Help with a patient (friend) problem

[Guest ral]

Guess I'll ask you experts in here.

Have a female friend, 45yrs, CAD, hyperlipidemia, smoker, no anticoagulants, who suffered a Colle's fracture of her nondominant wrist about a year and a half ago. She didn't have insurance at the time, and decided to just wear a splint, then short arm cast through her primary care doc, instead of having definitive care from an ortho. I wasn't around at the time, otherwise I would have made sure she got what she needed. By history, she likely needed a reduction at the minimum, possibly an ORIF. Anyhow, healed up (lousy position but no non-union) and now (past six to eight months) she has chronic skin problems over the dorsum (volar surface is fine) of that wrist, just at the location of the old fracture. Chronic purpura, chronic bleeding with the most minor of skin contact, xerosis, and pruritus. Everytime I turn around, she has a blood soaked bandaid on it. Just over the old fracture site. Thoughts?

[rcdavis]

Difficult problem due to inadequate information regarding the fx.

 

Let's think about whether the fracture is the cause of the continued tissue friability and bleeding ( which I doubt)

 

First off, a true colles has dorsal displacement of the distal segment, meaning the fracture "sharp" ends point volarly.

 

If the posit is that there was an occult open fracture and continued loss of tissue elasticity and strength due to persistent tenting of a sharp segment on the Dodson of the wrist, then the original fracture probably was a "smith 's" fracture, also called a reverse colles.. Which can happen just as you described.

 

But, after this amount of time, there should be a callous formation, which represents the normal blastic-clastic fracture healing cycle, wherein the fracture is reabsorbed by the body and a callous union is formed according to wolf's law ( the strength and position of a bone growth is dependent on the forces and shear applied to it).

 

And, you state that there is " no-non-union"... Which is usually impossible to diagnose without an X-ray.. So.. A recent X-ray has to have been taken which confirms normal union and possible function limiting deformity, but no spur or formation of bone to or through the dermis.

 

So, I suspect that the fracture per SE is not the problem.

 

I suspect there was a traumatic capillary or venous malformation that was created by the fracture event ( we have all seen hemorrhagic fracture blisters), and that the basic layering of the dermis and subcutaneous tissue was changed.. Increasing tissue friability.

 

Which bleeds easily on minimal contact.

 

Or, there is a small capillary hemangioma at the site which you are not seeing which is also bleeding easily with minimal insult.

 

Or there is an occult skin cancer causing the same problem, and the fracture is a red herring.

 

Either way.. The patient needs a current X-ray, and a close skin exam.

 

She needs to be seen first by an Ortho to assure functional preservation and no bone involvement creating abnormal interstitial pressures at the callous site, then

 

See a dermatologist.

 

The absence of other bleeding sites belies a true coagulopathy, but if cleared by derm and bone, then that needs to be pursued.

 

Do what you can to steer her to these specialists...

 

And let me know what her final dx is, please

 

 

V/r

[ventana]

needs good xrays and ortho consult - out of the league of a primary care PA (knowledge and liability wise)

[Guest ral]

Thanks for the tips. Distally and proximally, everything is fine. The fracture is completely healed. I've looked at the initial and follow up x-rays. Complete union, no aberrant fragments, just could have been a little better aligned is all. It could be complete coincidence that the skin problem developed in this area alone. I've convinced her to make an appointment with derm, and we'll see what comes of it. She doesn't want to go to ortho at this time. I'll keep you updated as my info comes in.