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 _______________                                                                                                                                                   IntroductionInthis assignment, I will examine the Colles’ fracture, a distal radius fracturenamed after Irish surgeon AbrahamColles who was the first to correctly describe the fracture in a paper hepublished in the Edinburgh Medical &Surgical Journal 1814 (Ellis,H.

(2012).). He described the fracture to be ‘… of the carpalextremity 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 theright, is the reason that the fracture is also known as the dinner forkfracture/deformity.

 I chose this fracture due to its highfrequency 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& PhysiologyNormalThe wrist is comprisedof a sophisticated system made from many bones,joints, muscles and ligaments. In addition, there is a complex neurovascularsystem that supplies the area with blood.Figure 1 on theleft shows a labelled x-ray taken of a normal wrist.

The wrist contains 8Carpal bones which are held together by interosseous ligaments. (Gunn, C. (2018).

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)Other relevantanatomy includes nerves of the wrist as these can be damaged by trauma. Thereare three nerves in the wrist.·        Radial·        Ulnar·        MedianThesenerves provide motor innervation which allows movement of the hand, fingers andwrist. The nerves carry the impulse stimulating the contraction of muscle. Thenerves also allow sensory information such as touch, pain and temperature toreach the brain. (Toole,G.

, & Toole, S. (2015).) According to BBCBitesize (2014) a joint is formed where two or more bones meet; they aredivided into three categories: ·        Synovial·        Cartilaginous·        FibrousThewrist is also known as the radiocarpal joint; it is comprised distally of theproximal row of the carpal bones bar the pisiform (scaphoid, lunate,triquetrum), proximally it is comprised of the distal end of the radius and notthe ulnar. Itis an ellipsoid synovial joint, this means that there is. an oval shaped articular surface thatcorresponds 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. Allsynovial joints are double layered.The carpal bones together form a surfacethat articulates with the surface of the radius.

These articulate with anarticular disk which covers the boney surfaces. (Gunn,C. (2018).) There are many ligaments in the wrist, threeof which are seen in the figure 4. The Palmar radiocarpal and Dorsalradiocarpal increase joint stability, ensuring that the hand follows theforearm in rotation. The Palmar ulnocarpal ligament limits the extension of thewrist by attaching the styloid process of theulna 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 collateralligaments work together to prevent excessive lateral joint displacement.

         Abnormal TheColles’ 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, thepresence of this fracture can indicate underlying pathology such asosteoporotic bones. (Luijkx, T.

Desai, P.K. et al.(n.d.)) For this reason, the Colles’ Fracture iscommonly associated with older women.

Bone density often decreases as a part ofthe normal aging process (Gunn, C. (2018).) it also makes the fracture more likelyto displace (Blakeney, W. G. (2010).

) The loss in bone density as a result of osteoporosis is causedby the rate of bone formation decreasing as the resorption of bone mineralstays the same. Over time this causes the bones to weaken. It is not just olderwomen who suffer with osteoporosis, other causes include scurvy (Gunn, C. (2018).). Osteoporosis is also more likely to occur after afracture due to long term immobilisation, however, when mobility is regainedcell activity increases and the bone will return to normal (Gunn, C.

(2018). ). Osteoporosis is diagnosable on x-rayas affected bone appears radiolucent meaning that the bone appears moretransparent to X-rays. The primary trabecular pattern may also appear moreprominent (Fan, Y., & Peh, W. (2016).).

However, a Danish study found the strong correlationbetween osteoporotic bones and the Colles fracture to be lacking. It statedthat “other factors were of equal or even greater importance.” (Hinds, K., , 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 displacementof the distal fragment Often associated with a fracture of the ulna styloid, itis not the only fracture that can be caused by a fall on outstretched hand. (Holmes& Misra, 2004). There is welldocumented evidence of damage to the vascular and median nerve by compressionas a result of a distal radius fracture. Compression of the median nerve causesCarpal tunnel syndrome (CTS). CTS is common condition that causes pain,numbness, muscle weakness and pins and needles.

(Ledford, M. (2014).The pronatorquadratus fat pad can normally be seen as a thin radiolucent triangle on alateral wrist x-ray. It can become elevated secondary to an effusion, displaced, or obliterated by trauma. It is anindirect sign of distal forearm trauma such as a Colles fracture. This sign canalso be indicative of other pathologies that can cause this including musclestrain, inflammatory arthritides, localinfections, 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 thatfollows specific regenerative patterns and involves changes in the expressionof several thousand genes.” (Marsell, R., & Einhorn, T.

A. (2011).)According to Gunn, C. (2018) the stages of indirect fracture healing are:1.   Ablood clot is formed due to damage blood vessels, medulla, cortex andperiosteum because of this the clot is formed by cells from both peripheral andintramedullary blood, as well as bone marrow cells.

2.   Theinjury causes an inflammatory response. This causes the hematoma to coagulatein between and around the fracture ends, and within the medulla forming atemplate for callus formation.3.   Within24 hours the hæmatoma is converted into vascular fibroblastic granulationtissue4.   Approx.7 days osteoblasts lay down osteoid tissue creating irregular new bone calledprovisional callus5.

   Thisis then converted into new bone containing the harversian systems6.   After a period, the bone is moulded backinto its original shape by osteoblasts and osteoclasts. In greaterdetail an article by Marsell, R., & Einhorn, T. A. (2011). talks of two possible pathways offracture healing.

1.    primary or direct healing by internalremodelling; 2.    secondary or indirect healing bycallus formation.  Treatment ofdistal radius fractures can occur in a number of ways. Depending on the severityof the fracture treatment can be conservatively managed, this means that thefracture will be treated by closed reduction and immobilization by casting.However, complications that can occur with this method include fracturecollapse.In recentyears, the useof non-conservative methodsof treatment havebeen on therise.

These includeopen reduction with internal fixation (ORIF), percutaneous pinning, external fixation. (Blakeney, W. G. (2010)) In the longterm, the patient will receive a referral to a physiotherapist. This shouldhelp the patient regain their full range of motion and build up the muscle.Optimisation of exam Standardradiographic technique in relation to Patient centred careAnteriorposterior (AP) and lateral views are the essential standard radiographicprojections associated with the wrist. Other views of the wrist include ulnardeviation and the Zitters/Banana view.

These are asked for when a scaphoidinjury is suspected due to tenderness in the anatomical snuffbox. (Lloyd-Jones, G. (2007)). Images of the wrist need to include the medial and lateralskin borders along with the proximal two-thirds of the metacarpals and thedistal third of the radius and ulnar.

(Whitley, S. A., Anderson, C.,Sloane, C., Holmes, K., & Jefferson, G. (2017).) The image istaken with a Source Image Distance (SID) of 100cm with no angulation.

Thepatient is seated sideways at the table with the wrist rested on the x-ray detectorpalmer surface down, this is best if the elbow is bent at roughly 90degrees. Forpatients 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 downhowever with encouragement, clear communication and empathy it is often easierto position the patient correctly.

To ensure correct positioning theradiographer can make sure by feeling the wrist and making sure that the radialand ulnar styloid are equidistant to the detector. (Whitley,S. A.

, Anderson, C., Sloane, C., Holmes, K., & Jefferson, G. (2017)) To get the bestAP image it is common for radiographers to position the patient with thefingers folded under the hand.

This often brings the wrist closer to thedetector, this is good because it reduces magnification. However, this step isnot essential and if the patient is in a lot of pain the simpler theinstruction the better. By adapting technique, the radiographer is showingcompassion as an effort to cause the least pain whilst also getting adiagnostic image. The standardkVp and mAs for these images will be different on different machines.Depending onthe size or age of the person this may be adjusted. For example, a larger kVpmay be needed if the patient is bariatric. However, the dose given shouldalways be as low as reasonably allowable (ALARA).

The entrance skin dose shouldbe 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 careas it is what is best for the patient.

  (Reynolds,A .(2009).).

  A lateral wristprovides the essential second view. It is very useful as it helps thedisplacement and degree of angulation be assessed when a fracture is present. Dependingon the fracture sometimes it can be very difficult or impossible to see just onthe AP image. The lateral x-ray is taken as before but with the wrist rotatedoutwards until the fat pads of the palm overlap. This should ensure that thestyloids are superimposed. Evaluation of ImageManyof the radiographers that I have come into contact with on my first placementhave their own ways of evaluating images.

Theset-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.  The1st point “ID” ensures that the correct X-ray is performed on thecorrect patient. This step also includes making sure that the date given on therequest card is accurate and that the X-ray is justified. For example – who hassigned the request and are they qualified to do so?The2nd point is to ensure a primary marker is in place and to ensurethat the image is labelled correctly.

Ensuring no confusion later in thepatient’s path. For example, if a knee x-ray is taken weight bearing this needsto be labelled as it could lead to an incorrect diagnosis.Collimationand the correct projections ensure that the images taken demonstrate anypathology.

  Errors/artefacts that wouldbe appropriate to a wrist x-ray would include the patient keeping a bracelet orwatch on. These 2 things are the last thing to check before setting theexposure and taking the x-ray. Ensuring that the tube is positioned correctly,and the correct wrist is being examined.

Exposureneeds to be correct to ensure that the image taken will be of diagnosticquality. Often the exposure is pre-set when a body part is selected. Forthe 9th point on the checklist “Pathology” there are multiple thingsto consider. A doctor will consider both clinical and radiological features todiagnose from wrist x rays. TheColles fractures most obvious clinical feature is the ‘dinner fork’ deformityhowever pain with marked swelling and bruising is also expected. (Holmes &Misra ,2004)Toconfirm the physician’s differential diagnosis radiologically, there are 5common signs the evaluator is looking for: (Holmes & Misra ,2004)1.    Dorsal displacement of the distalfracture 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. AColles’ fracture can present in many ways therefore a number of classificationsystems have been developed to assist with proper evaluation.

Using aclassification system also helps is making decisions regarding whetherconservative treatment or surgical treatment is more beneficial for eachpatient. (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.

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                                                                                                                                                                                                                AppendixThereare three commonly used classification systems.·        Frykman’s(1967) ·        Fernandez(2001)·        Universal(Cooney 1993).