Case Discussion...Colle's fracture || #aetcm || #emergencymedicine ||

Added: 2026-05-12

[00:00:06]Good morning. Welcome to ATCM the emergency medicine channel. So shall I present?

[00:00:10]>> Yes.

[00:00:11]>> So present the case of 67 female who presented to the emergency department with complaints of pain and deformity in the right witch following an alleged history of fall on outstretched hand.

[00:00:25]>> Right. Sir >> fall on an outstretched >> outstretched hand initial 10 seconds age >> 67 female sir >> 67 elderly female >> yes sir >> okay so chances of osteoporosis everything is there >> yes sir >> the underlying other co-obilities maybe may also be there c >> no other comb sir >> okay no like when when you consider a 67 year old lady you should be considering other coilities also The reason for the fall may be something something else like some cardiac problem or some neurological problem or some hyponetriia or some Alzheimer's Parkinson things like that. Okay.

[00:01:05]>> Okay sir.

[00:01:06]>> Or some drugs also somehow drugs and all was BP fall and she may fall down.

[00:01:14]>> Okay. Or the as you said it it could be a simply trip and for because of poor eyesight or something of that sort and chances of multiple fractures apart from wrist fracture other fractures are also possible. Yes sir.

[00:01:28]>> Because very fragile elderly female.

[00:01:32]>> Okay.

[00:01:32]>> Uh initial 10-second assessment. Airways patent. There is no pulling of secretion. No strider. No hoseness of voice. Breathing. Respiratory rate is 20 per minute. Saturation 99%age. Chest bilateral iron is present. Circulation.

[00:01:46]Heart rate is 76 per minute. PP 120 80 mm mercury. C uh capillary time is less than 2 seconds. Uh warm extremities and all peripheral pulses are present equally. Disabilities GCS is 15 by 15.

[00:01:59]Uh GR is 1112 exposure is normic.

[00:02:03]Uh adance to primary survey we did basic CBCC.

[00:02:06]>> Primary service is clear.

[00:02:07]>> Yes, primary service is here. Adance he did CBCC and BBG which is also with the normal limits. He since the patient had an obvious deformity in the right hand.

[00:02:16]We took a X-ray of right 80 at lateral uh which showed a transverse uh fracture of the distal radius with a dorsal tilt sir dorsal displacement go slowly go we took a X-ray right breast AP lateral or straight concern >> and it showed a transverse distal radius fracture sir >> for the pain you give >> yes sir we give uh one uh after uh getting the allergic history we gave her 1 g PCM IV stat was given. Uh, cold compression was given, sir.

[00:02:52]>> Um, >> okay. X-ray was taken.

[00:02:55]>> X-ray was taken, sir.

[00:02:57]>> But why why didn't you do the clinical examination?

[00:03:00]>> A clinical examination is taken. So, clinical examination.

[00:03:03]>> Normally, it's like that. No, >> you see the patient, give some analesics, control the pain, and then you go systematically. Okay, sir.

[00:03:11]>> Take a consent and do the clinical examination.

[00:03:15]Yes sir.

[00:03:16]>> Okay.

[00:03:17]>> I'll go with >> on out hand >> hand and all because straight away you can't go because after after taking this full sample history everything only straight away you're supposed to go and take the X-ray.

[00:03:29]>> Okay. Uh I'll go to sample history. Uh the 67 >> primary surveys are already clear. Now you got your secondary survey.

[00:03:37]>> Secondary surve first part of the secondary survey.

[00:03:39]>> Sample history.

[00:03:40]>> Sample history. So tell tell me about the samples.

[00:03:43]>> Okay. 67 female g history of slip and fall at home while trying to move a divot. Fell on her outstretched right hand and sustained trauma to it.

[00:03:52]Developed sudden onset severe pain over the right breast.

[00:03:55]>> Uh outstretched >> outstretch right >> while pulling the danc.

[00:03:59]>> Yeah, she was trying to move the danc accidentally slipped and >> how she fell in forward.

[00:04:06]>> So when you pull normally there's tendency to fall backwards. No, she was actually trying to push pull it like this and actually fall fell forward actually.

[00:04:15]>> Okay.

[00:04:17]>> And fell this hand.

[00:04:18]>> Yes, her right hand.

[00:04:20]>> Right hand. So pulled pulled it like that and then probably >> Okay. So the hand actually hit like that.

[00:04:29]>> Yes sir.

[00:04:29]>> On the floor.

[00:04:30]>> Yes sir.

[00:04:31]>> Okay. So what what what do you expect here when when it hits hits like that?

[00:04:37]Initially there'll be a dist fracture of the >> Yeah. It is likely to break break like that.

[00:04:43]>> Yes sir.

[00:04:43]>> The distal fragment distal part of the bone is likely to go >> uh upwards upwards.

[00:04:50]>> Right.

[00:04:50]>> Yes sir. Dorsal angulation.

[00:04:52]>> Yeah. Dorsal angulation and it may get disaced forward >> in this direction also.

[00:04:59]>> If if it falls like this >> polar displacement >> polar displacement will happen. That's that's when you call >> a Smith fracture.

[00:05:05]>> Smith fracture. When it hits like that, >> call is fire.

[00:05:08]>> Call is fire.

[00:05:10]>> Yes sir.

[00:05:14]>> And in this fall on an outstretched hand means you should suspect other injuries.

[00:05:22]>> Yes.

[00:05:22]>> Where all you should suspect?

[00:05:25]>> Uh there can be intricatic fs of the radar in radical >> which all parts of the hand. There can be wrist injuries, elbow, >> elbow injuries, elbow dislocation can be there, shoulder dislocation can be there, shoulder fracture can be there, clavicular fracture can be there.

[00:05:42]>> Yes sir.

[00:05:43]>> All these things should be like looked at.

[00:05:46]>> Yes sir.

[00:05:47]>> Apart from looking at the first and here you may also get some uh thing carpal bone fractures.

[00:05:58]>> Yes.

[00:05:59]>> Okay. and scaffoid both scuffid and all it's particularly you should look >> yes sir >> this >> okay there was a rapid swelling and visible deformity of the hand following the fall and there was restriction of movement >> so what are the bones here like just tell me what are the bones >> there is a radius >> where where is the radius here >> the lateral aspect is the radius medial side is the alna >> radius alna then >> uh then the carpal bones uh wbone launch that is.

[00:06:30]>> Yeah. From here.

[00:06:32]>> Scuffford. She looks too pretty. Try to catch her. Scuffford. Lunate.

[00:06:38]>> Yeah. Scuffford.

[00:06:39]>> Scuffford. Lunate.

[00:06:42]Uh, triricutral.

[00:06:44]Form >> again from here.

[00:06:47]>> Okay. Then >> uh it is trapezium.

[00:06:52]>> Trapezium. Trapord.

[00:06:55]>> Uh, capital. Okay. All right. And then >> Okay.

[00:07:11]Then here is the radius. This is the >> Okay.

[00:07:18]So cis means fracture is in >> uh distal radius.

[00:07:22]>> Dal radius >> with the dorsal angulations >> with the dorsal angulation. angulation and displacement.

[00:07:28]>> Okay.

[00:07:30]>> Okay.

[00:07:31]>> What what if we do not treat it at the appropriate time? What is what is wrong?

[00:07:35]>> There can be malunions mal can be there.

[00:07:39]>> Middle nerve compression >> medury compression injury can be there. Then >> uh deformity >> deformity permanent dinner fork deformity like a dinner fork deformity can be there.

[00:07:56]Yes.

[00:08:00]>> There could be a carpal tunnel >> syndrome also.

[00:08:05]>> Could be a compartment syndrome also.

[00:08:06]>> Yes, combinment syndrome also.

[00:08:15]>> Uh there was no history of trauma.

[00:08:17]>> And if if you if you miss a this is what is this? This is the anatomical.

[00:08:23]If if you if you touch there if there is tenderness what does it indicate?

[00:08:27]>> Scuffoid fracture.

[00:08:28]>> Okay. Scuffid fracture means what is wrong? If you do not like if you miss a scuffoid fracture >> a vascular neosis the blood supply is less. Yes sir.

[00:08:40]>> So a vascular necrosis may happen.

[00:08:42]>> Yes sir.

[00:08:43]>> Okay.

[00:08:45]>> Uh the there was no history of trauma to the head loss of consciousness or head injury. No seial activity of no history of loss of consciousness. trauma to the head.

[00:08:55]>> Uh no history of head injury, seizure activity, bleeding from the ear uh ear or nose. No other external injuries on examination. Patient is conscious and oriented. Uh CV >> but we didn't complete your this thing.

[00:09:10]History right?

[00:09:11]>> History >> you just told it's all on stress hand.

[00:09:14]That's all.

[00:09:15]>> Most of the things history you didn't mention your person past history. What all stays on?

[00:09:23]>> The patient has no known comops. Sir, the listening complaint is there is pain uh localized pain in the right breast following the fall. There's an obvious deformity and that is a clinical examination.

[00:09:34]>> Oh yes sir.

[00:09:35]>> You're talking about the clinical examination. I just want to know about history.

[00:09:38]>> History is background.

[00:09:41]>> No non comops patient has no known comops. Not on any regular medication.

[00:09:45]No non drug allergies.

[00:09:49]Okay.

[00:09:55]on examination conscious and oriented serious as soon as present no murmur CNS there is no focal neurological deficits >> why did you straight away go to serious examination patient is come has come with the muscular trauma >> so why you are concerned about the heart right here is going by the systemic examination >> no the primary problem is if if a patient comes So third injury why should you go and examine abdomen?

[00:10:22]>> Yes sir.

[00:10:23]>> If a patient compresses a seizure why you should be concerned about the CN aspect not about respiratory system. You shouldn't be straight away going and oscultating.

[00:10:33]>> Yes sir.

[00:10:34]>> The first thing first whatever the complaint is go examine that system first and then go to the >> other system >> other systems. Okay. So local examination of the right breast inspection the receive other systems are all fine.

[00:10:47]So straight away you are in muscular examination. Okay.

[00:10:51]>> Local examination of the right uh right breast on inspection there is a visible deformity of >> so the structure will be like inspect for any muscular skultal examination uh should be asking the patient to show the normal side as well as the abnormal side and then >> look feel move then special test plus neurovvascular examination.

[00:11:16]So look means inspection.

[00:11:18]>> Inspection >> anteriorly, side, posterior like all on all areas you compare.

[00:11:24]>> Yes sir.

[00:11:25]>> Then feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel feel for for >> local >> local rise of temperature is there or not.

[00:11:31]>> Then the tender any tenderness swelling you just see compare.

[00:11:37]>> Yes sir.

[00:11:37]>> Any gross deformity is there or not.

[00:11:40]>> Then then movement. Moment could be active moment or passive movement. You should ask the patient to actively move like this like this like this because in the case of a pol fracture you should suspecting a medial nerve injury. So whatever the activity is done by med you should be testing for that.

[00:11:57]>> Yes sir.

[00:11:58]>> If it is a radial nerve injury usually you'll have a >> a wrist drop sir >> wrist drop whereas if it is a nerve it will be claw claw >> claw hand claw hand. If it is a maiden nerve injury, it will be like >> Benedict >> Benedict sign.

[00:12:13]>> Okay. So that is what you're looking for.

[00:12:16]>> The corresponding there is a injury to the radial nerve you should get a stop whereas other one will be claw hand other one will be >> benediction.

[00:12:27]Okay. Then look uh feel looking for what all things asymmetry inspection asymmetry deformity >> swelling scar >> basting >> involved in movements tremors >> or discoloration deformity contusion abrasion puncture pen penating injuries bleeding laceration swelling tenderness like Decap BTLS you can just memorize or add swift asymmetry deformity swelling scar wasting involment circulation traumas like that these are the things you should be looking for then palpating for temperature tenderness >> tenderness all whatever things then >> then >> look feel then movement active movement and passive movement active movement you should be asking the patient to move like that whatever possible you actively see whether the movement is restricted or not because of the problem. Then passively you can keep moving.

[00:13:34]Okay. If the if it is painful do not move. Okay. Then special test special test is there.

[00:13:42]Special test means the corresponding >> uh whichever >> or whatever it is you can special test if it is a knee examination special test should be done for the knee. If it is a shoulder examination, special tests for the shoulder. If it is a wrist examination, we'll do for that.

[00:13:58]Okay. Then afterwards you should do a uh neurovvascular examination. Do you know what what are the nerves which are supplied?

[00:14:07]>> Yes. So the medial aspect of the pali side is supplied by the median nerve.

[00:14:11]The uh sorry the lateral aspect the medial aspect is supplied by the alna.

[00:14:15]The median uh the >> so the thumb how many fingers?

[00:14:19]>> Uh three and a half fingers. of it was by the >> median nerve.

[00:14:23]>> So college fracture involves >> usually lateral side. So it can be the median nerve.

[00:14:29]>> Median nerve is what what we are. Yes.

[00:14:31]College fracture.

[00:14:32]>> Then >> uh then the median aspect is supplied by the al and >> one and half side is supper and the dorsal aspect uh the dorsal uh 2/3 is supplied by the radial nerve.

[00:14:46]>> Okay.

[00:14:49]Then you should be asking looking for the pulsations distations whether the pal pulsations are >> there or not the radial and alnar pulsations look for the capillary time whether everything blood circulation is proper or not >> because you you want to rule out compartment syndrome and things like that pain bopization all these things are yes >> should rule out that also all sensations should be checked >> and compare with the other hand >> yes sir >> okay continue So on local examination inspection uh there is a visible deformity of the right hand. Swelling is present over the distal forearm. There is no open wounds. No open wounds are present.

[00:15:30]>> Okay. Swelling distal forearm.

[00:15:32]>> Yes for no open wounds. What if there is open wound?

[00:15:38]uh and if it's an open fracture we'll have to start on antibiotics and >> uh immediately reduce the residence of infection and also >> TT should be taken.

[00:15:51]>> Okay.

[00:15:53]>> On palpation uh there is slight local rise in temperature tenderness or other >> if it is a close to this thing you may attempt close reduction reduction other one may usually require surgery surgery the problem. Yes sir.

[00:16:08]Okay.

[00:16:08]>> And on palpation there is localizing temperature over the distal forearm.

[00:16:13]There is tenderness over the distal forearm lateral aspect. There is a bony irregularity can be felt. Uh active and passive movements are restricted due to pain. Uh the radial pulse is pable.

[00:16:25]Capillary refill time is less than 2 seconds. Sensation are intact. The motor function is preserved and patient is able to move all fingers.

[00:16:34]This then X-ray was taken.

[00:16:38]>> X-ray was first taken AP lateral.

[00:16:43]>> Which show the transverse >> sensations are all preserved?

[00:16:45]>> All sensations were intact sir and patient was able to move all fingers.

[00:16:50]>> Okay.

[00:16:53]So you're suspecting a problem in the >> median we suspected >> in the radius.

[00:16:59]>> Medal radius.

[00:17:00]>> Dist radius.

[00:17:02]>> Was there any tenderness here? Yes, the tenderness was present >> here. Here, here.

[00:17:06]>> No, there was no tenderness overp.

[00:17:15]>> Okay.

[00:17:18]>> So, we took an XR which showed a >> sty is another >> uh which show a transverse fracture in the distal radius and there's a dal displacement in the angulation of the distal fragment. Okay, >> that was a finding sir index.

[00:17:36]>> Uh coming to management analysia was given 1 g PCM IV stat was given patient the hand was immobilized with a below elbow splint and >> below elbow >> below elbow yes sir >> and elevation of limb was done. Uh since it was a closed fracture, there was no open one.

[00:17:53]>> Ice ice >> ice ice compression was done sir.

[00:17:56]>> Rest ice rest ice rice right rest ice compression elevation.

[00:18:00]>> Ice compression and elevation was done sir.

[00:18:03]>> And since it was a closed wound uh we tried to do close reduction close reduction was done and cast immobilization one was done after that sir.

[00:18:14]>> Close reduction.

[00:18:15]>> Yes sir.

[00:18:15]>> Okay.

[00:18:18]uh reduction was done under actually sir uh procedure sedation was given and reduction was done under procedure sedation sir >> what are other options >> other options s for procedural sedation >> other options other than procedure sedation for analysis uh hematoma block can be >> block can be given how how much >> of 10 tookin without adrenaline can be given into the >> directly into the wounds massage.

[00:18:47]>> Okay.

[00:18:48]>> Then beers block can be given by applying double cuff. Vers double cuff is app.

[00:18:54]>> Yeah. Double cuff can be applied and then you can give >> pressure is increased about the patient's systolic blood pressure and the analysis is inducted directly into the vein.

[00:19:03]>> Okay. But in all these cases the chances of arythmias are there because like no.

[00:19:09]So we to be prepared with 20% intra limpit.

[00:19:14]Uh so reduction.

[00:19:16]>> Yes sir.

[00:19:17]>> So traction was applied in the longitudinal uh plane uh and disinfection was done. We gently pulled it to disengage the fragments and palmer flexion and alna deviation was done and pressure over the distal fraction.

[00:19:30]>> Basically you're like if there is a fracture like that you just uh like increase the fracture.

[00:19:38]>> Yes. Increase the fracture then >> increase the fracture then pull then give traction and then put it back into place >> in a bitction.

[00:19:46]>> Yeah.

[00:19:47]>> Flexction flexion and >> deviation deviation.

[00:19:51]>> So when when it falls like this there are high chances that this is this is going to >> work. So increase the thing.

[00:19:58]>> Yes sir.

[00:19:58]>> Pull it and then go down and then keep it ination >> and then in that position you immobilize. So he's losing a bologoney cast >> uh the position is in breast wrist flexion and alma deviation cast was applied. So call is crash was applied and check x-ray was done to look for uh the completeness of the reduction. Uh since on check x-ray the dorsal t was less than 10°. So basically our idea is to keep the dorsal tilt less than >> than 10 10° >> 10°.

[00:20:39]Okay. How do you calculate the dorsal know the dorsal tilt in X-ray?

[00:20:43]>> Uh so in lateral lateral view >> how do you know >> what how to how to calculate the dorsal tilt?

[00:20:50]>> We drove two parallel lines from the uh distal fragment the apparent and proximal fragment. Yeah. If it is a fracture like this is the this is the bone and if there is it if it is broken.

[00:21:02]Okay.

[00:21:03]Okay.

[00:21:04]>> Then you line if it is the the proximal bone you just draw a line like that in the X-ray.

[00:21:10]>> The distal bone >> also >> the proximal the distal end of the >> fracture fracture >> fracture you just draw a line that like that also. So both these things are going to meet at one point.

[00:21:22]>> So this angle is what is called the >> dorsal angle. social angle then that should be less than 10° >> in a closed track after reduction.

[00:21:31]>> You should your idea is to bring it less than 10°.

[00:21:34]>> Yes sir.

[00:21:34]>> Otherwise there are high chances that there will be mal union or >> other complications.

[00:21:38]>> So surgical reduction is needed if the close reduction does not work out.

[00:21:42]>> Yeah.

[00:21:44]uh surgical fixation is usually done for unstable fractures when there is fail reduction or there is central articular involvement or there is any neurovvascular compromise immediate uh surgical intervention should be done that is usually done using or external fixation >> that is done by the orthopedics or >> it's possible if in your hospital you have an orthopedician you can straight away call call him and he'll do the needful but in places where there are there is no authoration uh and you are the only only one there.

[00:22:15]You'll have to do >> fly lab or cast or whatever and then refer to the >> sender with >> concerned or maybe after one week if there are no other complications after one week you can ask them to be an orthopedic center.

[00:22:31]>> Yes sir.

[00:22:32]>> Okay. Provided the dorsal angle everything is less than 10° there is no neurovvascular >> and rad shortening is less than 3 mm size.

[00:22:40]>> Yeah. red is less than 3 mm.

[00:22:43]>> Okay. So, and complications coming to the complications uh early complications are usually median nerve injury and combat syndrome. Uh the late complications are usually malonin that causes persistent deformity, carpal tunnel syndrome, stiffness and complex regional pain syndrome and there can be uh >> complex regional pain syndrome. Okay.

[00:23:05]You can also >> some other name is given to that reflex sympathetic something of that sort of okay >> but this problem with the sympathetic >> nerve right >> okay so pain out of proportion to the >> injury >> injury be posessed for many >> days >> days okay >> uh then the these are Smith's fracture which is reverse of collie fracture Here there is a wall or displacement of the dist and college fracture that alnar stylo >> that shouldn't be missed x-ray in x-ray that should also be looked at whether involment fracture is there or not that should be because there is high chances that that will be missed >> yes yes sir here there was no involvement >> and especially when when in such cases it's better to take an x-ray one joint above and below >> yes sir >> okay so elbow elbow also if possible you take it.

[00:24:06]>> Yes sir.

[00:24:09]Then >> uh then another um degree that is Barton's fracture which is inoticular fracture >> you already mentioned Smith you already >> Smith is mentioned a wall displacement is the latest fracture baller displacement here we get a garden spade deformity >> garden deformity here fall is on a flex >> then in Barton's fract like this al >> then bart is in articular fracture with radiorapel dislocation. It can be either distal or waller. It involves a joint surface and it is usually associated with corpal displacements Barton's fracture.

[00:24:51]>> Then there is choffus fracture where there is fracture of the radial styloid.

[00:24:56]>> Uh it is usually when there is a direct blow compression from the scuffoid region and there is isolated radial sty fracture. Uh then there can be scuff fracture indicated by anatomical snuff box tenderness. Then other injuries of wrist pain there can be no deformity and X-ray is normal but tenderness can be present in wrist pain. Uh coming to the classification of fractures.

[00:25:21]Uh there is two mainly two types of classification. Uh there is Gartland and Wesley classification and uh frag fragment classification. Accord classification it is four types are there. Type one is extra article non-displace structure. Type two is extraord structure. Extra articular intra articular means what?

[00:25:40]>> Involving of the joint.

[00:25:41]>> Joints.

[00:25:42]>> Yes.

[00:25:43]>> So type three is intra articular non-displaced and type four is intraarticular displaced. Uh that is gartland and vessel classification. Uh according to the fragment classification there is one to eight based on whether the fracture is extraord whether the style fragment is involved or not. We classify it into eight groups. Type one is extra articular. There is no sty fracture. Type two is extra articul with alna styloid fracture. Uh type three is radioouple joint involvement uh without alna styloid fracture. Type four is radical joint involvement with alna sty fracture.

[00:26:20]Five is five and six similar with the distal radial joint involvement and in seven and eight there is communicated fractures with and without all styid involvement. That is a classification.

[00:26:32]crystal radial joint dislocation is another uh thing that has to be ruled out.

[00:26:39]>> Yes sir.

[00:26:41]>> Okay.

[00:26:45]But is it relevant this classification is it relevant to the emergency physician >> uh to emergency physician uh if there is >> for orthopedication >> mainly for orthopedication sir.

[00:26:58]>> Are we going to benefit in any way by studying all these things? uh type one and type two extra fracture can be reduced uh by emergency physician if there is no open wound. Other types involved in intraatraic fractures needs orthopedic surgeon for further involvement sir. So basically type one and two we can manipulate on our do close reduction >> and coming to the uh what are the radological findings that you usually find in a colis fracture is dorsal displacement angulation the distal radius fracture is pushed backward and this can be radial shortening usually less than 10 mm. Uh the distal fracture impacted on the shaft reducing the normal radius height. There can be loss of radial tilt. There is a normal wall or tilt of approximately 11 to 15 degree in the fracture. There can be lost a linear reversal of the rad tilt more than 20° and that is reduced radial inclination that is the angle between radius and sty is reduced. The normal angle is 21 to 25°. These are the normal findings in a structure that we get.