A 57 yo male slipped and fell on ice and presents with right wrist pain.  He denies numbness, and seems to have intact sensation and strength distal to the injury; exam is only limited by pain.  An x-ray is shown.  What's the diagnosis?  Scroll down for answer.

Answer:  Colles' fracture (this patient also has ulnar styloid fracture)

Colles'

• common fracture of the distal radius that occurs from fall on an outstretched hand (FOOSH)
• there is dorsal angulation of the distal fracture fragments
• Exam
• check neurovascular status distal to injury (cap refill, sensation, motor strength)
• evaluate range of motion, snuffbox tenderness
• median nerve compression is common

• Differential : lunate or perilunate dislocation, scapholunate disslocation, DRUJ  (distal radial ulnar joint) dislocation, carpal bone fractures, TFC (traingular fibrocartilage complex) injury, Smith's fracture (distal radius fracture often from fall on flexed wrist)
• Management
• reduction
• can use finger trap for at least five minutes prior to relax/ fatigue muscles and bring radius into better alignment
• consider hematoma block / sedation
• traction and countertraction important  (finger traps or second operator helpful)
• maneuver: place your thumbs on dorsal aspect of distal fracture fragment and your wrap fingers around just proximal to the fracture line on the forearm, apply axial traction to the proximal fragment, pulling downward, and push thumbs on distal fragments up and over (palmarly)
• Splint - sugar tong splint with slight flexion and ulnar deviation, sling for comfort
• reexamine neurovascular status after reduction and splinting
• all patients need prompt orthopedic follow up
• Indications for consultation
• open fractures
• any neurovascular compromise
• compartment syndrome
• urgent referrals - discuss with orthopedic specialist - articular step off > 2mm, >20 degrees of dorsal angulation, fracture dislocation, distal radius plus scaphoid fracture or scapholunate dislocation, large ulnar styloid fractures with displaced fragments at the styloid base (increased risk of DRUJ instability)

References

Eiff MP, Hatch RL, Calmbach WL. Carpal fractures. In: Fracture Management for Primary Care, 2nd ed,Saunders, Philadelphia 2003.

Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of displacement after nondisplaced distal radialfractures in adults. J Bone Joint Surg Am. 2013 Aug 7;95(15):1398-402. doi: 10.2106/JBJS.L.00460.PMID: 23925744.

Earnshaw SA, Aladin A, Surendran S, Moran CG. Closed reduction of colles fractures: comparison ofmanual manipulation and finger-trap traction: a prospective, randomized study. J Bone Joint Surg Am.2002 Mar;84(3):354-8. doi: 10.2106/00004623-200203000-00004. PMID: 11886903