by Meghan Tracy
Distal radius fractures were first described by Abraham Colles in 1814.1 A Colles’ fracture is a distal radius fracture occurring within 2.5 cm of the wrist and typically involves some dorsal angulation at the site of the fracture.2 This type of fracture is one of the most common fracture sites for due to osteoporotic conditions.3
The wrist and hand complex is an intricate system of many bones, joints, muscles, ligaments, and the neurovascular system that supplies the region. The main bones in the wrist and hand include: radius, ulna, carpals, metacarpals, and phalanges. The radius and ulnar form the bony structure of the forearm and are held together by an interosseous membrane. This membrane spans the medial border of the radius to the lateral border of the ulna holding the bones together without restricting any movement specifically pronation and supination. The interosseous membrane also provides an attachment site for many anterior and posterior muscles.4
The distal radioulnar joint has both a proximal and distal component and is found between the articulation of the distal radius and ulna allowing for pronation and supination. The next major joint is the radiocarpal joint commonly referred to as the wrist where is radius contacts the carpal bones. The carpals are arranged in two distinct rows, a proximal and a distal row. The proximal row of carpals consists of the scaphoid, lunate, triquetrum, and pisiform bones where the distal row is made up of the articulations between trapezium, trapezoid, capitate, and hamate. The distal radioulnar joint is occurs where the radius articulates with both the scaphoid and the lunate. Uniquely, the radius is angled toward the ulnar aspect of the body at an angle between 15-20o. Unlike the radius, the ulna does not articulate with the carpal bones instead articulating with a cartilaginous disc known as the triangular fibrocartilage complex (TFCC) which lies between each. The TFCC traverses between the ulnar aspect of the distal radius and the base of the ulnar styloid process contacting the triquetrum, hamate, and base of the 5th metacarpal. The major function of the TFCC is to add stability at the wrist and allow forces to be dissipated between the radius and the ulna. Without the TFCC the radius would transmit 95% of the forces from the hand whereas, with the TFCC the radius experiences only 60% of the force and the ulna bears the other 40%. The other sets of joints that complete the wrist and hand complex are the intercarpal, midcarpal, carpometacarpal, intermetacarpal, metacarpophalangeal, and interphalangeal joints.5
Many of the muscles in the forearm function to control wrist motion but also movement of the digits. The anterior compartment of the forearm is divided into 3 layers: superficial, intermediate, and deep. The superficial layer is comprised of the flexor carpi ulnaris, palmaris longus, flexor carpi radialis, and pronator teres. The intermediate layer is made up of the flexor digitorum superficialis while the deep layer is the flexor digitorum profundus, flexor pollicis longus, and pronator quadratus. The posterior compartment is similar to the anterior compartment except it is lacking an intermediate compartment. The superficial layer of the posterior compartment is composed of brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, and anconeus. The deep layer muscles of the posterior compartment are supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis brevis, extensor indicis.4
An intricate network of dorsal and palmar ligaments stabilizes the wrist joint where the palmar ligaments provide the strongest stabilization. The most important ligament in the wrist is the scapholunate interosseous ligament, which has the primary role in stabilizing the carpals. The extrinsic palmar ligaments are the major ligaments responsible for controlling the movement at the wrist joint. Ligaments both palmar and dorsally that only allow small amounts of gliding to take place between each articulation holding the intercarpal joints together.5
The arteries contained in the forearm help to supply both the anterior and posterior compartment while supplying branches to the hand. The main arteries are: radial, ulnar, posterior interosseous, anterior interosseous. The major nerves crossing over the wrist joint are the median, ulnar, and radial nerves.4
The mechanism of injury of a Colles’ fracture is falling on an outstretched hand (FOOSH) that has been extended to help break a person’s fall. As the person falls and contacts a hard surface the wrist becomes hyperextended causing a fracture at the distal radius.
Specifically, a Colles’ fracture occurs when the wrist is in 40 to 90 degrees of extension when the hand makes contact with a hard surface causing the dorsal displacement of the radius. Due to the intense forces traveling through the wrist there is high association in not only a fracture at the distal radius but an avulsion fracture of the ulnar styloid process as the force travels through the TFCC.6 The rate of distal radius fracture is approximately 75% of all forearm fractures.7
Previous studies have shown that women over 65 years are at the highest risk for suffering Colles’ fractures over 7 times more than men as well as children between 6 and 10 years of age.2,3,7 One reason for the increase rate of fractures in women is due to decreased bone mass density which has shown to be a high predictor in increasing the risk of Colles’ fracture up to 50% compared to individuals with a normal bone mass density. Other studies have shown as much as a 60% increase in risk for individuals that are more active especially outdoors due to the greater risk of tripping and falling and also a delayed onset of menarche after the age of 15.3
In order to properly evaluate a Colles’ fracture a set of x-rays will be taken to determine the type of fracture and the degree of displacement present. The degree of displacement is measured using the radiograph and then the fracture can be separated into groups of minimal displacement and displacement. Upon measurement fractures that are minimally displaced have a dorsal angulation ≤ 15o whereas fractures that are displaced have a dorsal angulation that is greater than 15o.2
A Colles’ fracture can present in many ways therefore a number of classification systems have been developed to assist with proper evaluation. Using a classification system also helps is making decisions regarding whether conservative treatment or surgical treatment is more beneficial for each patient. Three common classification systems are Frykman’s classification, Fernandez, and the Universal classification.
The Frykman’s classification is as follows:
Colles' Fracture. Altizer, Linda (http://www.scribd.com/doc/77311113/PDF)
Another useful classification system for diagnosis of unstable versus stable fractures of the distal radius fractures and respective treatment options was presented by Diego Fernandez.6
Colles' Fracture. Altizer, Linda (http://www.scribd.com/doc/77311113/PDF)
Colles' Fracture. Altizer, Linda (http://www.scribd.com/doc/77311113/PDF)
The classic presentation of a Colles’ fracture is a ‘dinner fork’ appearance of the forearm. This presentation occurs due to the dorsal angulation of the distal fragment at the wrist.2
Conservative treatment of a Colles’ fracture takes place through nonsurgical closed reduction and cast immobilization.8 Conservative management is especially useful in fractures that are only minimally displaced with no instability but also elderly adults that have low demands or are unable tolerate surgical interventions.8 There are various methods for casting available including: circumferential cast, modified sugar-tong splinting, and volar-dorsal splinting. Each method of immobilization has individual advantages depending on the needs of each specific patient’s presentation at the time of management.9 Typically after the wrist has been placed in a cast the physician will take an x-ray in 2 weeks to ensure the fracture has not been displaced.2,6 One of the most common disadvantages of using a circumferential cast versus non circumferential casts initially is the decreased ability for the cast to accommodate for swelling that occurs after fracture. If the cast is unable to accommodate for swelling, an increase in pressure on the tissue can cause sores and along with neurovascular compromise. Noncircumferential casts and splits are able to reduce the pressure on surrounding tissues by allowing for some expansion with increased edema. A disadvantage of noncircumferential casts from the loss of some stability due to the decreased rigidity therefore predisposing the patient to slippage of the fracture site.9
Modified Sugar Tong
For Colles’ fractures, surgery is indicated for displaced intra-articular fractures. Typically, these fractures are unstable requiring the use of pins or other types of fixation devices to help facilitate proper healing between fracture segments. One of the more common surgical interventions a surgeon will perform is an open reduction and internal fixation (ORIF) which is especially useful for fractures classified as intra-articular and unstable.6 The use of locking plates has becoming increasingly popular in the surgical management of Colles’ fractures using screws attached to a plate to add angular stability.10 The plate and angular stability provided in the region help to transfer stress from the fixation to the radial shaft effectively bypassing the fractures site.11,12 The major advantage of this type of system is due to the multiple sites of fixation that allows the fracture segments to be aligned for optimal healing. The use of a volar locking plate is indicated when a patient’s fracture has a high possibility of losing reduction when a standard closed reduction is performed. The volar system is especially important and highly used in patients with osteoporosis. This locking system is contraindicated when fractures occur in an adolescent with an immature skeleton, if the patient cannot tolerate surgery and anesthesia and in cases where there is active infection present.12
To insert a volar locking plate, an incision is made on the volar aspect of the wrist with careful attention paid to both the flexor carpi radialis and the radial artery. The fracture is initially stabilized using Kirschner wires until the plate is properly inserted and fixated to the bone. Next, the plate is placed at the distal radius and cortical screws are inserted through the plate into the radial shaft followed by the insertion of either distal locking pins or screws as well as proximal screws. The proximal and distal screws allow for maximal stability and rigidity. After the plate is firmly secured, the Kirschner wires are removed.11 After surgery is finished, the wrist will be splinted in 30 degrees of extension to limit postoperative edema.12
One of the difficulties in surgical management of Colles’ fracture occurs when the bone is osteoporotic and the fixation device will not be able to reliably hold to the bone.8 An external fixator device has been recommended for patients that will not see favorable results using internal fixation particularly those with osteoporotic bone. The two major forms are external fixation are bridging and nonbridging. The bridging technique inserts pins distally into the second metacarpal where in nonbridging the pins are inserted in the distal radius fragment.8 Many randomized control trials have shown that patients with an external fixation yield better anatomical results in long term assessments. Another way a surgeon is able to facilitate better alignment and healing in fractures involving osteoporotic bone is to use percutaneous wires along with the external fixation.8
Rehabilitation and Post-Op Treatment
Once a Colles’ fracture has properly healed with conservative or surgical treatment, some form of rehabilitation is recommended in order to restore proper function and strength to the fractured wrist. The main focus in the beginning of rehabilitation is to mobilize the wrist which is indicated approximately 7-8 weeks after the fracture occurred when treated conservatively. If the fracture is managed using an internal fixation device early mobilization can begin approximately 1 week after surgery.12 Special attention should be paid to an externally fixated wrist as patients often keep the wrist in a pronated position predisposing the distal radioulnar joint to a contracture.13 After rehab has begun it is important to begin muscle strengthening while working to limit the amount of scar adhesions and scar tissue through early mobilization. If the patient had an ORIF the primary focus after surgery is reducing pain and edema.10 Initially, exercises to regain motion begin with passive range of motion (ROM) and progress to active ROM exercises as more motion becomes available. For surgically treated wrist, the majority of ROM should be regained between 6 to 8 weeks post-op.12 Edema massages can be performed in addition to ROM exercises and arm elevation if swelling remains in the wrist and hand area. Studies have shown it is easier to determine function available in wrist and hand the earlier edema is reduced or minimized.14 During strengthening it is important address all forearm muscles but also the extrinsic and intrinsic hand muscles progressively building resistance as the individual gets stronger.
Additional Web Based Resources
1. Belloti JC, Santos JBGd, Atallah AN, et al. Fractures of the distal radius (colles' fracture). Sao Paulo Med J. 2007;125(3):132-138. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=17923936&site=ehost-live.
2. Blakeney W, Webber L. Emergency department management of colles-type fractures: A prospective cohort study. Emerg Med Australas. 2009;21(4):298-303. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=19682015&site=ehost-live.
3. Silman AJ. Risk factors for colles' fracture in men and women: Results from the european prospective osteoporosis study. Osteoporos Int. 2003;14(3):213-218. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=12730767&site=ehost-live.
4. Drake R, Vogl A. Wayne, Mitchell Adam. 2nd ed. Philadelphia, Pennsylvania: Elsevier; 2010:1103.
5. Magee D. 4th ed. Philadelphia, Pennsylvania: Elsevier; 2002:1020.
6. Altizer LL. Colles' fracture. Orthopaedic nursing / National Association of Orthopaedic Nurses. 2008;27(2):140-145.
7. Smilovic J, Bilic R. Conservative treatment of extra-articular colles' type fractures of the distal radius: Prospective study. Croat Med J. 2003;44(6):740-745. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=14652889&site=ehost-live.
8. Blakeney WG. Stabilization and treatment of colles' fractures in elderly patients. Clin Interv Aging. 2010;5:337-344.
9. Grafstein E, Stenstrom R, Christenson J, et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced colles fractures. CJEM. 2010;12(3):192-200. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=20522283&site=ehost-live.
10. Krischak GD, Krasteva A, Schneider F, et al. Physiotherapy after volar plating of wrist fractures is effective using a home exercise program. Arch Phys Med Rehabil. 2009;90(4):537-544. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=19345766&site=ehost-live.
11. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci. 2007;12(2):134-140. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=17393268&site=ehost-live.
12. Smith D, Henry M. Volar fixed-angle plating of the distal radius. J Am Acad Orthop Surg. 2005;13:28-36.
13. Slutsky DJ, Herman M. Rehabilitation of distal radius fractures: a biomechanical guide. Hand Clin. 2005;21(3):455-468.
14. Dionyssiotis Y, Dontas IA, Economopoulos D, Lyritis GP. Rehabilitation after falls and fractures. J Musculoskelet Neuronal Interact. 2008;8(3):244-250. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=18799857&site=ehost-live.