Senior Report 5.19

Case Presentation by Dr. Ayse Avcioglu

CC: Bleeding from tracheostomy

HPI: A 48 year old male presents from a long-term care facility for bleeding from his tracheostomy tube.  Per nursing staff, about 10-20 cc’s of bright red bloody secretions were noted emanating from the tube which ceased spontaneously.  Information was obtained from transfer records as patient could not provide information because he had recently suffered anoxic brain injury.  Subsequently a surgical tracheostomy was performed 11 days ago.  There is no history of fever, increased sputum production, night sweats or weight loss.

ROS:  negative except for HPI

PMH: Diabetes, seizure disorder, hypertension, gunshot wound to chest

PSH:  Tracheostomy, gastrostomy tube

Meds:  Amlodipine, insulin, lorazapam, phenytoin, rosuvastatin, aspirin,

clonidine, isosorbide dinitrate, hydralazine

Allergies:  NKDA

SH:  history of polysubstance abuse including alcohol and cocaine.

FH:  diabetes, chronic kidney disease

 

Physical Exam

VS:  BP:  180/86 mmHg, P: 75, RR: 24 T: 36.0 C, Pulse ox: 95% on room air

General: eyes open, no acute respiratory distress

HEENT:  NC/AT, PERRL, borderline pallor, anicteric

Neck:  supple.  Tracheostomy tube with blood tinged sputum.  Gauze saturated in blood.  Minimal blood around stoma.

CVS:  normal S1/S2, no murmurs, rubs or gallops.

Lung:  scattered rhonchi 

GI:  abdomen soft, nontender, nondistended.  Peg-tube in place.

 Musculoskeletal: limbs atraumatic, nontender to palpation. Some atrophy of leg muscles.

 Neuro:  eyes open.  Does not verbalize, withdraws to pain.

 Skin: warm, dry, no decubitus ulcers, no petechiae

Questions: 

1.  Given the time frame of the tracheostomy stoma creation, what is the most likely cause of bleeding?

A.  Bronchopneumonia

B.  Erosions secondary to tracheal suction

C.  Granulation tissue

D.  Tracheo-innominate artery fistula

2.  What would be the next step in management?

A.  Admit to the medical intensive care unit.

B.  Attempt to suction trachea.

C.  Obtain surgical consultation in the emergency department.

D.  Place on humidified oxygen, observe for two hours, discharge if no

further bleeding occurs.

3. While examining the patient, a sudden massive gush of blood is noted from the tracheostomy and patient becomes hypoxic.  What is the FIRST step in management?

A.  Apply digital pressure through tracheal stoma and wheel patient to operating room

B.  Call blood bank for immediate 2 units of O negative blood

C.  Obtain stat surgery consultation for operative repair

D.  Overinflate tracheostomy cuff

Discussion

1.  The answer is D.  Bleeding around the stoma or hemoptysis in any patient with a tracheostomy should be fully investigated.  The differential diagnosis of the cause of bleeding is based on the lag time between tracheostomy creation and subsequent bleeding.   Tracheo-innominate artery fistula is a rare life-threatening complication of tracheostomy.  It usually results from direct pressure from the tracheal cannula against the innominate artery, or from a cuff that is overinflated.   The peak incidence of presentation is between the first and second week.  About 50% of patients have a sentinel bleed which may be mild and should not be ignored because of the potential for sudden massive hemorrhage.  (B, C) Hemorrhage occurring within 48 hours is usually associated with local factors such as puncture of anterior jugular or inferior thyroid veins, granulation tissue, erosions due to suction or coagulopathy.  A. Bronchopneumonia would be more likely if the patient had a history of fever and increased purulent secretions.

	Pressure of tracheal cannula against innominate artery

2.  The answer is C.    When tracheo-innominate artery fistula is suspected, the patient must be evaluated by a surgeon in the emergency department and transported to the operating room for fiberoptic bronchoscopy with definitive surgical repair. A.  The patient should ideally be admitted to a surgical services team who are familiar with the management of this complication as a delay in diagnosis may result in death through asphyxiation. B. If the bleeding has stopped and the airway is clear, it is best not to disturb clots in the trachea by suctioning or movement of the tracheostomy tube in order to prevent increased rate of hemorrhage.  D.  Observation followed by discharge would be inappropriate without further assessment of the source of bleeding. Consider more than 10 mL of blood to be arterial.

 

3.  The answer is D.  The first step would be to hyperinflate the tracheal cuff in an attempt to compress the artery against the sternal wall.  This maneuver alone is successful in 85% of cases.

	Hyperinflation of tracheostomy cuff

If this attempt fails, insert an endotracheal tube through oropharynx, remove tracheostomy tube and position the endotracheal tube cuff distal to bleeding site to protect airway.  B. Calling the blood bank for blood transfusion may become necessary if bleeding continues, but airway management takes priority.   C. Notifying the surgeon will become critical but is not the first step in management.  A. If initial attempts to control bleeding are unsuccessful, insert index finger through stoma, compressing the trachea against the sternum. This is the most reliable technique to stop the bleeding.  Hold continued pressure while simultaneously wheeling the patient to operating room.

References:

Roberts and Hedges Clinical Procedures in Emergency Medicine.  5^th ed.  Pages 124-137.

Tintinalli’s Emergency Medicine. 7^th ed. Pages 1592-1595.

Grant, C.A.  Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review.  British Journal of Anesthesia 96 (1): 127–31 (2006).

Senior Report 5.18

Case Presentation by Dr. Debia Kim

CC: “My eyes are blurry”

HPI:  31 y/o M reports 2 weeks of worsening headaches and 2 days of double vision after being hit in the back of the head with a metal napkin ring holder by his fiancee.  Since being hit in the head, he has been having intermittent, occipital, throbbing headaches which are partially alleviated by Motrin.  In addition to the headaches, he began experiencing double vision that began a day ago.  He tried to “sleep it off,” but on waking today he was still seeing double.  He denies pain in his eyes, denies red eyes, denies discharge, denies any new medications.  He states that when he closes one eye, the double vision does go away.  He can’t say which eye is worse.  He does not wear contacts or glasses, does not use eye drops.   Denies any numbness or tingling in his face, denies trouble with chewing, swallowing, or moving his facial muscles.  Denies change in hearing.  States he can walk “just fine” but prefers not to write and drive because of the blurry vision.  Denies nausea, vomiting, fever, neck ache, sick contacts.

REVIEW OF SYSTEMS: EYES:  Positive for double vision.  Negative for eye pain.  Negative for decreased vision.  Negative for photophobia. ENT: Negative for neck pain. GASTROINTESTINAL:  Positive for nausea, but negative for vomiting. MUSCULOSKELETAL:  No pain elsewhere in his body.  No trauma anywhere else in his body from the altercation with his girlfriend. NEUROLOGIC:  Positive for throbbing headache that waxes and wanes.

PAST MEDICAL, FAMILY, AND(OR) SOCIAL HISTORY:

PAST MEDICAL HISTORY:  None.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Motrin p.r.n. ALLERGIES:  NONE.

SOCIAL HISTORY:  Daily smoking, occasional ethanol, occasional marijuana, but he did not report any use of ethanol or drugs within the last few days.  He is currently unemployed.

PRIMARY CARE PHYSICIAN:  None.

EXAMINATION OF ORGAN SYSTEMS-BODY AREAS:

VITAL SIGNS:  Blood pressure 131/70, heart rate 65, respirations 16, temperature 36.6, and pulse ox is 97% on room air. CONSTITUTIONAL:  This is a well-nourished, adult gentleman, in no acute cardiopulmonary distress, sitting calmly on the stretcher.

HEENT:  Head is normocephalic and atraumatic.  Nontender over the face and scalp.  The patient has a slight right ptosis, but his facies are otherwise symmetric.  He has anisocoria with right pupil that is enlarged nearly 8 mm.  The left pupil that is normal about 4.  Both pupils are reactive with no afferent defect.  His vision is 20/100 in the right eye and 20/20 in the left.  He does have some binocular double vision; however, when each eye is covered independently, he has monocular vision restored.  His extraocular movements are restricted.  His right eye cannot abduct completely to the right and he has trouble looking up; however, he is able to look down and to the left without difficulty on my examination.  Funduscopic exam is incomplete, but normal vasculature is visualized in both eyes.  The optic disks are incompletely visualized.  Sensation to light touch in the face is symmetric.  The patient is nontender over the bony prominences of his face.  Posterior pharynx is clear.

NECK:  Throat supple.  Trachea midline with no meningismus.

CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1 and S2.  No tachycardia. LUNGS:  Clear bilaterally.

ABDOMEN:  Soft, flat, nondistended, and nontender.

MUSCULOSKELETAL:  Nontender over the arms and legs.

SKIN:  Warm and dry.

NEUROLOGIC:  Alert and oriented.  Speech fluent and appropriate.  Sensation to light touch intact over his facies symmetrically.  He can demonstrate a symmetric smile.  Midline tongue on protrusion.  He can lift his eyebrows and close his eyes.  He can shrug against resistance.  He can puff out his cheeks.  He demonstrates symmetric grip strength with normal finger-to-nose.  He has a normal gait and balance when walking through the emergency department.

QUESTIONS:

1)  Which cranial nerve(s) is(are) affected?

2)  What is the patient’s most likely diagnosis?

a) Bell’s Palsy

b) Multiple Sclerosis

c) PCA Aneurysm

d) Horner Syndrome

e) Brain bleed!

3)  Which imaging study would best provide a diagnosis?

ANSWERS:

1)  CN III palsy

2)  C – PCA Aneurysm

3)  MRI/MRA brain

DISCUSSION:

Neuro-ophthalmologic diagnoses are often challenging to sort out.  In this young patient with headache, a CN III palsy with ipsilateral pupillary dilatation is a posterior communicating artery aneurysm until proven otherwise.

PCOM aneurysms are the second most common Circle of Willis aneurysms (the first being ACOM).  PCOM aneurysms arise from the internal carotid artery near the PCOM origin.  Expansion here causes compression of the outer fibers of CN III as it travels out of the brain– which cause the nerve palsy and pupillary dilatation.

New onset diplopia is the most common presentation of CN III and VI palsies.  It can be painful or painless.  EOM testing will be abnormal with lateral gaze preserved in pure CN III palsy (unlike CN VI palsy, which will have abnormal lateral gaze with worsening diplopia on the affected side).  This patient presents with mixed EOM findings.  He also has decreased visual acuity in the R eye, which was thought to be secondary to his pupillary constriction problems (can’t focus) rather than an additional CN I issue.  This patient’s upward and medial gaze is preserved, which points away from a stroke or a demyelinating disease (such as multiple sclerosis) causing intranuclear ophthalmoplegia from lesion of the medial longitudinal fasciculus.  CN VII palsy (such as Bell’s palsy) can also present with ptosis but will classically be associated with problems of facial expression — it should not cause anisocoria or EOM issues.  Lastly, Horner syndrome also presents with ptosis and pupillary abnormalities.  In a Horner syndrome, the problem is interruption of the sympathetic inputs to the eye.  The classic physical findings would be ipsilateral ptosis, miosis (rather than dilatation as in our patient), and anhydrosis in a patient with a history of zoster, tumor, or trauma (to the ipsiliateral neck where the sympathetic plexus surrounds the carotid artery).  Lastly, this is a young nondiabetic and nonhypertensive patient.  Patients who do have such vasculopathies (diabetics especially) can develop acute CN III palsy due to vascular compromise of the nerve.  In vascular compromise of CN III, the central nerve fibers are most often infarcted first, which will cause a nerve palsy with pupillary sparing (EOM problems WITHOUT anisocoria).

The best imaging choice to diagnose a posterior circulation abnormality such as aneurysm is an MRI/MRA of the brain.  Given the broad differential for neuro-ophthalmologic emergencies and history of (relatively) recent trauma in our patient, a non-contrast head CT was the first test performed to rule out the possibility of an already bleeding significant aneurysm.  MRA of the neck was also done to assess the carotids and evaluate for Horner syndrome.  Neurosurgery, neurology, and ophthalmology services were consulted.  Blood pressure control was strictly monitored.

The patient underwent emergent coiling of the aneurysm, did well, recovered, and was discharged home.  He and his fiancee have cancelled their wedding plans.

Intern Report 5.17

Case Presentation by Dr. Arun Rajasekhar

CC: Right eye pain

HPI:  A 10 year old, otherwise healthy, Caucasian male presents to the ED complaining of right eye pain.  About one hour ago, he was playing racquetball.  He states that he never wears eye protection, and today the ball ricocheted off the wall and struck him in his right eye.  Patient denies any LOC.  The area around his eye began to swell immediately after he was struck.  Since the accident, his vision has been blurry in his right eye and light exacerbates his pain.  His mother gave him an icepack to put over his eye and brought him to the ED immediately after the accident occurred.  He is nauseous but has not vomited.  He denies having double vision or complete loss of vision in the right eye.  He denies any discharge from the eye.

ROS: Negative except for that described in HPI

PMH: Denies DM, denies asthma

PSH: None

ALL: NKDA

MEDICATIONS: None

FH: Negative for DM, Negative for HTN

SH:  Lives at home with his mother and father.  He attends the 4^th grade.  There are smoke detectors in the house.

PHYSICAL EXAM:

Vitals: BP 110/70     HR 105    RR 16    Sat 98%   Temp 36.8

Gen:  Patient his lying in stretcher with ice pack covering right eye.

HEENT:  Head is normocephalic.  There is mild periorbital swelling around the right eye.  No tenderness to palpation of the right orbit and no bony step-offs.  Nares are patent bilaterally.  Neck is supple.  Trachea is midline.

EYES:  EOMI.  Mild anisocoria.  Right eye is 2mm and reactive, left eye is 3mm.  Visual acuity is 20/20 OS and 20/50 OD.  There is no pupil eccentricity.  IOP measurement was deferred.  Slit lamp exam shows layered red blood filling about 20% of the anterior chamber (see picture below).  There are no corneal abrasions.  Negative Seidel sign.

RESP: CTAB

ABD: NTND

MUSC: Moving all extremities.  Normal muscle bulk and tone.

NEURO: Alert and oriented.  Answering  questions appropriately on exam.  No facial droop.  Normal speech and gait.

Question 1) What grade of hyphema does the patient have?

A)   Grade I

B)   Grade II

C)   Grade III

D)   Grade IV

Question 2) Which of the following co-morbidities places a patient at higher risk for developing glaucoma and vision loss from a traumatic hyphema?

A)   Diabetes

B)   Sickle cell disease

C)   HTN

D)   Hyperlipidemia

Question 3) What condition must be ruled out prior to measuring intraocular pressures in patient’s with traumatic hyphema

A)   Lens dislocation

B)   Corneal ulceration

C)   Globe rupture

D)   Subconjunctival hemorrhage

 

Discussion/Answers

1) A 

2) B 

3) C

Traumatic hyphema, or blood in the anterior chamber, is a common complication of blunt or penetrating injury to the eye and can result in permanent vision loss.  The goals of initial assessment include recognition and characterization of the hyphema and identification of associated orbital and ocular injuries.  Optimal outcome following a hyphema depends on early ophthalmologic intervention focused on prevention of rebleeding and avoidance of intraocular hypertension.

Hyphema’s are categorized based on the degree of anterior chamber hemorrhaging.  The amount of blood in the anterior chamber is correlated with prognosis for recovery of visual acuity.

 

Presentation – Vision loss and eye pain are common presenting complaints in patients with a traumatic hyphema. In addition, nausea and vomiting may accompany this injury.  History reveals blunt trauma to the eye in most cases of traumatic hyphema.  Younger children often report being hit in the eye by a ball.  Other common physical exam findings are photophobia, anisocoria, corneal blood staining, and elevated intraocular pressure.  In regards to photophobia, Exposure of the unaffected eye to bright light will frequently cause pain in the affected eye due to consensual pupillary constriction and associated traumatic iritis.  Torn iris sphincter muscles can result in miosis or mydriasis (pupillary dilation). The combination of physical damage to the iris and scarring in response to inflammation over the first 24 to 48 hours can result in poor pupil reactivity and anisocoria relative to the unaffected eye.  Corneal blood staining describes diffusion of red blood cell breakdown products into the corneal stroma resulting in golden discoloration of the cornea.  The risk of this complication is increased in patients with a large amount of blood in the anterior chamber (especially “eight ball” or Grade IV (100 percent) hyphema) and elevated intraocular pressure.  Intraocular hypertension (greater than 21 mmHg) occurs in over 30 percent of patients at some point following a hyphema.  Patients with sickle cell disease or trait are at higher risk for elevation of intraocular pressure within the first 24 hours.  Patients with sickle hemoglobinopathy (sickle cell disease or trait) can only withstand intraocular pressure (IOP) of 24 mmHg for 24 hours (Goldberg’s rule) before permanent ischemic damage to the optic nerve may occur.  Pressure elevation may not occur for several days after the injury, necessitating close monitoring during the first week.

Physical examination — Topical analgesia, reduced ambient light, and parental presence facilitate cooperation in the child.   The clinician should grossly inspect the lids, lashes, lacrimal ducts, and cornea as well as assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect, visual acuity, extraocular movement, and visual fields by confrontation.  If impact was from a blunt object larger than the orbital rim, patient should also be assessed for orbital floor fracture, orbital hemorrhage with proptosis, and orbital compartment syndrome.

An open globe must be excluded prior to any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry.  Flourescein examination should be deferred in patients in whom a ruptured globe is highly suspected or evident upon inspection.  In most instances, intraocular pressure measurement should be deferred until after complete evaluation by an ophthalmologist.  Injury from small, fast-moving projectiles that hit the eye with a force that is not cushioned by the surrounding orbit increase the risk of an open globe or damage to posterior segment structures.

Physical findings of globe rupture include:

• Markedly decreased visual acuity
• Eccentric pupil
• Increased anterior chamber depth
• Low intraocular pressure
• Extrusion of vitreous
• External prolapse of the uvea or other internal ocular structures
• Tenting of the cornea or sclera at the site of globe puncture
• Seidel’s sign, fluorescein streaming in a tear drop pattern away from the puncture site

A high index of suspicion for posterior rupture should be maintained in the setting of high-risk mechanism coupled with hyphema obscuring posterior visualization.  Patients with possible globe rupture should have an eye shield placed immediately for protection and should undergo prompt evaluation by an ophthalmologist. These patients require aggressive pain control and treatment of nausea and/or vomiting to avoid extrusion of ocular contents caused by crying or emesis.

Work up –  Patients with sickle cell disease or trait, bleeding dyscrasia, or concern for an open globe need emergent evaluation by an ophthalmologist.  All patients of African or Mediterranean heritage with family history of hemoglobinopathy and uncertain screening status require a sickle cell rapid preparation and hemoglobin electrophoresis.  Patients with suspected or known bleeding dyscrasia should have a complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR) measured.  Emergent imaging is necessary in patients with a suspected open globe or concern for serious orbital injury.  CT of the orbit without contrast and with 1 to 2 mm axial and coronal cuts through the orbits is indicated for patients with suspected open globe, intraocular foreign body, or intraorbital hemorrhage and for trauma patients already undergoing cranial CT for other indications.

Emergency Treatment – An eye shield should be placed over the affected eye as soon as possible and subsequently removed only as required for examination and imaging.  Limitation of activity to bed rest with bathroom privileges should occur until initial evaluation is complete.  Elevation of the head to 30 degrees promotes inferior settling of blood in the anterior chamber away from the visual axis while maintaining arterial blood flow to the eye relative to the fully erect position.  Topical analgesia with a drop of proparacaine or tetracaine ophthalmic drops may be applied in patients without globe rupture.  NSAIDs should be avoided because of their platelet inhibiting effects.  Patients with nausea or vomiting require treatment with antiemetics, to prevent sudden increase in intraocular pressure caused by emesis.  Cycloplegia often provides pain relief and allows for optimal examination of the posterior segment.  They are contraindicated in patients with suspected open globe rupture.

Disposition – Several observational studies suggest that most patients can safely receive treatment for hyphema in the outpatient setting.   Inpatient management is recommended for patients with other ocular injuries that require hospital care, suspected child abuse, bleeding dyscrasia, and sickle hemoglobinopathy and is suggested for intraocular hypertension on initial examination, delayed presentation, or large hyphemas (filling of 50 percent or more of the anterior chamber)  Additional considerations regarding patient disposition include the ability to adhere to the rigorous regimen of restriction of activity, multiple and frequent medication administration, and daily travel to the ophthalmologist for examination.

Prognosis – Prognosis for visual recovery is correlated with severity/grading of initial hyphema.  The main risk to vision from hyphema primarily depends on degree and duration of elevated intraocular pressure and rebleeding.  Secondary hemorrhage typically occurs two to five days after initial injury in patients with hyphema and is correlated with anterior chamber clot retraction [9]. Rebleeding predisposes the patient to increased intraocular pressure, secondary glaucoma, and corneal blood staining. Each of these conditions increases the risk of permanent vision loss.

Intern Report 5.16

Case Presentation by Dr. Adam Bartsoff

CC: Right wrist pain

HPI: A 52 year old female presents to the emergency department accompanied by her daughter with the chief complaint of right wrist pain.  The patient states that approximately two hours ago she was walking down her basement stairs when she stumbled and fell the final two steps onto the basement floor.  Her fall was broken by an empty laundry basket and there was no LOC. Since the time of the fall, she complains of 10/10 throbbing pain in her right wrist and numbness and tingling in the fingers of her right hand. Additionally, her right wrist and forearm have become progressively more swollen.  Her wrist pain is exacerbated by movement of the joint and has not been alleviated by one extra strength Tylenol.

ROS: Negative except for that described in HPI and stress incontinence

PMH: Hypertension, Hyperlipedemia.

Meds: None

Allergies: PCN

PSH: Appendectomy, Cholecystectomy, C-section

Physical Exam:

Vitals: T  37.8, BP 165/100, HR 95, RR 20, SpO2 100% RA.

Gen: Healthy, well nourished appearing female. Cooperative. Sitting up in stretcher and holding right wrist with left hand.

HEENT: NC/AT. PERRLA, EOMI. Full ROM of Neck.  No C-spine tenderness/deformity.

NEURO:  Exam of right hand:

Light touch, pinprick and two point discrimination absent in palmer aspect of distal thumb, index and middle finger.  Sensation intact in ring finger, little finger and web space between thumb and index finger. Wrist extension intact, although painful.  Flexion of R MCP, PIP and DIP joints intact but painful.  Tinel’s sign weakly positive.

MSK: Obvious deformity of R wrist with dorsal angulation.  Decreased grip strength in right hand, 2/5. ROM of right wrist and digits elicits pain. Pain to palpation of right wrist and distal forearm. Symmetrical swelling of the R wrist and distal forearm.  Full ROM of elbow and shoulders bilaterally.

Skin: Mild erythema and swelling to R wrist with no tenting of skin or bony protrusion.

RESP: Clear to auscultation bilaterally with symmetrical chest expansion.

CVS: Tachycardic, S1, S2. No murmur, rubs or gallops. Radial pulses 2+ bilaterally.

Course in the ER:

The patient was given IV morphine for pain and radiographs of the right forearm were obtained.

Imaging:

imageinterpretation.co.uk

Questions:

1. What is the most frequent nerve damaged in this type of fracture?

(A) Median

(B) Radial

(C) Ulnar

(D) Axillary

(E) Vagus

2. Which of the following is a sign of instability in a Colles fracture?

(A) Intraarticular radiocarpal extension

(B) Distal radial ulnar joint extension

(C) Radial shortening

(D) Loss of radial inclination

(E) All of the above

3. Which of the following is true regarding the radial inclination?

(A) The correct radial inclination range is 15-20 deg

(B) Loss of radial inclination will increase the load across the Lunate

(C) The radial inclination is measured on the lateral radiograph

(D) A and B

4. What is a Smith’s fracture?

(A) An isolated fracture of the radial styloid process

(B) A reverse Colles fracture

(C) A fracture/dislocation of the volar rim of the radius

(D) An isolated fracture of the ulnar syloid process

 

Answers/Discussion

1) A

The radiograph demonstrates a Colles Fracture and the stem describes the classic presentation of an elderly person who falls on an outstretched hand.  The Colles fracture is a fracture of the distal radius with dorsal displacement and volar angulation.  It is the most common fracture of the wrist in adults and is especially more common in the elderly as they often have osteoporosis or osteopenia and are unstable ambulating. It was first described before the advent of radiology in 1814 by Dr. Abraham Colles who was an Irish surgeon. He defined a distal radial fracture as a “low-energy, extra-articular fracture to the distal radius in the elderly population.”

The radial, ulnar and median nerve’s are primarily responsible for sensation to the hand.  The sensory distribution of the hand is shown in figure 1.  The motor function of the hand is also primarily a function of the radial, ulnar and median nerves.  However, many of the motor functions of the hand are controlled by muscles originating in the forearm which are called extrinsic muscles. The muscles originating in the hand are called intrinsic muscles.  The radial nerve does not innervate an intrinsic

muscle. The radial nerve innervates forearm muscles responsible for extension of the wrist, thumb and MCP joints. The median nerve is responsible for thumb opposition and flexion of the thumb, index and middle fingers at PIP and DIP joints. Finally the ulnar nerve provides the most of the motor function of the intrinsic muscles of the hand. Ask the patient to hold a piece of paper between their index and middle fingers to evaluate ulnar nerve motor function.

Figure 1. Sensory Distribution of Hand (www.drtomaino.com)

For more on the normal hand exam see: Normal Hand Exam from practicalplasticsurgery.org

Neuropraxias can develop following a Colles fracture.  The most common nerve injured is the median nerve.  Because the median nerve travels through the carpal tunnel it is especially susceptible to compression and contusion as the wrist becomes more edematous following a fracture.  Patients may complain of paraesthesias in the distal palmer tips of the thumb, index and middle fingers.  Paralysis is usually transient if present. Patients may also develop ulnar and radial neuropraxias following a Colles fracture however they occur less frequently than median nerve injuries.

For anesthesia and analgesia during reduction of a Colles fracture the physician may perform a hematoma block. This is done by aspirating blood from the fracture hematoma and replacing it with 10-15 cc of 1% lidocaine. Allow approximately 10 minutes for proper anesthesia of the nerve fibers surrounding the periosteum and soft tissue. The efficacy of a hematoma block is best acutely and diminishes with time as the hematoma coagulates.

2) E

Intraarticular radiocarpal extension, distal radial ulnar joint extension, radial shorting and loss of radial inclination are all radiographic signs of instability and are high risk for patients to develop secondary displacement following primary reduction.

Indications or Instability:

• > 10 degree loss of radial inclination
• > 5 mm of axial radial shortening
• > 2 mm of articular incongruity
• Comminution of cortex across the midaxial line on lateral xray
• Comminution of dorsal and palmer cortices
• Irreducible fracture
• Loss of reduction at follow up

Articular congruity is very important so that patients do not develop post traumatic arthritis of the wrist.

3) B

The radial height, inclination and tilt are three important measurements when interpreting radiographs of the forearm following a Colles fracture.  The radial height is measured on the PA radiograph and is the distance between two lines perpendicular to the long axis of the radius.  The first line is drawn to intersect the distal articular surface of the ulnar head and the second line is drawn at the distal tip of the radial styloid.  The average radial height is approximately 10-13 mm. See Figure 2.

Radial Height

Figure 2

Radial inclination is also measured on the PA radiograph.  Radial inclination is the angle between one line drawn between the radial styloid and the ulnar distal radius.  The second line is drawn perpendicular to the long axis of the radius. The average radial inclination is approximately 21 to 25 degrees.  Loss of radial inclination will result in increase load on the lunate complications in the future including post traumatic arthritis and potentially an operation.

Radial Inclination

Figure 3

Radial tilt is measured on the lateral radiograph.  It is the angle between a line that runs along the distal radial articular surface and the line perpendicular to the long axis of the radius.  The normal volar tilt is 11 degrees but has a range of 2-20 degrees.  See Figure 4.

Radial Tilt

Figure 4

4) B

A Smith’s fracture is also known as a reverse Colles fracture and is often mislabeled as a Colles fracture.  In a Smith’s fracture, the distal radius is fractured and the distal fragment is displaced volar instead of dorsal as in a Colles fracture.  This type of fracture is much more uncommon and is referred as a “garden spade” deformity. Likewise, a Colles fracture is sometimes referred to as “silver fork” deformity.

An isolated fracture of the radial styloid process is called a chauffeur’s fracture and is often associated with injury to the scapholunate ligament.  This occurs from tension forces sustained during ulnar deviation and suppination of the wrist. The name is derived from chauffeurs in previous eras who would have to start a car by hand cranking it.  When the car would backfire, the crank would violently snap back into the chauffer’s palm and produce the characteristic fracture.

A fracture/dislocation of the volar rim of the radius is known as a Barton’s fracture, specifically a volar Barton’s fracture.  This results from high velocity impact across the articular surface of radiocarpal joint with the wrist in volar flexion at the moment of impact.  Radiographs demonstrate a wedge-shaped articular fragment sheared off the volar surface of the radius and displaced volarly.  These fractures have a high tendency for redislocation and often require an operation.

An isolated fracture of the ulnar styloid process is rare and is often clinically insignificant.  However, fractures of the ulnar styloid process are often associated with fractures of the radius.

References:

Rosen’s Emergency Medicine. 7th editon. Page 467-477.

www.radiologyassistant.nl

Altizer, Linda L. Colles’ Fracture, Orthopaedic Nursing, March/April 2008

Figure 1. Sensory Distribution of Hand. www.drtomaino.com.

Normal Hand Exam practicalplasticsurgery.org