A 68-year-old woman presents to the emergency department 2 hours after a fall on an outstretched hand (FOOSH). X-rays confirm a Colles fracture with dorsal angulation of 35° and dorsal comminution involving the radiocarpal joint. Neurovascular examination is intact. What is the most appropriate immediate next step in management?

Explanation

## Management of Colles Fracture with Dorsal Comminution ### Clinical Context This patient has a displaced Colles fracture with dorsal comminution and intra-articular involvement. The neurovascular status is intact, and the fracture is recent (< 6 hours), making it an ideal candidate for closed reduction. ### Why Closed Reduction is the Next Step **Key Point:** Closed reduction under procedural sedation (propofol, midazolam, or ketamine) is the gold standard for acute Colles fractures presenting within 6–8 hours of injury, regardless of comminution pattern, provided neurovascular status is preserved. **High-Yield:** The timing of reduction is critical: - Swelling peaks at 6–8 hours post-injury - Reduction becomes progressively difficult after this window - Early reduction reduces soft tissue trauma and improves outcomes ### Reduction Technique (Lister's Maneuver) 1. **Longitudinal traction** — counteract shortening 2. **Dorsal pressure on the distal fragment** — correct dorsal angulation 3. **Radial deviation correction** — restore radial inclination 4. **Pronation of the forearm** — reduce supination deformity ### Post-Reduction Immobilization **Above-elbow plaster cast** is preferred over below-elbow because: - Immobilizes the elbow, preventing pronation/supination - Better control of rotational forces in comminuted fractures - Reduces re-displacement risk - Maintained for 4–6 weeks depending on fracture pattern ### Indications for ORIF (When NOT to Choose Option 0) | Scenario | Action | |----------|--------| | Failed closed reduction (> 2 attempts) | ORIF with volar plate | | Neurovascular compromise | Urgent reduction ± ORIF | | Intra-articular step-off > 2 mm | Consider ORIF | | Unstable fracture (loss of reduction on post-reduction X-ray) | ORIF | | Open fracture | ORIF after debridement | In this case, although there is dorsal comminution, the fracture is recent, neurovascular status is intact, and no mention is made of failed reduction attempts — closed reduction remains the standard of care. ### Post-Reduction Follow-up **Clinical Pearl:** Serial X-rays at 1 week and 3 weeks are essential to detect loss of reduction, which occurs in 10–20% of cases. If loss of reduction occurs, consider conversion to ORIF or external fixation. **Mnemonic: CAST** — **C**losed reduction, **A**bove-elbow immobilization, **S**erial imaging, **T**herapy (hand physiotherapy after 4–6 weeks).