University: after Irish surgeon Abraham Colles who was

 
University:
Sheffield Hallam University
 BSc Diagnostic Imaging
 
Module:
Musculoskeletal Imaging 1
Task 1 – Assignment
 
 
Assignment Name: The Colle’s Fracture
Date: _18/01/18_          Word Count _2197_
 
 
Student
Name: Ruth Brown
Student
Identification: b7013863
Learning Contract
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Introduction

In
this assignment, I will examine the Colles’ fracture, a distal radius fracture
named after Irish surgeon Abraham
Colles who was the first to correctly describe the fracture in a paper he
published in the Edinburgh Medical &
Surgical Journal 1814 (Ellis,
H. (2012).).

He described the fracture to be ‘… of the carpal
extremity of the radius’, His understanding was based from the deformity seen,
as at the time radiography did not exist. (Ellis, H. (2012).). Its characteristic appearance, depicted to the
right, is the reason that the fracture is also known as the dinner fork
fracture/deformity.

 

I chose this fracture due to its high
frequency in Accident & Emergency departments across the country. In fact,
~15% of people will experience a Colles’ fracture in their lifetime. (Blakeney, W. G. (2010).)

Anatomy& Physiology

Normal

The wrist is comprised
of a sophisticated system made from many bones,
joints, muscles and ligaments. In addition, there is a complex neurovascular
system that supplies the area with blood.

Figure 1 on the
left shows a labelled x-ray taken of a normal wrist. The wrist contains 8
Carpal bones which are held together by interosseous ligaments. (Gunn, C. (2018).)

Other relevant
anatomy includes nerves of the wrist as these can be damaged by trauma. There
are three nerves in the wrist.

·        
Radial

·        
Ulnar

·        
Median

These
nerves provide motor innervation which allows movement of the hand, fingers and
wrist. The nerves carry the impulse stimulating the contraction of muscle. The
nerves also allow sensory information such as touch, pain and temperature to
reach the brain. (Toole,
G., & Toole, S. (2015).)

 

According to BBC
Bitesize (2014) a joint is formed where two or more bones meet; they are
divided into three categories:

·        
Synovial

·        
Cartilaginous

·        
Fibrous

The
wrist is also known as the radiocarpal joint; it is comprised distally of the
proximal row of the carpal bones bar the pisiform (scaphoid, lunate,
triquetrum), proximally it is comprised of the distal end of the radius and not
the ulnar.

It
is an ellipsoid synovial joint, this means that there is. an oval shaped articular surface that
corresponds an elliptical cavity (biology-online.org(n.d.)) It is biaxial, this means that it allows flexion,
extension adduction and abduction because it allows movement in two planes. All
synovial joints are double layered.

The carpal bones together form a surface
that articulates with the surface of the radius. These articulate with an
articular disk which covers the boney surfaces. (Gunn,
C. (2018).)

 

There are many ligaments in the wrist, three
of which are seen in the figure 4. The Palmar radiocarpal and Dorsal
radiocarpal increase joint stability, ensuring that the hand follows the
forearm in rotation. The Palmar ulnocarpal ligament limits the extension of the
wrist by attaching the styloid process of the
ulna to the lunate and triquetral bones. (anatomyexpert.com (n.d.))

Movement

Muscles (Gunn, C.
(2018). )

Flexion

Flexor carpi radialis and flexor carpi
ulnaris

Extension

extensor carpi radialis and the
extensor carpi ulnaris

Abduction

 flexor and extensor carpi radialis

Adduction

flexor and extensor carpi ulnaris

The Radial and Ulnar collateral
ligaments work together to prevent excessive lateral joint displacement.

 

 

 

 

 

 

 

 

 

Abnormal

 

The
Colles’ fracture is usually the result of a fall on an outstretched hand (FOOSH)
as the patient attempts to break a forward fall (Luijkx, Desai et al. (n.d)).
The wrist fractures due to the hyperextension of the wrist.

 

While falls are quite a common mechanism for this injury, the
presence of this fracture can indicate underlying pathology such as
osteoporotic bones. (Luijkx, T. Desai, P.K. et al.(n.d.)) For this reason, the Colles’ Fracture is
commonly associated with older women. Bone density often decreases as a part of
the normal aging process (Gunn, C. (2018).) it also makes the fracture more likely
to displace (Blakeney, W. G. (2010).)

 

The loss in bone density as a result of osteoporosis is caused
by the rate of bone formation decreasing as the resorption of bone mineral
stays the same. Over time this causes the bones to weaken. It is not just older
women who suffer with osteoporosis, other causes include scurvy (Gunn, C. (2018).). Osteoporosis is also more likely to occur after a
fracture due to long term immobilisation, however, when mobility is regained
cell activity increases and the bone will return to normal (Gunn, C. (2018). ). Osteoporosis is diagnosable on x-ray
as affected bone appears radiolucent meaning that the bone appears more
transparent to X-rays. The primary trabecular pattern may also appear more
prominent (Fan, Y., & Peh, W. (2016).).

However, a Danish study found the strong correlation
between osteoporotic bones and the Colles fracture to be lacking. It stated
that “other factors were of equal or even greater importance.” (Hinds, K., &
Lauritzen, J. B. (2001).)

 

A Colles fracture is defined as transverse fracture,
classically within 2cm of the

articular surface of the radius with posterior and lateral displacement
of the distal fragment Often associated with a fracture of the ulna styloid, it
is not the only fracture that can be caused by a fall on outstretched hand. (Holmes
& Misra, 2004).

 

There is well
documented evidence of damage to the vascular and median nerve by compression
as a result of a distal radius fracture. Compression of the median nerve causes
Carpal tunnel syndrome (CTS). CTS is common condition that causes pain,
numbness, muscle weakness and pins and needles. (Ledford, M. (2014).

The pronator
quadratus fat pad can normally be seen as a thin radiolucent triangle on a
lateral wrist x-ray. It

 can become elevated secondary to an effusion, displaced, or obliterated by trauma. It is an
indirect sign of distal forearm trauma such as a Colles fracture. This sign can
also be indicative of other pathologies that can cause this including muscle
strain, inflammatory arthritides, local
infections, localised inflammations and severe soft-tissue injuries. (Fallahi,
F., Jafari, H., Jefferson, G., Jennings, P., & Read, R. (2013))

 

Fracture and bone healing

“Fracture healing is a complex biological process that
follows specific regenerative patterns and involves changes in the expression
of several thousand genes.” (Marsell, R., & Einhorn, T. A. (2011).)

According to Gunn, C. (2018) the stages of indirect fracture healing are:

1.   
A
blood clot is formed due to damage blood vessels, medulla, cortex and
periosteum because of this the clot is formed by cells from both peripheral and
intramedullary blood, as well as bone marrow cells.

2.   
The
injury causes an inflammatory response. This causes the hematoma to coagulate
in between and around the fracture ends, and within the medulla forming a
template for callus formation.

3.   
Within
24 hours the hæmatoma is converted into vascular fibroblastic granulation
tissue

4.   
Approx.
7 days osteoblasts lay down osteoid tissue creating irregular new bone called
provisional callus

5.   
This
is then converted into new bone containing the harversian systems

6.   
After a period, the bone is moulded back
into its original shape by osteoblasts and osteoclasts.

 

In greater
detail an article by Marsell, R., & Einhorn, T. A. (2011). talks of two possible pathways of
fracture healing.

1.    primary or direct healing by internal
remodelling;

2.    secondary or indirect healing by
callus formation.

 

Treatment of
distal radius fractures can occur in a number of ways. Depending on the severity
of the fracture treatment can be conservatively managed, this means that the
fracture will be treated by closed reduction and immobilization by casting.
However, complications that can occur with this method include fracture
collapse.

In recent
years, the use
of non-conservative methods
of treatment have
been on the
rise. These include
open reduction with internal fixation (ORIF), percutaneous pinning, external fixation. (Blakeney, W. G. (2010))

 

In the long
term, the patient will receive a referral to a physiotherapist. This should
help the patient regain their full range of motion and build up the muscle.

Optimisation of exam Standard
radiographic technique in relation to Patient centred care

Anterior
posterior (AP) and lateral views are the essential standard radiographic
projections associated with the wrist. Other views of the wrist include ulnar
deviation and the Zitters/Banana view. These are asked for when a scaphoid
injury is suspected due to tenderness in the anatomical snuffbox. (Lloyd-Jones, G. (2007)). Images of the wrist need to include the medial and lateral
skin borders along with the proximal two-thirds of the metacarpals and the
distal third of the radius and ulnar. (Whitley, S. A., Anderson, C.,
Sloane, C., Holmes, K., & Jefferson, G. (2017).)

 

The image is
taken with a Source Image Distance (SID) of 100cm with no angulation. The
patient is seated sideways at the table with the wrist rested on the x-ray detector
palmer surface down, this is best if the elbow is bent at roughly 90degrees. For
patients this is an easier exam as the movement required of them is minimal.
For patients in a lot of pain they may be reluctant to rest the wrist down
however with encouragement, clear communication and empathy it is often easier
to position the patient correctly. To ensure correct positioning the
radiographer can make sure by feeling the wrist and making sure that the radial
and ulnar styloid are equidistant to the detector. (Whitley,
S. A., Anderson, C., Sloane, C., Holmes, K., & Jefferson, G. (2017))

 

To get the best
AP image it is common for radiographers to position the patient with the
fingers folded under the hand. This often brings the wrist closer to the
detector, this is good because it reduces magnification. However, this step is
not essential and if the patient is in a lot of pain the simpler the
instruction the better. By adapting technique, the radiographer is showing
compassion as an effort to cause the least pain whilst also getting a
diagnostic image.

 

The standard
kVp and mAs for these images will be different on different machines.

Depending on
the size or age of the person this may be adjusted. For example, a larger kVp
may be needed if the patient is bariatric. However, the dose given should
always be as low as reasonably allowable (ALARA). The entrance skin dose should
be around 0.072mGy. (Whitley, S. A., Anderson, C., Sloane, C., Holmes,
K., & Jefferson, G. (2017). )
By using the ALARA principle the radiographer is showing patient centred care
as it is what is best for the patient.  (Reynolds,
A .(2009).).

 

 

A lateral wrist
provides the essential second view. It is very useful as it helps the
displacement and degree of angulation be assessed when a fracture is present. Depending
on the fracture sometimes it can be very difficult or impossible to see just on
the AP image. The lateral x-ray is taken as before but with the wrist rotated
outwards until the fat pads of the palm overlap. This should ensure that the
styloids are superimposed.

 

Evaluation of Image

Many
of the radiographers that I have come into contact with on my first placement
have their own ways of evaluating images.

The
set-out procedure I have been taught to use is called the “10 Point Checklist”.
It covers from the start to the end of the exam.

 

The
1st point “ID” ensures that the correct X-ray is performed on the
correct patient. This step also includes making sure that the date given on the
request card is accurate and that the X-ray is justified. For example – who has
signed the request and are they qualified to do so?

The
2nd point is to ensure a primary marker is in place and to ensure
that the image is labelled correctly. Ensuring no confusion later in the
patient’s path. For example, if a knee x-ray is taken weight bearing this needs
to be labelled as it could lead to an incorrect diagnosis.

Collimation
and the correct projections ensure that the images taken demonstrate any
pathology.  Errors/artefacts that would
be appropriate to a wrist x-ray would include the patient keeping a bracelet or
watch on. These 2 things are the last thing to check before setting the
exposure and taking the x-ray. Ensuring that the tube is positioned correctly,
and the correct wrist is being examined.

Exposure
needs to be correct to ensure that the image taken will be of diagnostic
quality. Often the exposure is pre-set when a body part is selected.

 

For
the 9th point on the checklist “Pathology” there are multiple things
to consider. A doctor will consider both clinical and radiological features to
diagnose from wrist x rays.

The
Colles fractures most obvious clinical feature is the ‘dinner fork’ deformity
however pain with marked swelling and bruising is also expected. (Holmes &
Misra ,2004)

To
confirm the physician’s differential diagnosis radiologically, there are 5
common signs the evaluator is looking for: (Holmes & Misra ,2004)

1.    Dorsal displacement of the distal
fracture fragment

2.    Radial tilt of the distal fragment

3.    Dorsal angulation with the loss of the
(5-10 degree) volar tilt of the articular surface of the radius

4.    Impaction of the fracture site.

5.    Radial displacement of the distal fragment.

 

A
Colles’ fracture can present in many ways therefore a number of classification
systems have been developed to assist with proper evaluation. Using a
classification system also helps is making decisions regarding whether
conservative treatment or surgical treatment is more beneficial for each
patient. (Tracy, M (n.d.))

Bibliography
3D – muscles of the antebrachial
region  Retrieved from http://www.anatomyexpert.com/app/structure/15323/184/
Blakeney, W. G. (2010). Stabilization and
treatment of Colles’ fractures in elderly patients. Clinical
Interventions in Aging, 5, 337–344. http://doi.org/10.2147/CIA.S10042
 
Chen,
C.-E., Juhn, R.-J., & Ko, J.-Y. (2008). Treatment of Distal Radius
Fractures with Percutaneous Pinning and Pin-in-plaster. Hand (New York, N.Y.), 3(3), 245–250. http://doi.org/10.1007/s11552-008-9093-3
 
Chung, K. C., & Mathews, A. L. (2015).
Management of Complications of Distal Radius Fractures. Hand Clinics, 31(2),
205–215. http://doi.org/10.1016/j.hcl.2014.12.002
 
Colles’
fracture. (2017). Retrieved from https://en.wikipedia.org/wiki/Colles%27_fracture
Colles fracture.(2017) Retrieved from https://netterimages.com/images/vpv/000/000/039/39872-0550×0475.jpg
 
Dinner fork deformity. (2006). Retrieved from https://www.pinterest.co.uk/pin/132785888985741118/
Ellipsoidal joint. (n.d.) Retrieved from https://www.biology-online.org/dictionary/Ellipsoidal_joint

 
Ellis, H. (2012). Abraham colles: Colles’
fracture. Journal of Perioperative Practice, 22(8), 270-271.
Retrieved from http://search.ebscohost.com/login.aspx?direct=true=ccm=108145083=ehost-live
 
Fallahi, F., Jafari, H., Jefferson, G., Jennings, P., &
Read, R. (2013). Explorative study of the sensitivity and specificity of the
pronator quadratus fat pad sign as a predictor of subtle wrist fractures.
Skeletal Radiology, 42(2), 249–253. http://doi.org/10.1007/s00256-012-1451-0
Fan, Y., & Peh, W. (2016). Radiology of osteoporosis: Old
and new findings. Seminars in Musculoskeletal Radiology, 20(3), 235-245.
doi:10.1055/s-0036-1592371
Forearm exercise – wrist curls. (2013). Retrieved from https://noexcuseshealth.wordpress.com/2013/03/13/forearm-exercise-wrist-curls/
Fuller, M. (2013). Wrist radiographic anatomy. Retrieved from http://www.wikiradiography.net/page/Wrist+Radiographic+Anatomy
Gunn, C. (2018). Bones and joints (7th
ed.) elsevier.
 
Harcus,J.
(2017). Introdution to Image
interpretation ppt. Retrieved from https://shuspace.shu.ac.uk/webapps/blackboard/content/listContent.jsp?course_id=_307821_1=_7057916_1

 
Hinds?, K.,
& Lauritzen, J. B. (2001). Osteoporosis and colles’ fracture. Ugeskrift
for Laeger, 163(40), 5503.
 
Holmes, E. J., & Misra, R. R.
(2004). A-Z of emergency radiology. Cambridge: Cambridge
University Press. Retrieved from http://lib.myilibrary.com?ID=56760
 
 
Joints and their function. (2014). Retrieved from http://www.bbc.co.uk/schools/gcsebitesize/pe/appliedanatomy/2_anatomy_skeleton_rev3.shtml
Jones, O.(2017). The wrist joint. Retrieved
from http://teachmeanatomy.info/upper-limb/joints/wrist-joint/
Ledford, M. (2014). Carpal tunnel syndrome.
Lloyd-Jones, G. (2007). Trauma X-ray – upper
limb
wrist X-ray. Retrieved from https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_upper_limb/wrist_trauma_x-ray
 
Luijkx, T. Desai, P.K. et al. Radiopeadia colles& nbsp;
Retrieved from https://radiopaedia.org/articles/colles-fracture
 
Marsell, R., & Einhorn, T. A. (2011). THE BIOLOGY OF
FRACTURE HEALING. Injury, 42(6), 551–555. http://doi.org/10.1016/j.injury.2011.03.031
Matthias, R., & Wright, T. W. (2016).
Interosseous Membrane of the Forearm. Journal of Wrist Surgery, 5(3),
188–193. http://doi.org/10.1055/s-0036-1584326
Reynolds, A .(2009). Patient-centered care. Radiologic
Technology, 81(2), 133. Retrieved from http://www.radiologictechnology.org/content/81/2/133.abstract
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Tracy, M.Colles fracture.(n.d.) Retrieved
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ed.). London: CRC Press.                                                                                                                                                                                                               
 

Appendix

There
are three commonly used classification systems.

·        
Frykman’s(1967)

·        
Fernandez(2001)

·        
Universal
(Cooney 1993).