EPL ▪ Median N stretch and post traumatic carpel tunnel syndrome ▪ Reflex sympathetic dystrophy ▪ Secondary Osteoarthritis ▪ more frequently seen in patients with intraarticular involvement Late complications ▪ Malunion ▪ shortening ▪ radial deviation ▪ Sudek atophy Colles # at week 7 Shortening 7 weeks Day 1 Summary ▪ Formulate a reasonable ddx for falling on the hand ▪ Diagnosis (Xray interpretations) and Management of wrist fractures ▪ Close Reduction and aftercare of Colles’ fracture The end
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