In this paper I will be discussing Colles' fracture and describing in detail the X-ray procedure for the patient in the scenario, I will go on to outline the role of the radiographer in patient management and in the understanding and application of the radiographic process.
In addition, I will relate the principles of patient centred care to radiographic procedures, taking account of understanding the behavioural aspects of the examination. This will discuss the emotions and possible feelings the patient may be experiencing and how this could affect their performance during examination.
PATHOPHYSIOLOGY
Overview
According to Begg James (2005), Colles' fracture is the most occurring type of wrist fracture and was first described by Abraham Colles in 1814; hence it was named after him. Simply put, it is the fracture of the distal radius with dorsal and lateral angulations of the lower radial fragment resulting in rotational deformity often referred to as 'dinner fork deformity' because the lateral view of the wrist is comparable to the shape of a fork. Also, rupture of the ulnar collateral ligament or fracture of the ulnar styloid is naturally associated with Colles' fracture (Begg James, 2005). The fracture is most common in postmenopausal women with osteoporosis being the leading risk factor.
Mechanism of injury
Knowledge of mechanism of the injury is useful as it helps the radiographer to look for a certain type of fracture and associated fractures and enables him describe the fracture with greater accuracy (Culmer P, 1995). Colles' fracture is usually secondary to a FOOSH with a pronated forearm in dorsiflexion (backward and outward displacement of hand). Due to impact of the fall and body weight on the arm the proximal row of the carpus transfer energy to the distal radius in the dorsal direction and along the axis of the radius, thus, resulting in the radius tilting backwards- dorsal angulation (Deakin, 2010).
Signs and symptoms
These may include bruising, limited mobility, numbness in fingers, highly sensitive area and severe pain, deformed swollen wrist which appears out of line, loss of function and so on (Molloy Deirdre, 2011).
NORMAL AND ABNORMAL APPEARANCES
In order to understand problems we first have to know what is normal, hence knowledge of the normal radiographic appearance of the wrist bones is needed to identify any abnormal form and Colles' fracture.
http://www.imageinterpretation.co.uk/images/wrist/NORMAL%20WRIST.jpg Fig 1: normal PA and lateral wrist.
Distal radius fractures are classified depending on the direction of the displacement of the distal fragment. Colles' fracture describes the posterior displacement of the distal fragment. Smiths' fracture is very similar but instead it describes the anterior displacement of the distal fragment (Deakin, 2010).
On the normal PA view in Fig 1, the distal articular surface of the radius has a natural palmar tilt of about 17 degrees towards the ulna. Also, the radius articulates medially with the head of ulnar notch and the head of ulna slightly overlaps the radius at the distal radioulnar joint because the head of ulna is approximately 2mm shorter than the radius. In addition the intercarpal joint spaces have uniform width of about 2mm and a total number of three carpal arcs should be identified with no break or uneven disruption of these lines (Nunn Heidi, 2009 and Wheeless R. Clifford, 2012). These three carpal arcs include:
At the proximal aspect; along the proximal row of carpal bones (yellow line)
At the distal aspect; along the distal row of carpal bones (red line)
Proximally along the capitate and hamate (blue line)
(Pls see Fig 2 below)
C:\Users\Otonye\Downloads\NORMAL WRIST AP PA.jpg
Fig 2: showing the three carpal arcs that should be traced on a normal PA wrist.
On the normal lateral view from Fig 1, the distal articular surface is angled anteriorly at 10-15 degrees with articular surfaces of distal radius, lunate and capitate congruent or parallel in a straight line, this can be visualised as an apple (capitate) sitting in a cup (lunate) on a saucer (radius). Also, the dorsal aspect of the distal radius is completely smooth with no irregularities or crinkles, also the lateral soft tissue borders are smooth with no signs of swelling.
C:\Users\Otonye\Downloads\NORMAL WRIST lateral.jpg
Fig 3: illustrates the parallel alignment of the radius, lunate and capitate on a normal lateral right wrist view.
In contrast, Colles' fracture may be seen as a transverse lucent or sclerotic distal radius fracture line, if it is an impacted undisplaced fracture the line is lucent (dark) but if displaced it appears sclerotic (white), also fracture is often comminuted ( Begg James, 2005).
From Fig 4 below, the lateral view shows the fracture as a step in radial articular surface and dorsal displacement of the distal radial fracture fragment. This causes loss of normal palmar tilt of the radial articular surface and shortening of the radius, hence the radial articular surface, lunate and capitate no longer articulate parallel, and intercarpal joint spaces may also appear disorientated and out of place.
The fracture can also be seen within 2.5cm of the wrist on the PA view with radial tilt of the distal fragment with impactation and shortening of the radius in relation to the ulna caused by comminution. The natural palmar tilt is also flattened out and there is evident crinkle and irregularity of the cortex at distal radius. This dorsal tilt and loss of radial inclination coupled with shortening of the radius leads to angularly deformity of the distal radius (Nunn Heidi, 2009 and Wheeless R. Clifford, 2012).
Swelling is also evident around the soft tissue borders of the wrist.
http://www.imageinterpretation.co.uk/images/wrist/COLLES.jpg
Fig 4: Colles' fracture AP and Lateral views
RADIOGRAPHIC TECHNIQUE
Before performance of the projections, the radiographer may begin assessment even before seeing the patient, for instance by looking at the information on the request card the radiographer can assess her clinical history and other relevant information so he can be aware of her capabilities (Culmer, 1995).
Pathology that demonstrates fractures of the distal radius require two basic positions, these include: Postero-anterior (PA) also referred to as dorso-palmar (DP) and lateral projections (Sloane Charles et al, 2010), however some hospitals/trusts perform PA oblique view for trauma patients as this forms part of their local rules.
Based on the assessment of the patient's condition, the radiographer is able to organise the projections in order of priority with the DP projection to be performed first as it is much easier than the lateral, this way it is easier to ensure the patient co-operates for the more difficult lateral projection. Also the radiographer should aim to ensure that minimum amount of movement is required on the patient's part (Culmer, 1995).
Postero-anterior (PA) projection
Patient positioning
This wrist projection is useful to demonstrate comminuted articular fracture of distal radius with ulna shift relative to the radius. To assume this position, the patient seats at the end of the table with the affected side nearest to the table. The elbow joint is flexed about 90o and the arm is abducted so that the palm of the hand and wrist rests on the cassette. The radiographer should ensure shoulder joint is at the same height as forearm if the patient's mobility permits but shoulder, elbow and wrist not on same horizontal plane. The wrist joint is placed central to the cassette and adjusted so that the distal radius, ulna and proximal two-thirds of the metacarpals are included. The wrist joint is moved such that radial and ulnar styloid processes are equidistant from the cassette and a sand bag is used to keep the forearm in place (Bontrager, 2010 and Sloane Charles et al, 2010).
In addition, the radiographer must be considerate of the patient's condition at all times while performing the examination and should be ready to modify the sequence of the examination to adapt to any unplanned situation (Culmer, 1995). For instance, if the patient is unable to keep her wrist straight and central on the cassette the radiographer can use a radiolucent wedge block to support her arm on each side and place a sand bag on her elbow region to keep her arm in place.
An alternative AP wrist may also be taken if patient is unable to assume the PA position (Bontrager Kenneth, 2010)
Centring of X-ray beam
With hand pronated, hand should be slightly arched; this places carpal area and wrist in close contact with cassette, the vertical Central ray (CR) should be perpendicular to image ray (IR) and directed midway between the radial and ulnar styloid processes with minimum focus film distance (FFD) of 100cm. Also, collimate to wrist on all four sides to include the distal radius, ulna and mid carpal area (Sloane Charles et al, 2010).
PA Oblique projection
Patient positioning
From pronated position as in the PA projection, wrist and hand should be rotated laterally 45o and a 45o wedge block placed under thumb side of hand to support wrist at that oblique position, alternatively, the fingers can be partially flexed so fingertips rest slightly on cassette and the hand is arched. With this projection, the scaphoid and trapezium are well visualized (Sloane Charles et al, 2010).
Lateral projection
Patient positioning
Lateral radiograph often demonstrates a distal radius fracture with displaced fracture fragments angled dorsally. It involves the patient seated at the end of the table with affected side nearest to table. The elbow should be extended to include distal radius, ulna and proximal two-thirds of metacarpals on the cassette. The hand is then slightly rotated externally to superimpose the radial and ulna styloid processes. The forearm can be immobilized using a sandbag (Sloane Charles et al, 2010).
However, if she is unable to rotate hand for a lateral projection, the use of a horizontal beam centred to the radial styloid process while supporting her wrist on a radiolucent block and placing the cassette on the ulnar aspect of the wrist will be effective as an adaptive technique.
Centring of X-ray beam
With CR perpendicular to IR, direct to midcarpal area over the styloid process of the radius.
OPTIMIZATION OF IMAGE QUALITY
To optimize image quality, knowledge and correct use of appropriate exposure factors is vital, the correct exposure factors should be set following the preparation for the examination and in accordance to the set local rules, for instance 60kvp/2mAs for DP projection and 63kvp/2mAs for lateral projection ensures the initial images are appropriate enough so that more views are not required hence prevent exposing patient to more radiation. High mAs and low kV will produce a short grey scale and good bone/soft tissue contrast (Ball John et al, 2008 and Culmer, 1995).
In addition, the radiographic contrast/density of image affects the ability to make any accurate diagnosis. There should not be so much blackening that it is impossible to see any detail within structures on images, instead structures should be well defined having more shades of grey. Different range of densities should be identified, for example, difference between soft tissue and bone. Therefore, the overall range of optical densities should lie between 0.5 and 2.2 (Ball John et al, 2008).
Also using an FFD of 100cm has a considerable impact on image quality, to improve the definition of fine structures this can be increased to 120cm.
Furthermore, from an experiment carried out during my clinical placement by one radiographer showed that by using the smallest size cassette (18x 24), the image produced is exact size to object, hence improves more detailed visualization.
Also, the film-object distance (FOD) should be kept as small as possible to minimise magnification and loss of detailed definition in the image.
IMAGE ASSESSMENT CRITERIA
Before the patient is sent away, the image has to be evaluated to determine if further examinations or repeats are required. If a repeat is required this could arouse the old lady's fear and anxiety as she may think an abnormality has been detected, hence, it is important the radiographer explain the reasons to relieve her fears (Culmer, 1995).
Correct patient name, date of birth and examination.
Correct marker should be in primary beam but away from the area of interest.
Correct area of interest from the proximal two-thirds of metacarpals to the distal radius and ulna, including the carpals and soft tissue borders.
Correct positioning should be evident, for instance;
True PA is evidenced by:
-equal concavity shapes on each side of shafts of the proximal metacarpals
-proximal metacarpals should have similar distances
-radius and ulna should be separated except for possible minimal superimposition at the distal radioulnar joint
- No rotation of the wrist
True lateral is evidenced by:
-Ulna head should be superimposed over distal radius
-proximal second to fifth metacarpals should all appear aligned and superimposed.
-No rotation of the wrist (Wikiradiography, 2010).
Correct exposure, optimal contrast and density and sharpness with no motion visualised, soft tissue and sharp bony margins of the carpals with clear trabecular markings.
There should be evidence of collimation around the area of interest to increase image quality and reduce radiation dose to patient.
Relevant anatomy should be visualised and the area of interest sufficiently penetrated.
Any evident pathology should be identified. The radiographer must look through four corners of the image to identify all pathologies.
Image should be free from artefacts which may obscure relevant details.
PATIENT MANAGEMENT
The patient who just suffered trauma often feel worried and depressed because of the thought that her hand may never function as before, this may also be coupled with a feeling of low self esteem due to loss of individuality. In addition, the pain from the injury as well as a feeling of not being in control of the situation may leave her totally overwhelmed and as she tries to adjust to the new changes she may feel like she has lost ability to cope with the emotions and ideas connected with the accident (Niven Neil, 2000). This may lead to a feeling of frustration and manifestation of anger as a result of having to cope with such a serious injury at her age. In some cases, this leaves her feeling agitated, moody, unhappy, short tempered and uncooperative during examination.
Again, since it is her first time at hospital the sight of the X-ray machine may make her feel nervous as she is not used to it nor fully understand its functions, she is unsure if the procedure will hurt or not and unaware of the result of the examination, this may leave her feeling anxious.
The radiographer must be aware of these feelings and emotions connected to illness and understand the impact the trauma has on the patient's development and physical wellbeing, it is important he shows empathy and try to share feelings with what the old lady is passing through whilst assuring her and calming her down to creating a more comfortable and pleasant environment, this helps to ease her discomfort and makes her more confident during examination. Furthermore, he must not overlook explaining all the procedures in terms she understands during the examination as this ensures patient gives informed consent, keep her aware of what is happening and also increases her confidence in the radiographers practice, thus establishing a relationship between her and the radiographer which ensures easier/faster positioning during examination (Culmer, 1995 and Gunn Christine et al, 1991).
In addition, radiographer should adopt effective non-verbal communication while communicating with the patient, for instance maintaining good eye contact and try to be at same eye level as patient, listening to patient and giving her enough time, facial expressions, good orientation, gestures and postures which relate to what he is saying to the patient, for example nodding and whilst reassuring patient shows interest. Also, radiographer should ensure he follows guidelines from the health bodies such as RIDDOR, and CQC to maintain good general hygiene and reduce risk of accidents before, during and after examination.
Finally, he must abide by code of professional conduct for radiographers, treat the old lady with courtesy and respect, refer to her by name, be polite, uphold confidentiality and not reveal patient's diagnosis. Finally, he must follow IRMER regulations to protect patient from ionising radiation (Gunn Christine et al, 1991).
CONCLUSION
In conclusion, for effective and appropriate diagnosis of Colles' fracture, full reference and understanding of the radiographic process is important for the examination and to ensure patient care and management is established.
