- The patient is a 42-year-old Thai female nurse who fell in the bathroom and injured her right wrist. X-rays showed a closed fracture at the distal end of the right radius bone (Colles' fracture). - Distal radius fractures are common injuries, especially in older patients. They result from falls onto an outstretched hand. - Treatment depends on the fracture pattern and stability. Most can be treated with closed reduction and casting, while unstable or displaced fractures may require surgery.

1. EXTERN CONFERENCE
Banthita Udompipat

2. PATIENT PROFILE
ผู้ป่วยหญิงไทย อายุ 42 ปี อาชีพ รับราชการพยาบาล

3. CHIEF COMPLAINT
ปวดข้อมือขวา 1ชั่วโมงก่อนมาโรงพยาบาล

4. PRESENT ILLNESS
1 ชั่วโมงก่อนมาโรงพยาบาล ผู้ป่วยเดินเข้าห้องน้ำ ลื่นล้ม มือขวา
กระแทกพื้น เอาฝ่ามือขวาลง หลังล้มเจ็บข้อมือขวา ขยับนิ้วได้เล็ก
น้อย มือบวมเล็กน้อย ขณะล้มไม่มีอาการหน้ามืด เวียนศีรษะ ศีรษะ
ไม่กระแทก ไม่หมดสติ จำเหตุการณ์ได้

5. PAST HISTORY
No underlying disease
No drug or food allergy
No current medication

6. PHYSICAL EXAMINATION
Primary survey
A: can speak , c-spine not tender
B:equal breath sound borh lungs,CCT negative
C:v/s stable,no active bleed
D: E4V5M6, pupis 3 mm RTLBE
E:tender at right wrisr, limit ROM due to pain

7. Secondary survey
Allergy : no food or drug allergy
Medication : no current medication
Past history : no underlying disease
Last meal : 5 hr prior to hospital
E : as in PI
PHYSICAL EXAMINATION

8. PHYSICAL EXAMINATION
Vital signs BP 160/85 Pulse 95 RR 20 T 36.6 c
GA : alert, well cooperative
HEENT: no pale conjunctivae,anicteric sclerae
Heart : normal s1s2, no murmur
Lungs : clear breath sound equal both lungs
Abdomen : soft, not tender
Neuro : E4V5M6, pupils 3 mmRTLBE , motor power grade IV all except right upper extremity limit
ROM due to pain
Extremities : no external wound, deformities at right wrist, tender, limit ROM due to
pain,neurovascular intact

9. INVESTIGATION : FILM RT WRIST
AP, LATERAL

10. DIAGNOSIS : CLOSE FRACTURE AT RIGHT
DISTAL END OF RADIUS
(COLLES’ FRACTURE)

11. DISTAL END RADIUS FRACTURE

12. EPIDEMIOLOGY
Distal radius fractures are among the most common fractures of
the upper extremity.
Fractures of the distal radius represent approximately one-sixth
of all fractures treated in emergency departments and about 16%
of all fractures treated by orthopaedic surgeons.
The incidence of distal radius fractures in the elderly correlates
with osteopenia and rises in incidence with increasing age.

13. ANATOMY
The metaphysis of the distal radius is composed primarily of cancellous bone.The articular
surface has a biconcave surface for articulation with the proximal carpal row (scaphoid and
lunate fossae), as well as a notch for articulation with the distal ulna.
Eighty percent of axial load is supported by the distal radius and 20% by the ulna and the
triangular fibrocartilage complex (TFCC).
Reversal of the normal palmar tilt results in load transfer onto the ulna and TFCC; the
remaining load is then borne eccentrically by the distal radius and is concentrated on the
dorsal aspect of the scaphoid fossa.
Numerous ligamentous attachments exist to the distal radius; these often remain intact during
distalradius fracture, facilitating reduction through “ligamentotaxis.”
The volar ligaments are stronger and confer more stability to the radiocarpal articulation than
the dorsal ligaments.

15. MECHANISM OF INJURY
Common mechanisms in younger individuals include falls from a height,
motor vehicle accidents,or injuries sustained during athletic participation.
In elderly individuals, distal radial fractures may arise from low-energy
mechanisms, such as a simple fall from a standing height, and as such are
considered a fragility fracture.
The most common mechanism of injury is a fall onto an outstretched
hand with the wrist in dorsiflexion.
Fractures of the distal are produced when the dorsiflexion of the wrist
varies between 40 and 90 degrees.

16. MECHANISM OF INJURY
The radius initially fails in tension on the volar aspect, with the
fracture propagating dorsally, whereas bending moment forces induce
compression stresses, resulting in dorsal comminution. Cancellous
impaction of the metaphysis further compromises dorsal stability.
Additionally,shearing forces influence the injury pattern, often resulting
in articular surface involvement.
High-energy injuries (e.g., vehicular trauma) may result in significantly
displaced or highly comminuted unstable fractures to the distal radius.

17. CLINICAL EVALUATION
wrist deformity and displacement
swollen with ecchymosis
tenderness, and painful range of motion
The ipsilateral elbow and shoulder should be examined for
associated injuries.
A careful neurovascular assessment should be performed, with
particular attention to median nerve function.

18. RADIOGRAPHIC EVALUATION
Posteroanterior and lateral views of the wrist should be
obtained, with oblique views for further fracture definition, if
necessary.
Computed tomography scan may help to demonstrate the extent
of intra-articular involvement.

19. RADIOGRAPHIC EVALUATION

20. RADIOGRAPHIC EVALUATION

21. CLASSIFICATION
Fernandez Classification
This is a mechanism-based
classification system.

22. CLASSIFICATION
Type I: Metaphyseal bending fracture with the inherent problems
of loss of palmar tilt and radial shortening relative to the ulna
(DRUJ injury ex. Colles’, Smith’s fracture
Type II: Shearing fracture requiring reduction and often
buttressing of the articular segment
Type III: Compression of the articular surface without the
characteristic fragmentation; also the potential for significant
interosseous ligament injury

23. CLASSIFICATION
Type IV:Avulsion fracture or radiocarpal fracture-dislocation
TypeV: Combined injury with significant soft tissue involvement
owing to high-energy injury

24. COMMON DISTAL END RADIUS
FRACTURE
Colles fracture
Transverse fracture of radius
1 inch proximal to the radio-carpal
joint
Dorsal displacement and angulation
The mechanism of injury is a fall onto
a hyperextended, radially deviated
wrist with the forearm in pronation.
Clinically, it has been described as a
“dinner fork” deformity.

25. COMMON DISTAL END RADIUS
FRACTURE
Smith fracture (reverse Colles
fracture)
This describes a fracture with
volar angulation (apex dorsal)
of the distal radius with a
“garden spade” deformity or
volar displacement of the hand
and distal radius.
The mechanism of injury is a
fall onto a flexed wrist with the
forearm fixed in supination.

26. COMMON DISTAL END RADIUS
FRACTURE
Barton fracture
This is a shearing mechanism of
injury that results in a fracture-
dislocation or subluxation of the
wrist
Intra-articular fracture
Volar type/Dorsal type
The mechanism of injury is a fall
onto a dorsiflexed wrist with the
forearm fixed in pronation.

27. COMMON DISTAL END RADIUS
FRACTURE
Die-punch fracture
A depression fracture of the
lunate fossa of the distal
radius
High energy compression
force

28. COMMON DISTAL END RADIUS
FRACTURE
Radial styloid fracture
The mechanism of injury is
compression of the scaphoid
against the styloid with the
wrist in dorsiflexion and ulnar
deviation.
It is often associated with
intercarpal ligamentous
injuries (i.e., scapholunate
dissociation,perilunate
dislocation).

29. TREATMENT
Factors affecting treatment include:
Fracture pattern
Local factors: bone quality, soft tissue injury, fracture
comminution, fracture displacement, and energy of injury
Patient factors: physiologic patient age, lifestyle, occupation,
hand dominance, associated medical conditions, associated
injuries, and compliance

30. TREATMENT
Acceptable radiographic parameters for a healed radius in an
active, healthy patient include:
Radial length: within 2 to 3 mm of the contralateral wrist
Palmar tilt: neutral tilt (0 degrees)
Intra-articular step-off: <2 mm
Radial inclination: <5-degree loss

31. TREATMENT
All fractures should undergo closed reduction, even if it is expected that
surgical management will be needed.
Nonoperative management is indicated for:
Nondisplaced or minimally displaced fractures
Displaced fractures with a stable fracture pattern which can be
expected to unite within acceptable radiographic parameters
Low-demand elderly patients in whom future functional impairment is
less of a priority than immediate health concerns and/or operative risks

32. CLOSE REDUCTION

34. FILM RT WRIST AP,LAT
หลังใส่ AP SLAB

35. TREATMENT
Indication for surgery
1. Unstable
1) Fernandez type II, IV,V and some case in I, III
2) Lafontaine criteria > 3 of 5 instability parameters
3) Secondary displacement after casting

36. TREATMENT
2. Irreducible fracture
1) Double die punch
2) Displaced comminuted PM fragment
3) Articular step off > 2 mm
4) Severe comminution
5) Shortening > 5mm

37. TREATMENT
3. Unacceptable alignment
1) Radial inclination < 15°
2) Shortening > 5 mm
3) Dorsal tilt > 10°
4)Volar tilt > 20°
5) Articular step off or gap > 2 mm
4. Open fracture
5. Associated injury

38. FILM RT WRIST AP,LAT
หลังทำ ORIF

39. COMPLICATION
Median nerve dysfunction
Malunion or nonunion
Posttraumatic osteoarthritis
Finger, wrist, and elbow stiffness
Tendon rupture, most commonly extensor pollicis longus
Midcarpal instability

40. ADVICE
ใส่ arm sling โดยระดับของข้อมืออยู่เหนือระดับหัวใจไม่ห้อยแขน
เวลานอนวางบนอก หรือ หมอน
ให้ผู้ป่วยขยับข้อข้างเคียงเพื่อป้องกันภาวะข้อติด
หากมีอาการผิดปกติ เช่น ปวดมาก หรือ บวมมาก ให้กลับมาพบแพทย์ได้
ก่อนวันนัด

41. FOLLOW UP
จุดมุ่งหมายของการfollow up
1) เพื่อประเมิน สภาพของเฝือก การใช้งานของมือ และภาวะแทรกซ้อนต่างๆ
2) เพื่อfollow film หลังการจัดกระดูก หรือเมื่อเฝือกเริ่มหลวม
3) เพื่อเปลี่ยนเฝือกเมื่อหลวม หรือเพื่อเปลี่ยนจากslab เป็นเฝือกเมื่อยุบบวมแล้ว
Non displace fracture ที่ไ่ม่บวมมากนัด F/U1-2 weeks หากนัดตรวจซ้ำแล้วเฝือกไม่หลวมให้นัด
ต่อจนครบ6week แล้วถอดเฝือก
Displace fracture ที่ได้รับการ close reduction ครั้งแรกควรนัด F/U 2-3 week ถ้าไม่มีบวมกำมือ
ได้ดี นัดต่ออีก 1-2week เพื่อประเมินเฝือกและติดตามfilm xray ถ้าไม่มีปัญหาให้นัดอีกครั้งเมื่อ
ครบ6week เพื่อถอดเฝือกและประเมินการเชื่อมกันของกระดูก(Union)

43. REFERENCES
Kenneth A. Egol.2558.distal radius.Handbook of fractures
5th edition