Station Title & Timing
- Title: Right Wrist Injury Following a Fall
- Duration: 10 minutes (2 minutes reading time + 8 minutes performance)
Learning Objectives
- Examination Skills: Demonstrate a systematic “Look, Feel, Move” approach and a rigorous neurovascular safety check.
- Investigations: Correctly interpret a wrist X-ray showing a distal radius fracture.
- Clinical Reasoning: Demonstrate the “Joints Above and Below” rule and identify the need for orthopedic follow-up.
- Communication: Explain the diagnosis and “safety-netting” (Compartment Syndrome/Ischemia) in lay terms.
Patient Profile
- Name: James Miller
- Age: 24 years old
- Ethnicity: Any
- Occupation: Graphic Designer (Heavy computer user)
- Relevant Social History: Plays amateur soccer on weekends.
Presenting Complaint
“I fell during my soccer match an hour ago. I landed hard on my right hand and now my wrist is extremely painful and swollen.”
Contextual Information
- HPC: Accidental trip; fell on an outstretched hand (FOOSH). Immediate pain. No other injuries.
- PMH: Fit and healthy. No previous fractures.
- Medications: Nil.
- Allergies: No known drug allergies.
Exam Instructions
Candidate Instructions
James Miller has presented to the Emergency Department with a right wrist injury. An X-ray has already been performed and is available on the monitor.
- Take a brief, focused history.
- Perform a physical examination of the right upper limb.
- Interpret the X-ray provided.
- Discuss the diagnosis and management plan with James.
Standardised Patient (SP) Instructions
- Affect: You are in pain but calm. You are holding your right wrist with your left hand.
- Examination Findings: * If the candidate feels the wrist: “Yes, it’s very tender right on the bone just above the thumb.”
- If the candidate checks sensation: “Yes, I can feel you touching all my fingers normally.”
- If the candidate checks the elbow/shoulder: “No, those feel fine, no pain there.”
- Key Concern: “I’m a graphic designer. Will I be able to use my mouse and draw? How long will this be in a cast?”
Examiner Checklist Items
- Inquires about the mechanism of injury (FOOSH).
- Performs “Look, Feel, Move” systematically.
- Critical Step: Performs a full neurovascular check (Radial pulse, CRT, and Median/Ulnar/Radial nerve function).
- Critical Step: Mentions checking the elbow and shoulder (Joints above and below).
- Correctly identifies the “Distal Radius Fracture” on the X-ray.
- Explains the management: Analgesia $\rightarrow$ Splint (Backslab) $\rightarrow$ Orthopedic referral.
- Provides safety-netting (warns about blue fingers, coldness, or tingling).
Key Clinical Findings
- Inspection: Moderate swelling of the dorsal wrist; no gross “dinner fork” deformity (undisplaced).
- Palpation: Point tenderness over the distal radius. No tenderness in the anatomical snuffbox (scaphoid).
- Neurovascular: Radial pulse is $2+$ (strong); Capillary Refill Time (CRT) $< 2$ seconds. Sensation intact to light touch in all distributions.
- X-ray Interpretation: Transverse fracture line through the distal metaphysis of the radius. Minimal displacement.
Communication Triggers (Murtagh-Aligned)
- Open-ended: “James, can you walk me through exactly how you landed on your hand?”
- Summarising: “So, you fell on your hand while running, you felt an immediate snap, and the pain is localized to the wrist. Is that correct?”
- Empathy: “I understand you’re worried about your work as a designer. We’ll focus on getting this stabilized so you can recover quickly.”
- Simplifying: Use “wires” for nerves and “tubes” for blood vessels to ensure the patient understands the safety check.
Assessment & Marking Guide
| Domain | Example Checklist / Rating Scale |
| History | Mechanism of injury identified; assessed for other injuries (head/neck). |
| Examination | Systematic “Look, Feel, Move”; Must check distal pulses and sensation. |
| X-ray | Identified the correct bone (Radius) and the location (Distal). |
| Management | Offered analgesia; proposed a “backslab” (plaster) and specialist follow-up. |
| Global Rating | Safety: Did the candidate check for neurovascular compromise and safety-net? |
Sample Answers / Model Performance
Suggested History Questions:
- “Did you land with your palm flat or on the back of your hand?”
- “Are you experiencing any numbness or tingling in your fingers right now?”
- “Did you hit your head or injure your elbow or shoulder during the fall?”
Explaining the Plan:
“James, looking at your X-ray, you have a distal radius fracture. That means you’ve broken the larger bone in your forearm near the wrist joint.
The good news is that when I checked your hand, the tubes (your blood vessels) are providing good flow, and the wires (your nerves) are all sending signals correctly.
Our plan today is:
- Give you some stronger pain relief.
- Place your arm in a ‘backslab’—this is a partial plaster cast that allows for some swelling while keeping the bone still.
- I will refer you to the Orthopedic Fracture Clinic to see a specialist in about a week. They will likely do another X-ray then to make sure the bone is staying in the right place.”
Safety Netting (The “Pass” Requirement):
“It is very important that you come back to the Emergency Department immediately if you notice your fingers turning blue or feeling very cold, if you get new ‘pins and needles,’ or if the pain becomes so bad that even the medication doesn’t help. These could be signs that the cast is too tight or the pressure is too high.”