A 68-year-old postmenopausal woman presents to the emergency department after a fall on an outstretched hand (FOSH) while gardening. X-rays of the wrist show a fracture of the structure marked **A** (distal radius) with dorsal angulation and impaction, creating a characteristic "dinner fork" deformity on the lateral view. Which of the following is the most appropriate initial management for this fracture?

Explanation

## Why Option 1 is correct A Colles fracture of the distal radius (marked **A**) with dorsal angulation and impaction is the most common adult upper extremity fracture, particularly in osteoporotic postmenopausal women. According to Gray's Anatomy and Apley's Orthopedic Surgery, the management algorithm for distal radius fractures depends on displacement, comminution, and intra-articular involvement. An undisplaced or minimally displaced extra-articular Colles fracture is best managed with closed reduction followed by short-arm cast immobilization for 4–6 weeks. This approach is cost-effective, non-invasive, and achieves good functional outcomes in stable fractures. The key is assessing stability after reduction; if the fracture maintains its reduction in the cast, operative intervention is not required. ## Why each distractor is wrong - **Option 2**: Immediate ORIF with a volar locking plate is reserved for displaced intra-articular fractures, highly comminuted fractures, or fractures that are unstable after closed reduction. A straightforward Colles fracture without intra-articular involvement does not mandate surgery as the first step. Operative fixation is not the initial choice for all distal radius fractures. - **Option 3**: Percutaneous pinning alone without cast immobilization does not provide adequate immobilization and risks loss of reduction. Pinning is typically used as an adjunct to casting or as part of a more complex fixation strategy, not as monotherapy for a simple Colles fracture. - **Option 4**: External fixation is reserved for complex, highly comminuted, or intra-articular fractures with significant soft-tissue injury or when volar plating is contraindicated. It is not the sole definitive treatment for a standard Colles fracture and would be unnecessarily aggressive for this presentation. **High-Yield:** Colles fracture = dorsal angulation + FOSH + postmenopausal women; undisplaced/stable extra-articular → closed reduction + cast 4–6 weeks; displaced intra-articular or unstable → ORIF with volar locking plate. [cite: Gray's Anatomy 42e Ch 49; Apley's Orthopedic Surgery 10e]