Trauma

Wrist injury after fall — suspected distal radius fracture

Intermediate

Elderly · 74yr · female

Patient Information

Dispatch	You are called to a 74-year-old female (Dorothy Flanagan) at a community fair who has fallen on the footpath near the entrance and is sitting on the ground cradling her right arm. Bystanders report she tripped on an uneven paving slab.
Patient	Dorothy Flanagan — 74yr (61kg)
Incident History	Patient tripped on an uneven paving slab and fell forward, instinctively putting out her right hand to break the fall (FOOSH mechanism). Immediate onset of severe right wrist pain and visible deformity. No head impact. No loss of consciousness. Right-hand dominant. Denies neck or back pain.
Emergency Contact	Robert Flanagan (Son) — 0412 741 863

Initial Rapid Assessment

Response	Alert
Airway	Patent. Speaking in full sentences.
Breathing	Comfortable. RR 16. No respiratory distress.
Circulation	Left radial pulse strong and regular. Right radial pulse present but weaker than left — assess carefully. Skin warm and dry. CRT <2s. Swelling and bruising developing rapidly around right wrist.
Disability	GCS 15 (E4V5M6). Alert, orientated, in significant pain. Protective of right arm.
Exposure	Right wrist — visible 'dinner fork' deformity (dorsal displacement of the distal fragment). Swelling present. Overlying skin intact — no open fracture. Point tenderness over the distal radius. No finger deformity.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	16	88	158/92	<2s	15	4 4 ++	36.8	–	8
15 mins	97% (RA)	Nil	14	80	146/88	<2s	15	4 4 ++	36.8	–	5

History Taking

Treatment Response

Diagnosis

Suspected Colles (distal radius) fracture of the right wrist from a FOOSH (fall on outstretched hand) mechanism. Characteristic 'dinner fork' deformity visible — dorsal displacement of the distal fragment. Complicated by osteoporosis (increased fracture risk and potentially comminuted pattern) and Warfarin anticoagulation (increased haematoma risk around the fracture site — swelling may develop rapidly). Median nerve is transiently irritated (tingling on movement) but intact at rest. The right radial pulse is present but slightly weaker than left — likely due to swelling. Neurovascular status is the critical assessment. Do NOT attempt to realign the fracture. Requires CSP support for transport to ED for X-ray, reduction, and immobilisation.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not assess the right radial pulse before splinting — prompt: 'Before you immobilise the wrist, what vascular check is needed?' Facilitator note: the right radial pulse is present but slightly weaker — this must be documented before and after splinting. Absent pulse post-splint requires immediate loosening.)
! (If trainees do not assess sensation in the right hand — prompt: 'The median nerve runs through the carpal tunnel at the wrist — what should you check?' Expected: assess light touch on the palmar surface of the thumb, index, and middle fingers. Tingling on movement is present but sensation is intact at rest.)
! (If a trainee attempts to reduce (straighten) the deformity — patient cries out in pain. Facilitator note: fracture reduction is not within EHS scope. Immobilise in the position found — do NOT attempt realignment.)
! (If trainees do not offer analgesia before splinting — patient becomes increasingly distressed as swelling increases. Prompt: 'She is in significant pain — is there anything you can offer before immobilising the wrist?' Facilitator note: Methoxyflurane is appropriate here and will improve patient cooperation with splinting.)
! (If trainees do not note the Warfarin — prompt after reviewing medications: 'She is on Warfarin with an INR of 2.4 last week — does that change your assessment or management?' Facilitator note: Warfarin increases the risk of significant haematoma around the fracture. Swelling may be greater than expected and requires closer monitoring.)

Treatment Objectives

1. Ensure scene safety — assess paving area for further trip hazards; request the venue address the uneven surface.
2. Don appropriate PPE.
3. Perform Primary Survey — confirm no life-threatening injuries from the fall; assess for any other injury sustained (no head impact, no spinal tenderness).
4. Obtain history — confirm FOOSH mechanism, medications (Warfarin — note anticoagulation), osteoporosis, assess for any other fall-related injury.
5. Inspect the right wrist — note 'dinner fork' deformity, swelling, bruising, and intact overlying skin (closed fracture).
6. Assess neurovascular status of the right hand BEFORE immobilisation:
7. — Radial pulse: present but slightly weaker than left — document and monitor.
8. — Capillary refill: fingers — confirm <2 seconds.
9. — Sensation: light touch to palmar surface of thumb, index, and middle finger (median nerve). Document result.
10. — Motor: ask patient to gently wiggle fingers if tolerated. Document.
11. Offer Methoxyflurane (Penthrox) for pain management prior to splinting — self-administered by patient.
12. Immobilise the wrist in the position of comfort — do NOT attempt to correct or straighten the deformity. Use a padded board splint or SAM splint with a sling. Apply padding around any bony prominences.
13. Reassess neurovascular status AFTER splinting — confirm radial pulse still palpable and sensation unchanged.
14. Complete Vital Sign Survey — note BP elevated at 158/92, likely pain-related; known hypertension. Repeat post-analgesia.
15. Contact CSP — this patient requires ambulance transport to an Emergency Department for X-ray, formal reduction, and plaster immobilisation.
16. Advise patient and son — document Warfarin use in handover notes; swelling may be significant given anticoagulation.
17. Keep patient warm — elderly patient on the ground is at risk of hypothermia.
18. Scenario ends on CSP arrival and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Musculoskeletal Injuries · Methoxyflurane · Primary Survey · Secondary & CNS Survey · Pain Assessment · Blood Pressure

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Signs/Symptoms	Severe right wrist pain with visible deformity. Rapid swelling and bruising. Right hand fingers can be moved but movement is painful. No numbness or tingling in the fingers at rest — slight tingling in the thumb and index finger on movement (median nerve irritation, resolves at rest).
Allergies	NKDA.
Medications	Warfarin (AF — INR target 2.0–3.0, last INR check one week ago was 2.4). Amlodipine 5mg (hypertension). Calcium/Vitamin D supplement.
Pertinent History	Known AF — on Warfarin. Known osteoporosis — diagnosed 6 years ago; on Calcium/Vitamin D supplementation. Hypertension — well-controlled on Amlodipine. No prior fractures. Lives independently at home. Non-smoker.
Last Oral Intake	Morning tea approximately 2 hours ago.
Events Leading	Patient was attending the community fair with a friend. Tripped on a raised paving slab near the entrance gate. Fell forward and landed on her outstretched right palm. Bystanders assisted her to a sitting position.
Treatment Prior	Bystanders helped her sit down and supported her arm. No analgesia taken.

Onset	Immediate — at the moment of the fall.
Pain	Severe, constant wrist pain.
Quality	Severe, throbbing aching pain over the wrist and distal forearm. Worse with any movement of the wrist or fingers.
Radiates	Pain radiates up the forearm to the elbow. No shoulder or neck pain.
Severity	8/10 at rest. 10/10 with movement.