AMC Clinical Exam Station: The Throb of Danger

Station Title & Timing

  • Title: Acute Wrist Injury and Severe Pain
  • Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objectives

  • History & Examination: Identify a Colles fracture and recognize the clinical “red flags” for Acute Compartment Syndrome.
  • Clinical Reasoning: Differentiate between expected post-fracture pain and pain “out of proportion” to the injury.
  • Management: Demonstrate immediate emergency steps and prioritize urgent surgical referral.
  • Communication: Explain a surgical emergency and the need for fasciotomy to a distressed patient.

Patient Profile

  • Name: Mrs. Margaret Higgins
  • Age: 65 years old
  • Occupation: Retired Librarian
  • Relevant Social History: Lives alone in a two-story house; uses a walking stick occasionally for balance.

Presenting Complaint

Mrs. Higgins tripped over her rug and fell on her outstretched right hand two hours ago. She was brought to the ED, an X-ray was taken, and a temporary back-slab (splint) was applied. However, her pain is now rapidly worsening despite 5mg of IV Morphine given 20 minutes ago.

Contextual Information

  • HPC: Fell on outstretched hand (FOOSH). Distal radius deformity noted on arrival (“dinner fork”).
  • Past Medical History: Osteoporosis, Hypertension.
  • Medications: Amlodipine, Alendronate.
  • Allergies: Penicillin (Rash).

Exam Instructions

Candidate Instructions

You are the ED Registrar. Mrs. Higgins has a confirmed Colles fracture of the right wrist. A splint was applied by the junior resident. You have been called because she is distressed by worsening pain.

  1. Perform a focused assessment of the patient.
  2. Formulate a management plan.
  3. Explain the diagnosis and the required urgent steps to the patient.

Standardised Patient (SP) Instructions

  • Affect: You are very distressed. You are cradling your right arm. You must emphasize that the pain is “12 out of 10” and feels like “burning or bursting.”
  • Reaction to Examination: * If the candidate tries to move your fingers back (passive stretch), cry out in severe pain.
    • If they ask about sensation, say you feel “pins and needles” in your thumb and index finger.
    • If they offer more pain medicine, say: “The last dose did absolutely nothing! It’s getting worse!”
  • Key Question: “Am I going to lose my hand? Why does it hurt so much if it’s already in a cast?”

Examiner Checklist Items

  • Checks “The 6 Ps” (Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Pain on passive stretch).
  • Correctly assesses for Pain on Passive Stretch (the most sensitive sign).
  • Identifies the emergency: Acute Compartment Syndrome.
  • Immediate Action: Mentions removing/splitting the cast/bandage.
  • Immediate Action: States the limb must be kept at heart level (not elevated).
  • Surgical Referral: Calls the Orthopedic Registrar “STAT” for emergency fasciotomy.

Key Clinical Findings

  • Vital Signs: HR: 110 bpm (Tachycardia due to pain); BP: 145/90 mmHg; Temp: 37°C.
  • Physical Exam:
    • Right Wrist: “Dinner fork” deformity under a tight bandage and back-slab.
    • Neurovascular: Radial pulse is still palpable (Important: pulse presence does NOT rule out Compartment Syndrome).
    • Skin: Tense, “wood-like” feeling to the forearm; fingers are slightly dusky but not yet white.
    • Sensation: Decreased sensation over the median nerve distribution (index/middle finger).

Communication Triggers (Murtagh-Aligned)

  • Open-ended questions: “Mrs. Higgins, can you describe exactly what the pain feels like right now?”
  • Summarising: “So the pain is a burning sensation, it’s getting worse despite the morphine, and it feels like your arm is going to burst. Is that right?”
  • Handling Emotion: “I can see you are in a lot of distress. I am going to examine you quickly and we will take immediate steps to help you.”
  • Lay Language: Avoid saying “fasciotomy” without explaining it as “an incision to release pressure.”

Assessment & Marking Guide

ItemCriticality
Recognized Pain out of proportion to injuryCRITICAL
Tested for Pain on Passive StretchCRITICAL
Did NOT excessively elevate the limbSAFETY
Ordered immediate removal of constrictive dressingsCRITICAL
Explained the need for emergency surgery clearlyCOMMUNICATION
Called Orthopedics for immediate FasciotomyMANAGEMENT

Global Rating:

  • Pass: Recognizes the emergency immediately, initiates cast removal, and arranges surgery.
  • Fail: Suggests more analgesia and “wait and see,” elevates the limb, or waits for the pulse to disappear before calling for help.

Sample Answers / Model Performance

Suggested History/Assessment Questions:

  1. “On a scale of 1 to 10, how would you rate the pain now compared to when you first arrived?”
  2. “Does the pain feel like it’s deep inside the muscle, perhaps a bursting or burning feeling?”
  3. “Are you feeling any new tingling or numbness in your fingers?”

Explaining the Diagnosis and Plan:

“Mrs. Higgins, I am very concerned. While you do have a broken wrist, the pain you are describing tells me that the pressure inside your forearm muscles has risen to a dangerous level. We call this Compartment Syndrome.

Because the pressure is so high, it is cutting off the blood supply to your nerves and muscles. We need to act immediately to save the function of your hand. First, I am going to cut this bandage off to give the arm room to expand. Then, I need to call the bone specialists immediately. You will need an emergency operation to make an opening in the skin to release that pressure. I know this is scary, but it is the only way to prevent permanent damage.”

Next Steps

  • STAT Orthopedic consult.
  • Keep patient NPO (Nil per os) for surgery.
  • Consent for emergency fasciotomy.