((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.))

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.

• Ensure scene safety — assess paving area for further trip hazards; request the venue address the uneven surface.
• Don appropriate PPE.
• Perform Primary Survey — confirm no life-threatening injuries from the fall; assess for any other injury sustained (no head impact, no spinal tenderness).
• Obtain history — confirm FOOSH mechanism, medications (Warfarin — note anticoagulation), osteoporosis, assess for any other fall-related injury.
• Inspect the right wrist — note 'dinner fork' deformity, swelling, bruising, and intact overlying skin (closed fracture).
• Assess neurovascular status of the right hand BEFORE immobilisation:
• — Radial pulse: present but slightly weaker than left — document and monitor.
• — Capillary refill: fingers — confirm <2 seconds.
• — Sensation: light touch to palmar surface of thumb, index, and middle finger (median nerve). Document result.
• — Motor: ask patient to gently wiggle fingers if tolerated. Document.
• Offer Methoxyflurane (Penthrox) for pain management prior to splinting — self-administered by patient.
• 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.
• Reassess neurovascular status AFTER splinting — confirm radial pulse still palpable and sensation unchanged.
• Complete Vital Sign Survey — note BP elevated at 158/92, likely pain-related; known hypertension. Repeat post-analgesia.
• Contact CSP — this patient requires ambulance transport to an Emergency Department for X-ray, formal reduction, and plaster immobilisation.
• Advise patient and son — document Warfarin use in handover notes; swelling may be significant given anticoagulation.
• Keep patient warm — elderly patient on the ground is at risk of hypothermia.
• Scenario ends on CSP arrival and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

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