COLLES' FRACTURE

Introduction

Fractures of the distal radius were first accurately described by Abraham Colles as injuries that “take place at about an inch and a half above the carpal extremity of the radius” and “the carpus and the base of metacarpus appears to be thrown backward.” Although the eponym, “Colles’ fracture” has been used to characterize this injury, more comprehensive, reliable and prognostic classification systems have been introduced. Distal radius fractures are most commonly the result of a fall onto an outstretched hand (FOOSH) and are one of the most common types of fractures seen in Emergency Departments. Older individuals with osteoporosis are at a significantly increase risk for Colles’ fractures. Osteoporosis weakens the bones and makes the distal radius fragile and very susceptible to fracture. The vast majority of this type of fracture is successfully treated with closed reduction and casting. More recently, many unreducible or poorly reduced fractures have been treated with surgical reduction and internal fixation.

Many distal radius fractures are low-energy injuries that occur after a fall from standing height and therefore, are classified as fragility fractures. Fragility fractures are frequently associated with osteoporosis and are at risk for additional fractures. Osteoporotic bone does not have the normal compact structure seen in the diagram below. Other risk factors for osteoporosis include female gender, especially postmenopausal women, a positive family history, thin, small-build patients of Caucasian or Asian ethnicity, cigarette smoking, steriod use, increased age, lack of exercise and low dietary calcium or Vitamin D.

Because Colles' fractures are frequently associated with osteoporosis and other risks fractures, these patients should be evaluated for osteoporosis. Patients should have a dual-energy X-ray absorptiometry (DEXA) scan. If the patient has osteoporosis (T-score <2.5 using WHO criteria), they should be considered for treatment with calium and vitamin D supplements, fall prevention and balance exercises, and pharmacologic agents. Some currently recommended pharmacologic agents for treating osteoporosis are alendrronate, risedronate, raloxifene and terparatide (PTH) injections.

Related Anatomy

Distal radius
Radiocarpal joint
Lister’s tubercle
Distal radial ulnar joint (DRUJ)

Incidence and Related Conditions

Among the most common fractures seen in the Emergency Department
Incidence is highest among adolescents/young adults and those aged ≥65 years
Incidence is 7 times higher in women than in men
Osteoporosis accounts for ~250,000 wrist fractures annually

Clinical Presentation Photos and Related Diagrams

Silver Fork Deformity Secondary to Distal radius Fracture (Hover over right edge to see more images)
Histology of normal bone: A = Long bone (femur); B = Harvested section; C = Medullary cavity; D = Osteons; E = Concentric lamellae; F = Circumferential lamellae; G = Central canal with artery (a), vein(v), nerve(n); H = Periosteum; I = Lacunae with osteocytes

Symptoms

Skeletally mature individual

History of trauma - fall on the outstretched hand (FOOSH)

Pain, swelling and bruising of the wrist

Pain with wrist motion or pressure on the wrist area

Wrist deformity (Silver Fork Deformity)

Typical History

A 64-year-old right-handed female fell over her dog and landed on her outstretched right hand. She was seen in an emergency room. The doctor numbed her wrist. Next, the doctor pulled on her wrist and placed her in a splint. She now presents to the Hand Center complaining of less pain, moderate swelling, and mild tingling in her fingers. She has a history of osteoporosis.

Positive Tests, Exams or Signs

Fracture Crepitus, Deformity, Motion and Tenderness

Muscle Test and Tendon Exam: Flexor Pollicis Longus (FPL)

Tinel's Sign: Median Nerve

Passive Stretch Test

Range of Motion: Active

Range of Motion: Passive

Silver Fork Deformity

Capillary Refill

Muscle Test and Tendon Exam: Extensor Pollicis Longus (EPL)

Radial Pulse

Sensory Exam by Nerve

Work-up Options

Radiology studies - Computerized tomography (CT) scanning

Electrophysiological testing - EMG/NCV

Radiology studies - X-ray

Images (X-Ray, MRI, etc.)

Unreduced classic Colles" Fracture lateral view distal fragment of distal radius dorsally displaced, dorsally comminuted and dorsally tilted. (Hover over right edge to see more images)
Unreduced classic Colles" Fracture AP view
$Classic Colles" Fracture Oblique view Note ulna head also fractured$
Classic Colles" Fracture Oblique view Note ulna head also fractured
Reduced classic Colles" Fracture lateral view with near anatomic alignment
Reduced classic Colles" Fracture AP view with near anatomic alignment

Treatment Options

Conservative:

Treatment algorithms: parameters for decision making

Displaced/non-displaced
Stability
Extra-articular (osteoporotic/not osteoporotic)/intra-articular (die punch/articular shear)
DRUJ stability

Conservative management - closed reduction and sugar tong splint initially followed by casting particularly for stable, non-displaced or fractures without significant intra-articular deformity

Operative:

Extrafocal percutaneous pinning for extra-articular or simple intra-articular fractures
External fixation (bridging, non-bridging) with closed reduction
Open reduction and internal fixation (ORIF) with volar plate fixation or dorsal plating
Arthroscopically assisted reductions: can be used to assess joint congruity and associated ligamentous injuries
ORIF with fragment-specific internal fixation: use of low-profile implants to restore stability and articular congruity
Bone-graft substitutes: autologous or allogenic cancellous bone graft, demineralized bone matrix, calcium phosphate-based void fillers, autologous bone marrow fillers

Treatment Photos and Diagrams

$Short arm cast holding a non-displaced or reduced and stable distal radius fracture while it heals$
Short arm cast holding a non-displaced or reduced and stable distal radius fracture while it heals
$Lateral X-ray of a distal radius fracture in a short arm cast. Alignment acceptable$
Lateral X-ray of a distal radius fracture in a short arm cast. Alignment acceptable
$Silver fork deformity in young patient with a untreated partially healed distal radius fracture$
Silver fork deformity in young patient with a untreated partially healed distal radius fracture
Fracture after open reduction and internal fixation with percutaneous pins
Incision healing well, pins secure and deformity corrected
$Intra-articular displaced distal radius fracture$
Intra-articular displaced distal radius fracture
$Intra-articular displaced distal radius fracture reduced and secured with pins and external fixation$
Intra-articular displaced distal radius fracture reduced and secured with pins and external fixation
$Older external fixation device for stabilizing a distal radius fracture$
Older external fixation device for stabilizing a distal radius fracture
$Modern distal radius external fixation device which aides reduction and stabilizes the fracture after reduction$
Modern distal radius external fixation device which aides reduction and stabilizes the fracture after reduction
Note the multiple adjustment options
Wrist jack with pins in radius and index metacarpal bone
$Intra-articular partially dislocated distal radius fracture which requires ORIF$
Intra-articular partially dislocated distal radius fracture which requires ORIF
$Internal fixed distal radius fracture lateral view$
Internal fixed distal radius fracture lateral view
$Internal fixed distal radius fracture AP view$
Internal fixed distal radius fracture AP view

Complications

Injury related: post-traumatic arthritis, nerve injury, stiffness, failure to maintain reductions, compartment syndrome, skin tearing during reduction, carpal tunnel syndrome (CTS), EPL and FPL ruptures
Splint/cast: EPL rupture(rare-incidence about 3%), CTS, loss of range of motion, post-traymatic arthritis in RC or DRUJ joints, complex regional pain syndrome (CRPS)
Percutaneous pinning: increases risk for injury to the superficial cutaneous branch of the radial nerve and damage or irritation to tendons of the first dorsal compartment
Internal fixation: increases risk of soft tissue injury, infection and late extensor or flexor tendon ruptures

Outcomes

Worse outcomes are associated with axial shortening (>6 mm) during healing, comorbid injuries (eg, TFCC, scapholunate ligament tears), instability of the DRUJ, and work-related injuries
Fractures that heal with >20° of dorsal angulation, 10° of radial shortening, and/or 2 mm of articular incongruity also have a less favorable functional outcome

Key Educational Points

The goals of treating a distal radius fracture is to achieve a healed fracture which does not cause pain, allows a normal range of motion and has a normal or nearly normal external appearance. These goals do not always reguire a perfect looking X-ray but rather a healed aligned fracture that will allow the patient to fuction without pain and look reasonably normal. The treatment of the Colles' fracture should achieve these goals by using the simplest treatment method that will produce a result that meets these targets. If the fracture is nondisplaced, a simple spint followed by a cast once the swellling has subsided will often work well. If the fracture is displaced but can be reduced (manipulated under sedation and local anesthesia) so that the parts of the fracture are anatomically or nearly anatomically aligned, then a splint and cast will be adequate treatment if the reduction is stable (stays aligned). If the fracture cannot be reduced or held in a reduced postion then surgical treatment is indicated. If the fracture line goes into a joint and makes the joint incongruent (joint surface is not smooth), then aligning the fracture anatomically is even more immportant. An irregular joint surface can lead to early, painful post-traumatic osteoarthritis. The first level of surgical treatment maybe a reduction under anesthesia and pinning of the fracture followed by a splint and/or cast. Additionally, the fracture may have to be held in place by an external fixation device. If a closed reduction is inadequate then an open reduction where the fracture fragments are surgically exposed and aligned will be needed. Once reduced and aligned anatomically, the fragments may be held in place by pins, screws, an external fixation device and/or internal fixation with screws and a plate. This type of open reduction and internal fixation (ORIF) is now commonly used for displaced and unreducible Colles' fractures. ORIF is also indicated for fractures with a displaced intra-articular component that must be aligned to prevent arthritis.

Practice and CME

References

New articles

Finsen V, Rajabi B, Rod O, et al. The clinical outcome after extra-articular colles fractures with simultaneous moderate scapholunate dissociation. J Wrist Surg 2014;3(2):123-7.
Giannotti S, Alfieri P, Magistrelli L, et al. Volar fixation of distal radial fracture using compression plate: clinical and radiographic evaluation of 20 patients. Musculoskelet Surg 2013;97(1):61-5.

Reviews

Kvernmo HD and Krukhaug Y. Treatment of distal radius fractures. Tidsskr Nor Legeforen nr 2013;133(4):405-10.
Alshryda S, Shah A, Odak S, et al. Acute fractures of the scaphoid bone: Systematic review and meta-analysis. Surgeon 2012;10(4):218-29.

Classics

Colles A. On the fracture of the carpal extremity of the radius. Edinb Med Surg J 1814;10:181.
Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthoped Surg 1997;5:270-81.