A 28-year-old woman falls on an outstretched hand while playing badminton. She presents with wrist pain, swelling over the dorsal aspect of the wrist, and a 'dinner fork' deformity. Plain radiographs confirm a Colles' fracture with dorsal angulation of 35° and dorsal displacement. She has no neurovascular compromise. What is the most appropriate immediate next step in management?

Explanation

## Clinical Scenario This is a classic Colles' fracture (distal radius fracture with dorsal angulation and displacement) in a young, active patient with no neurovascular compromise. The 'dinner fork' deformity is pathognomonic. ## Why Closed Reduction is the Correct First Step **Key Point:** Colles' fractures are initially managed by closed reduction under procedural sedation (propofol, midazolam, or nitrous oxide) followed by immobilization in a plaster cast. This is the gold standard for uncomplicated, non-comminuted fractures in patients with intact neurovascular status. **High-Yield:** The **Lister's tubercle** is the key anatomical landmark for reduction: - Reduction restores radial length, radial inclination (22°), and volar tilt (11°) - Dorsal angulation > 20° or displacement > 5 mm requires reduction - This patient's 35° angulation is well above the threshold ## Reduction Technique (Colles' Fracture) | Step | Technique | Goal | |------|-----------|------| | **Analgesia** | Procedural sedation ± hematoma block | Pain control, muscle relaxation | | **Traction** | Longitudinal pull on extended wrist | Restore length | | **Correction** | Flex wrist, apply volar pressure | Correct dorsal angulation | | **Immobilization** | Above-elbow plaster cast | Maintain reduction | | **Follow-up X-rays** | At 1 week, 4 weeks, 8 weeks | Monitor for loss of reduction | **Clinical Pearl:** Colles' fractures are prone to **loss of reduction** in the first 2 weeks. Weekly X-rays are essential. If reduction is lost, consider percutaneous pinning or ORIF. **Mnemonic:** **COLLES** = **C**losed reduction → **O**ver-extension → **L**ateral (radial) displacement → **L**oss of volar tilt → **E**levate → **S**tab with cast ## When to Consider ORIF **Warning:** Open reduction is reserved for: - Comminuted intra-articular fractures - Fractures with loss of reduction after closed reduction - Fractures in patients requiring early mobilization (athletes, elderly with osteoporosis) - Associated injuries (ulnar fracture with displacement, median nerve compression) This patient has a simple displaced fracture without comminution — closed reduction is appropriate. [cite:Rockwood & Green's Fractures in Adults Ch 10]