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Copyright

1980 by The Journal

Complications
BY

WILLIAM

P.

COONEY,

III,

M.D.t,

of Bone

Patients

ABSTRACT:

rious

complications

appreciated.

more

A study

per
cent)
neuropathies

with
of

(forty-five
(thirty-seven

the Department

with Colles
frequently

of 565

JAMES

H.

DOBYNS,

of Orthopedics,

revealed

such
complications
the median,
ulnar,

Mayo

177

(31

as persistent
or radial
nerves

cases),
radiocarpal
or radio-ulnar
cases),
and malposition-malunion

arthrosis
(thirty

cases) . Other
complications
included
tendon
ruptures
(seven)
,
unrecognized
associated
injuries
(twelve),
Volkmanns
ischemia
(four cases),
finger stiffness
(nine
cases),
many

and shoulder-hand
patients,
incomplete

or secondary

loss

of the

syndrome
restoration
reduction

(twenty
cases).
In
of radial
length
position

caused

the

complications.
Current
opinion
seems
to be that there are no important problems
relating
to the treatment
of Colles
fractures2212
, despite admonitions7#{176} that many patients
who have had such a fracture
are found to have permanent
disability
and poor function
of the hand and wrist.
In our
hospitals,

we

have

seen

a steady

flow

of patients

referred

ment,
figures

we have
on the

accumulated
incidence

fracture.

Treatment

consideration
that
cept in delineating

to us for early
of

of these
will not
a general

and

of the
These
present

bate manage-

sufficient
material
to report
complications
from
Colles
complications

is a separate

be discussed
or analyzed,
exapproach
to a specific
compli-

AND

Clinic

cation

and

Read

at the

Annual

Meeting

Material

of The

American

Academy

thopaedic
Surgeons,
New Orleans,
Louisiana,
February
2,
t Department
of Orthopedics,
Mayo
Clinic,
Rochester,
55901 . Please address
reprint
requests
to Dr. Cooney.

62-A,

NO.

4, JUNE

1980

RONALD

Foundation,

who

was

L.

LINSCHEID,

M.D.t,

respect

to the

Rochester

sent

ered to be a referral.
and follow-up
data

to us for treatment

was

The case histories,


on all 565 patients

mechanism

of the

fracture
into the radiocarpal
into the radiocarpab
joint

also

consid-

roentgenograms,
were assessed

injury

juries.
In evaluating
and tabulating
the
used the Frykman
classification
of the
an extra-articular
radial
fracture;
articular
radial
fracture
plus an ulnar

and

with

associated

in-

results
(Table
I), we
fracture.
Type I was
Type
II, an extrafracture;
Type III, a

joint; and Type IV,


plus an ulnar fracture.

a fracture
Type
V

was a fracture into the radio-ubnarjoint; Type VI, a fracture into the radio-ulnar joint plus an ubnar fracture; Type
VII, a fracture
into both joints;
and Type VIII, a fracture
into both joints plus an ulnar fracture.
When
there
were
complications,

we

especially

studied
the method
ofreduction,
the anesthesia,
immobilization,
and the post-fracture
care, and
correlate
each with the type of complication.

the type
we tried

In the
complications
eight
major

of Or-

1976.
Minnesota

total
of 565 cases,
in 128 patients,
types:
compression

there
were
as categorized
neuropathy

cases),
arthrosis
after fracture
(thirty-seven
ion after boss of reduction
(thirty
cases),
(seven

cases),

unrecognized

cases),
complications
of
manns
ischemic
contracture
the fingers
(nine
cases),
dystrophy)

Some
tients with

treatment
of the Cobles fracture,
while the others
were referred
for evaluation
and treatment
because
of complications,
either early (during
the acute treatment
of the fracture)
or late (with
specific
complications).
All patients
who were referred
had had primary
treatment
of the fracture elsewhere,
and any patient
with a recognized
compli-

VOL.

M.D.t,

(upper-limb

All patients
treated
for Cobles
fractures
at the Mayo
Clinic
from January
1968 through
December
1975 were
studied.
There
was a total of 565 patients.
Of these,
356
(63 per cent)
were
seen
primarily
at our hospitals
for

Fractures*

of
to

Observations

cation.
Clinical

Incorporated

of complications

which
has significantly
sharpened
our awareness
many
difficulties
associated
with
treatment.
difficulties
are not commonly
appreciated.
In the
study

Surgery.

MINNESOTA

fractures
have sethan is generally

fractures

Join:

of Colles
ROCHESTER,

From

and

presenting
trophy.

patients
had
shoulder-hand

associated

cases),
tendon
injuries

malunrupture
(twelve

fixation
(thirteen
cases),
Volk(four cases),
arthrofibrosis
of
and shoulder-hand
syndrome

(twenty

cases).

more than
syndrome

complications
that
tenth
complication,

(forty-one
cases),
was
to record
its occurrence
arthrosis
or malunion.
Minor complications
They included
transitory

177 serious
into these
(forty-five

one complication.
Paoften had two or more

contributed
early
boss

to the dysof reduction

not included
in the analysis,
except
when it produced
a symptomatic
were
radial

not recorded
and median

in this
neuritis;

study.
flexor

and extensor
tendinitis;
cast-pressure
sores;
pin-site
irritation; and stiffness
of the wrist, elbow,
and shoulder
joints.
Conservative
treatment,
applied
early,
relieved
most of
these minor
complications.
Complications
were encountered
whatever
the
of fracture
treatment
used.
Among
the 356 patients
were primarily
treated
at our institution,
sixty-eight

form
who
pa613

614

COONEY,

P.

W.

III,

J.

H.

DOBYNS,
TABLE

COM

Frykman

No.

PLICATIONS

of

Type

Complications

OF

No.

OLLES

FRAC

TURE

Local

R.

L.

LINSCHEID

I
ACCORDING

TO

TREATMENT

Anesthesia
Block/General

of

Patients

AND

METHODS

Unknown

Immobilization
Pins

Cast

Unknown

12

II

14

10

III

IV

16

12

19

12

11

VI
VII
VIII

24

19

II

27

18

10

3
2

16
14

2
3

1
1

42
16

32

20

12

26

14

12

12

Unknown

tients
(19 per cent)
had seventy-eight
complications.
Among
the referred
patients,
sixty had ninety-nine
complications.
Ofthe
128 patients
with complications,
seventy-

patients).

eight
block

compression
at the spiral groove
of the humerus
or on the
dorsum
of the hand),
was diagnosed
in three patients.
Irri-

had had local


anesthesia
and thirty-eight
or general
anesthesia;
in twelve
cases,

anesthesia
was
not
closed
reduction
and
had primary
external

had had
type of

the

recorded.
Eighty-six
patients
had
immobilization
in a cast, seventeen
pin fixation,
and twenty
had failure

This

chiab block
neuropathy,

tation
from
neuropathy
six patients

was

less

frequent

after

anesthesia
(eleven
patients).
to improper
immobilization

braRadial
(cast

external
pin fixation
caused
a severe
radial
in two patients.
Ulnar
neuropathy
occurred
in
as a result of cast compression.
All but five of

of cast immobilization
with secondary
pin fixation.
For
five patients
the types
of reduction
and immobilization
were
not specified.
The
comminuted
displaced
intraarticular
fractures
(the unstable
ones,
Frykman
Types
IV
through
VIII) were associated
with an increased
number
of

the

complications,
especially
the more comminuted
Type-Vu
and VIII fractures
(sixty-nine
of the 177 complications).

Late
forty-one

For sixteen
termined.

fractures,
The largest

not be de(74 per

additional
patients,
the median
neuropathy
with
ulnar
neuropathy.
There
were

cent)

in patients

of

neuropathies.
Thirty-one
of the forty-five
patients
required
release
of the carpal
tunnel
or Guyons
canal,
or both, and

was

the Frykman
number
of
who

had

class could
complications

had

injection

a local

anesthetic
into the fracture
site, although
that method
of
anesthesia
was used in only 56 per cent of the patints
who
had treatment
for Colles
fracture.
Complications
after the
reduction
of displaced
comminuted
fractures
were
less
likely
to occur
if either
general
anesthesia
or an axiblary
block

was

given,

followed

utes)

and

gentle

reduction.

by sustained
After

traction

primary

(ten

external

mmpin-

fixation
techniques
in seventy-five
fractures
there
were
twenty-one
complications,
while after failed closed
reduction and secondary
external
pin fixation
in forty fractures,
twenty-eight
complications
were encountered.
There were
1 28 complications
reduction
and

in patients
who
plaster-cast
fixation,

were
but

treated
by closed
that routine
was

followed
three
times
more
frequently
than
the other
methods
of treatment
combined.
The age of the patient,
sex, and mechanism
of injury
seemed
to have no relationship to the incidence
of complications.
Compressive

This

Neuropathv

was

the

most

frequent

single

complication

(7.9

per cent),
occurring
in twenty-one
patients
treated
locally
and in twenty-four
who were referred
to us for treatment.
It was observed
both acutely
and bate after the injury
had
occurred.
Median
neuropathy
developed
early
in thirtyone patients,
ture

in the

usually
emergency

associated
room

with
under

local

reduction
anesthesia

of the frac(twenty

early

complication

or general
attributable

after

neuropathies

the

required

offending

removed.
neuropathy

no treatment

compressing

agent

and

(cast

resolved

or pin)

was

The five exceptions


were
patients
who had a
as a result
of initial
injury.
They
had im-

mediate

carpal-tunnel

release

neuropathy
patients.

and

no permanent

of the median
All had persistent

sequelae.

nerve
occurred
in
symptoms.
In four
was combined
no late
radial

extensive
exploration
through
an appropriate
palmar
or
forearm
incision
was essential
for adequate
decompression
(Fig.
1). In six patients,
volar
fracture
fragments
were
found
were

compressing
removed.

both the ulnar


Excessive
callus

and median
formation

nerves
(seven

and
pa-

tients),
persistent
hematoma
(six patients),
and localized
swelling
(twelve
patients),
usually
the result of the forced
volar
flex ion-ulnar
deviation
position
(Cotton-Loder),
were considered
to be responsible
for most of the other late
neuropathies.
Eleven
of the twenty-four
patients
who were
referred
to us and seven of the twenty-one
treated
primarily had one additional
complication
associated
with a compressive
neuropathy,
and one referral
patient
had three
associated

complications.

Arthrosis

after

Fracture

When
either
painful
motion
of the wrist
or forearm
was evident
or there
was a mechanical
obstruction
to
motion
after fracture,
we diagnosed
the condition
as arthrosis.
It was observed
in thirty-seven
patients
and represented

20 per

throsis

(twenty-seven

radiocarpab
VII, and
tion.

When

VIII

cent

of the

arthrosis
fractures
external

complications.

patients)

was

(ten patients).
most often
pin-fixation

THE

JOURNAL

Radio-ulnar
more

Frykman
elicited
this
techniques

OF

common

BONE

AND

arthan

Type-VI,
complica-

that

restored

JOINT

SURGERY

COMPLICATIONS

the

radial

length

was a lower
the fact that
more

were

used

incidence
pin fixation

comminuted
Of the ten

prosthetic
patients

fractures.
patients
with

fractures

two

that required
ubna (fourteen
or a Silastic

two
two

Of the
nineteen

a Darrach
patients),
replacement

Six other patients


with a mechanical

Ten of the twenty-one


sixteen
primary
patients

nine

by dorsal ostectomy,
by arthrodesis,
and

had

motion
and required
Darrach
excision
of
the ulna.
All twenty
of the patients
who
procedure
had improvement
in motion
of
particular,
in pronation
and supination
of
the

despite
for the

arthrosis,

arthropbasty
of the wrist.
with radio-ubnar
arthrosis,

patients).
subluxation

there

patients),
treatment

radiocarpal

three

painful
radio-ulnar
joint
of the distal
end of the
procedure
(one patient),
plasty
(four
radio-ulnar

those

of arthrosis
(four
was the preferred

were treated
surgically:
proximal
row carpectomy,
total
seven

to treat

OF

by
by

twentyhad a
resection
a Mibch
arthro-

symptomatic
obstruction

to

the distal end of


had the Darrach
the wrist and, in
the forearm.

referral
patients
and seven
of
had an additional
complica-

tion.
Ma/position-

patients

had

this

complication,

the

majority

having
been referred
for treatment.
Five patients
had fractures that were not yet fully united when they were seen for
treatment.
They required
early open reduction.
The other
twenty-five
patients
required
osteotomy.
Mabunion
was
most
which

commonly
commonly

comminuted.

rebated
occurs
This

to loss of the reduction


position,
when the fracture
is unstable
and

boss of reduction

period
was a frequent
problem.
loss of reduction
was required
patients.

A corrective

early

in the

treatment

In this series,
treatment
in 27 per cent of the

reduction

was

usually

for
565

performed

by

distraction
and gentle
manipulation,
the patient
having
had
brachiab
block or general
anesthesia.
It was successful
in
most patients
(more
than 92 per cent) when accomplished
within
two weeks
of the fracture
and when the reduction
was maintained
with some form of external
pin fixation.
Our preference
third
metacarpals

was

to insert in the base of the second


and
two 2.0-millimeter
(5/64-inch)
Stein-

mann pins oriented


at 60 to 90 degrees
slightly
larger
pins
(2.3
millimeters,

to each
3/32

placed

A Roger

in the middle

third

of the radius.

external-fixation
apparatus
attached
to these
tamed
the reduction
and provided
stabilization.
pins or Kirschner
wires were used,
as required,
loose
were
done

other.
inch)

Two
were

Anderson
pins mainAdditional
to secure

fragments.
When the pins applied
above
and below
inadequate
to maintain
reduction
open reduction
was
(five patients),
with satisfactory
results.
After
inadequate
treatment
of the fresh fracture
was

followed
deformity,

by malunion,
and limitation

the

complaints
of motion

of significant
pain,
present
in twenty-five

patients
led to recommendations
Fourteen
patients
had that
Three
patients
accepted
the

for corrective
osteotomy.
operation
at our institution.
deformity
or preferred
not

have

the

VOL.

surgery,
62-A,

NO.

and
4, JUNE

615

FRACTURES

community.

lost

to follow-up.

fourteen
patients
the corrective
ted by bone-grafting
(Figs.

Two

were

osteotomy
2-A through

ment in grip strength


and motion
was
one of these fourteen
patients,
and that
throdesis.
Nine
of the referral
patients
in
additional
complication,
as did one of
patients.

Two

referral

patients

had

two

In most

of our

was supplemen2-D).
Improveachieved
in all but
patient
required
arthis group
the twelve

had an
primary

additional

compli-

cations.
Tendon

Rupture

Rupture
five patients

of the extensor
poblicis
rupture
of the index

fundus
or flexor
each. The rupture
from

bongus
was noted
in
flexor digitorum
pro-

, and

displaced

pollicis
bongus
was primarily
fractures

that

was noted
in one patient
rebated to bone fragments

abraded

the tendon

during

the

weeks
after healing
of the fracture.
All five patients
with
boss of the extensor
polbicis
bongus
tendon
had rupture
within
two months
from the initial injury (two, two, three,
four,
and eight
weeks),
while
in the two patients
with
flexor
tendon
rupture
the rupture
occurred
after
three
months.
All patients
had either
a tendon
transfer
or a ten-

Ma/union

Thirty

COLLES

six
1980

had

operation

in

their

home

don graft.
Direct
several
centimeters
Associated

(two

fractures
patients),

and intercarpal
were recognized

from the time


were caused

because
lost.

Primari/y

scaphoid

fractures

(one patient),
tients),
which
month
usually

Unrecognized

included

head

(four

patients),

Bennetts

ligament
between

fracture

injuries
(five
two days and

of the original
injury.
by the same
mechanism

paone

These
injuries
that caused

the Cobles
fracture.
In our series,
ligament
instability
of
the
wrist
required
operative
reconstruction
of the
scaphobunate
ligament
in four patients.
Scaphoid
fractures
required
open reduction
in two patients,
and radial
head
fractures
required
excision
of the radial
head in two patients.
Comp/ications

Three

of Fixation

patients

required
operative
purulent
drainage
ation of the area
patient
sustained

with

pin fixation

had

pin breakage

that

removal
of the pins. Pin loosening
with
occurred
in eight patients,
and an ulceraround
a pin occurred
in one patient.
One
a fracture
through
the pin site in the distal

end of the radius.


Two patients
had nerve irritation
caused
by the cast, which led to sympathetic
dystrophy
(as will be
discussed).
Casts caused
other complications,
as described
in the paragraphs
on compressive
neuropathies,
Volkmanns
ischemia,
and shoulder-hand
syndrome.
Vo/kmann

to

Injuries

These
radial

tendon
repair
was not possible
of tendon
substance
had been

5 Ischemic

Contracture

This was seen in four referral


had had a constricting
cast that
patients
complaints
of persisting
analgesics
in two patients
further

patients,
three of whom
was retained
despite
the
pain. Continued
use of
masked
the symptoms.

616

W.

P.

COONEY,

III,

J.

H.

DOBYNS,

AND

R.

L.

LINSCHEID

Shou/der-Hand

Syndrome

This

is more

appropriately

called

upper-limb

dys-

trophy
or pain-dysfunction,
and was a significant
problem
in twenty
patients,
sixteen
of whom
had been referred.
Four patients
had acute symptoms
with predominant
sympathetic
components
of change
in skin temperature,
color,
and texture;
pain and loss of motion
in the shoulder;
and
stiffness
of the hand or specific
local trigger
areas of cxquisite
pain and tenderness
(or both).
In one patient
it was
the result
of radial-nerve
irritation
from pin fixation;
in
two patients,
from excessive
wrist flexion
which produced
acute median
neuropathy;
and in one, from an unreduced,
Median
neuropathy
associated
with Colles
fracture
may involve
a
prominent
volar
callus,
which
in this patient
compressed
the median
nerve proximal
to the carpal
tunnel.
Surgical
release was extended
into
the distal
end of the forearm
to ensure
adequate
decompression.

severely

One

of the three patients


had had an undisplaced
fracture.
Our treatment
of these patients
was difficult
and prolonged.
We variably
used nerve
and muscle
decompres-

trophy.
They
the patients

sion,

the

lysis

of tendons

and

nerves,

release

or lengthening

FIG.

Figs.

of

limb.

displaced
Two

and

fracture

of the four

with

patients

associated

had

one

disuse

other

two had two additional


complications.
The sixteen
referral
patients
had late

established

had fewer
with
the
clinical

shoulder,

2-A

FIG.

upper-limb

sympathetic
components
acute
condition,
but

complaints

stiffness

of stiffness

of the hand,

of the

complication

and

painful

dys-

than did
had longdisuse

motion,

of

carpal

2-B

of the distal
end of the radius
developed
in the wrist of a forty-five-year-old
farmer
who had been gored by a bull.
During
fracture
was overlooked.
Figs.
2-A and 2-B:
When
treatment
of the malunion
was begun
at six months,
there was marked
shortening
and radial
angulation,
median
neuropathy,
and weak grip. An open-wedge
osteotomy,
a bone graft
from
the distal end ofthe
ulna, and a small plate were employed
to regain length
and restore
alignment
of the forearm.
The carpal tunnel
was released.
2-A through
life-saving

muscle-tendon
and
The
have

2-D:
Malunion
measures
the

units,

the long-term
fourth
patient
a below-the-elbow

and

tendon

results
in three
had persistent
amputation.

transfers

when

indicated,

patients
were only fair.
pain and finally
had to

tunnel
teen
were
proved

symptoms,
patients
referred

and radiocarpal

arthrosis.

had fracture
mabunion.
with bong-established

on conservative

treatment
THE

JOURNAL

Ten ofthe

Fourteen
complaints,
extending

OF BONE

AND

six-

of them
but imfor

JOINT

from
SURGERY

six

COMPLICATIONS

weeks

to four

complication
Stiff

months.
and

four,

Six

of the

two

or more

sixteen

had

OF

one

other

complications.

COLLES

reduction

(seven

cast (four
patients),

patients),
poor
and inadequate

patients),

improper

immobilization

in the

mobilization
of the joint
efforts
at rehabilitation.

(eight

Hands

Stiff hands
from arthrofibrosis
of the fingers
were a
severe
complication
in nine patients.
It was manifested
by
pain and swelling
limited
to the hand,
with a loss of finger
motion
and occasionally
a loss of motion
of the wrist.
Swelling
synovial

and pain, particularly


in the structures
tissue,
were
the most characteristic

lined with
findings
in

seven
patients.
Swelling
of the proximal
interphalangeal
joint was the major source
of pain and resulted
in a severe
boss of motion.
The factor most commonly
associated
with
the clinical
symptoms
and signs was improper
application
of a cast. Stiff hands
occurred
most
cast application
(seven
of nine patients
lack of early motion
of the hand was
nine

patients,

present
in
Dupuytrens

and

Mu/tiple

pre-existing

often after improper


in this category).
A
evident
in five of the

degenerative

arthritis

was

three
patients.
Three
patients
had
a mild
contracture
in the affected
hand.
Six of the

nine patients
had
improved
function

full recovery,
and
after conservative

the other
treatment.

three

had

Complications

Discussion
Severe
complications
to occur
frequently.
We

largest

was

(within

when
nosis

as repeated

FIG.

The

NO.

4.

JUNE

1980

patient

was satisfied

attempts

at

neuropathies
two

When
was

weeks)

result

later

during

the median
nerve
common.
However,

syndrome.
Median
neuropathy

series
of patients
probably
because

both

early

the period

of

was involved,
early
in some
patients,

and

and returned

because

to farming

such

as a stiff

was

identified

than in previously
there
is increased

FIG.
the final

occurred
and

preciate
or suspect
that
the
nerve
stretched,
or irritated.
This failure
was
when fixation
pins were utilized.
Delay

2-C
with

required
of complica-

the radial or ulnar nerve was compressed,


the diagwas delayed
because
the physicians
failed
to ap-

condition

such

continue
more pa-

neuropathies.

the first

treatment.
recognition

with

62-A,

the

Compression

ably led to complications

in treatment,

Colles
fracture
that there
were

tions in this report


is higher
than in other reports
because
more than 46 per cent of the patients
(sixty
of 128) with
complications
were referred
for treatment.
We have divided
the complications
into nine groups,
of which
the

nd

difficulties

from
found

tients
than we anticipated
whose
complications
extensive
treatment.
Possibly
the percentage

A study
of the patients
who had multiple
complications that usually
included
the shoulder-hand
syndrome
revealed
that the underlying
cause of the dystrophy
appeared
to be a combination
of predisposing
factors
in conjunction

VOL.

617

FRACTURES

more

patients

2-D
without

restrictions.

was
compressed,
especially
evident
in diagnosis
usuhand

or carpab

more
reported
recognition
are referred

often

tunin this

of

this

for surgi-

618

W.

P.

COONEY,

III,

J.

H.

DOBYNS,

AND

R.

L.

LINSCHEID

cab decompression.
We agree
with previous
authors10#{176}
that a significant
contributor
to the neuropathy
is the force
of fracture
reduction
and the position
of immobilization;
the higher
frequency
of this complication
after local block,
with
or without
systemically
administered
analgesics,

produce
a proximal
compressive
force

tends

fractures,
maintain
the volar
We have

to support
Post-fracture

this belief.
arthrosis

was

the second

most

common

complication
in our patients,
yet often
it went unrecognized for some time. Subtle
forms of this arthrosis
are responsible
for a barge portion
of the weakness
of grip and
limited
motion
that are commonly
seen after this fracture.
When the condition
is recognized,
the patient
often can be
improved
by conservative
measures,
such as splinting,
the

local

Present

port

do

forces,

carpab
leading

methods

not always
particularly

thrust
that results
in a dorsal
to collapse
and displacement.

of fracture

reduction

prevent
these
in comminuted

and

potentially
fractures.

cast

sup-

deforming
In unstable

we prefer to use external


pin fixation
in order to
a distracting
force,
prevent
collapse,
and allow
fragments
of the cortex
to unite in good position.
used this method
for patients
in whom reduction

of the fracture
was lost
for potentially
unstable
Types
V through
VIII),
sults3.

after cast immobilization


and also
intra-articular
fractures
(Frykman
and have achieved
satisfactory
re-

Operative
treatment
for radiocarpal
arthrosis
was necessary in only nine patients
in our series.
The radio-ubnar
arthrosis
that was seen
in twenty-seven
patients
mostly

Open
reduction
of Colles fracture
is rarely
advocated,
despite
the need for accurate
reduction
of the fracture8.
Because
the functional
results
so closely
parallel
the
anatomical
results,
it is our practice
that when closed
re-

stemmed
from
cal
reduction,

duction,
successful,

injection

malalignment
radius
with
dorsiflexion
inadequate
lationship

of

steroids,

and

the inability
manifested

the

use

of

salicybates.

to obtain
an adequate
in two
ways.

of the sigmoid
the ulnar head,

notch
owing

anatomiOne
was

of the distal end


to radial
deviation

of the
and

of the distal radial component.


The other
restoration
of length
to maintain
the normal
of the radio-ubnar
joint.
This problem
was

nificant
enough
the twenty-seven
technique

to require
patients.

of reduction

surgical
treatment
in nineteen
of
We believe
that the common
and

immobilization

tion with ulnar deviation


so that
provides
stability
is mechanically
displaced,
highly
comminuted
radio-ulnarjoint
often
luxation
or dislocation

in full

the distal
unsound,
fractures.

is unstable,
that exists

prona-

end of the ulna


particularly
in
The
distal

and any radio-ulnar


is only increased

subby im-

mobilizing
the hand in full pronation.
The end result
be that rotation
of the forearm,
especially
supination,
comes
We

severely
agree

the best
minimizing

limited.
with Sarmiento

position
for
deforming

was
resig-

et ab.

maintaining
forces

proper
length
of the distal
maintain,
strong,
protracted

and

others36,

may
bethat

normal
alignment
supination.
When

is

and
the

end of the radius


is difficult
to
traction
and external
pin fixa-

tion

may be the best form of treatment.


Early loss of reduction
and late collapse
after Colles
fracture
probably
are two common
complications
that are
too readily
accepted
by treating
physicians.
To us, each of
these conditions
signifies
that the fracture
being treated
is
unstable.

It usually

has

one

or

more

of

the

following

characteristics:
extensive
comminution,
marked
displacement of fragments,
or interposition
of soft tissue
and
any one of them
can lead to an incomplete
reduction.
We
amount

believe
of

that
residual

whenever
dorsal

fracture

angulation

is
after

unstable,
reduction

no
is

permissible.
Adequate
reduction
requires
that the full dorsal length
of the radius
be restored
and maintained.
This
requires
a stable volar buttress
plus dorsal tension
by tissue
or an apparatus
that prevents
dorsal
collapse.
Otherwise
the force
of active
finger
flexor
and extensor
tendons,
combined
with dorsal
translation
of the lunate,
tends
to

including
open

the use
reduction

of external
is indicated.

pin

fixation,
Definite

is not
criteria

for open
reduction
of Colles
fractures
have
not been
completely
formulated,
but for the present
the technique
should
be more strongly
considered
for use in young
adults
in whom
comminuted,
unstable
intra-articular
fractures
have
been
treated
unsuccessfully
by closed
reduction
techniques.
The incidence
of complications
from Cobbes fractures
reported
here does not differ
significantly
from the types
and frequency
of problems
reported
noted
the significant
sequebae
of

by others
radio-ubnar

Frykman
arthrosis

(18.6 per cent),


shoulder-hand
syndrome
(2 per cent),
and
peripheral
neuropathy
(3.5 per cent)
in his series
of 430
cases.
He found
that symptoms
at the distal
radio-ubnar
joint were most frequently
related
to fractures
into the joint
(41 per cent) combined
with dorsal angulation
and shortening of the distal end of the radius.
Lippman
and Lidstr#{246}m
had similar
findings
(10 per cent and 15 per cent mcidences
of radio-ulnar
arthrosis,
respectively)
and stressed
that radio-ulnar
instability
was the most common
cause of
a poor

result.

Gartland

and

Werley

reported

an incidence

of arthrosis
of 22 per cent. In combining
both
and radio-ulnar
arthroses,
we found
symptoms
significant
enough
to require
surgical
treatment
seven

(6.5

per

cent)

Shoulder-hand
of patients
reviewed

of 526

radiocarpab
that were
in thirty-

patients.

syndrome
was present
in 1 .4 per cent
by Bacorn
and Kurtzke,
in 3.4 per

cent in Rosens
series,
and in 10 per cent
ries of 515 patients.
The latter
included
ness and S#{252}decks atrophy.
Unsatisfactory

in Lidstr#{246}ms sefinger-joint
stiffresults
were re-

ported
in 67 per cent. The incidence
in our series
was four
( 1 1 per cent) of 356 local patients
While affected
patients
are fewer in number,
this complication
is the most difficult
to treat,
and prevention
by the techniques
described
by
.

Moberg
should
be studied.
Peripheral
neuropathy
as a serious
complication
was
not noted by others
to be as frequent
as we have reported
it
to be (forty-five
patients
over-all
and twenty-one
[3.7 per
cent]
of patients
who
were
primarily
under
our care).

THE JOURNAL

OF BONE

AND

JOINT

SURGERY

COMPLICATIONS

Lidstr#{246}m believed

that

tures of the distal


per cent).
Bacorn
per cent
1 ,000
were

and

Schlesinger

fractures.
due

concern
sequelae.

nerve

end of the
and Kurtzke
We

in part

and

are

rare

after

radius
(slightly
more
reported
an incident
Liss

believe

to a lack

with treatment
Lynch
and

injuries

OF

noted

that

these

of recognition

of the
Lipscomb,

only

one

and

frac-

common

whenever

throsis,
Frykman

and shoulder-hand
found that of eighty

per

throsis,
five (6.3
had shoulder-hand

reports

possibly

fracture
than
Frykman,

619

FRACTURES

than 1
of 0.2
case

negative

COLLES

three

neuropathy
sympathetic

others5
have placed
proper
emphasis
on the causes
of median neuropathy
and the need for aggressive
treatment
in
certain
acute as well as late cases.
Complications
related
to more
than one factor
were

sixteen
(arthrosis

neuropathy,

syndrome
patients

with

per cent) had median


syndrome.
Of our

shoulder-hand
syndrome,
sociated
complications

more

with potential
Robbins,
and

complications

ar-

were
present.
radio-ubnar
ar-

neuropathy
and five
twenty
patients
with

had one or
in ten patients,

in nine patients,
malunion
dystrophy
in five patients).

more
asmedian

in ten patients,
Evidently,

and
these

complications
and others contribute
directly
to the 24 to 27
per cent incidence
of poor functional
results
that has been
reported369
from the treatment
of Colbes
fractures.

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