THE

TREATMENT
WITH

OF

COLLES
WRIST

FRACTURE
DORSIFLEXED

IMMOBILISATION

THE

AJAY

GUPTA

From

LNJP

Hospital,

New

DeThi

In a prospective study, 204 consecutive patients with displaced Colles fractures had closed reduction then plaster immobilisation. Three different positions ofthe wrist in plaster were randomly allocated: palmar flexion, neutral and dorsiflexion. The results in the three groups were compared. Fractures immobilised with the wrist in dorsiflexion showed the lowest incidence of redisplacement, especially of dorsal tilt, and had the best early functional results. Immobilisation of the wrist in palmar flexion has a detrimental effect on hand function; it is suggested that it is also one of the main causes for redisplacement of the fracture. This is discussed in relation to the functional anatomy of the wrist and the mechanics of plaster fixation. Colles fracture is a very common injury, but there is no agreement on the best way of treatment. A wide variety ofmethods have been described, including reduction and immobilisation of the wrist and forearm in various
immobilised with the wrist in palmar flexion, 75 in

open
quite

positions, percutaneous reduction with

pinning, external internal fixation.

fixation

and

Although easily,

a Colles fracture can usually be reduced it is difficult to maintain the reduction,

there is comminution or intra-articular

especially

where

extension. Gartland and oftheir patients healed When the wrist is there is a risk ofstiffness
metacarpophalangeal

Werley (1951)reported that 60% in an unreduced position. immobilised in palmar flexion, ofthe fingers, and especially the
This is a common compli-

joints.

cation 1953). hand,

results

(Gartland Dorsiflexion so it was

of and

and Werley 1951 ; Bacorn and Kurtzke is the best functional position for the decided to evaluate and compare the
of Colles fractures in three

immobilisation

different
neutral

positions
dorsiflexion.

of the

wrist

joint

: palmar

flexion,

neutral position and 69 in dorsiflexion. Selection was made on a random basis. There were 122 women and 82 men, with 106 left sided and 98 right sided fractures. The mean age of the patients was 46 years (range 18 to 74), evidence of the younger population at risk in India. Management. Anteroposterior and lateral radiographs were taken of both the injured and the uninjured wrists. The fractures were manipulated under intravenous diazepam and pentazocine sedation, using manual traction with the forearm in pronation. A below-elbow plaster cast was applied, and moulded very carefully around the fracture. The distal radial fragment was pressed in a volar direction with counter pressure against the proximal fragment in a dorsal direction (Fig. la). This local moulding holds the fracture in flexion, maintaining the normal anterior tilt of the distal radial articular surface. While the surgeon was moulding the plaster, an
assistant, holding the fingers, moved the wrist to the

PATIENTS

AND

METHODS

selected position dorsiflexion(Fig.

is applied carpal to the bones. This

of palmar flexion, lb). It is essentialthat

lower end of the ensured is best

neutral position or the volar pressure

radius if the and wrist not to the is moved

A prospective study was made of204 consecutive patients with displaced Colles fractures at LNJP Hospital, New Delhi from June to November 1986. Of these, 60 were

A. Gupta,

MS Orth,
Medical

Assistant
College

Professor
and

in Orthopaedics
Hospital, New Delhi 110

Maulana Azad 002, India.

LNJPN

1991 British Editorial Society ofBone 030l-620X/91/2082 $2.00 JBoneJointSurg[Br] 1991; 73-B:312-5.

and Joint

Surgery

___________

into dorsiflexion : volar pressure can then only be applied to the distal radius. The final movement, as the plaster hardened was to bring the wrist into slight ulnardeviation. At the extremes of flexion or extension of the wrist, the joint is locked (Weber 1984) and ulnar deviation can take place only at the fracture site. This helps to maintain the normal alignmentofthe distal radialsurface. A check radiograph was taken the next day, and again after 10 days. Plaster
THE JOURNAL OF BONE AND JOINT SURGERY

312

THE

TREATMENT

OF COLLES

FRACTURE

313

Fig. Ia Figure 1a - The fragment. Figure cast 1b is moulded around the fracture A well moulded cast, with the

Fig. lb by pressing the distal fragment in a volar direction, with counter pressure wrist in dorsiflexion making a tube with a double curve in an S shape. on the proximal

was after

kept five

intra-articular,

on for six weeks, in which weeks.

except where the fracture was case the plaster was removed

V (28%).

The

distribution

of these

types

according
I. (five months

to

position of immobilisation The average follow-up

to two

is given in Table was 1 5 months

Review.

Fractures

were

classified

radiographically

into

five types : type I were undisplaced and extra-articular; type II, undisplaced with intra-articular involvement; type III displaced, extra-articular but with no comminution ; type IV, displaced, extra-articular with comminution ; and type V displaced Types I and II were excluded with articular involvement. from the study. There were

years). Measurements ofvolar tilt, radial deviation and radial length before reduction were made on anteroposterior and lateral radiographs, of the injured and the uninjured wrist. Measurements were repeated on the postoperative, 10-day, and last available review films.

94 type

III fractures

(46%),

53 type

IV (26%),

and 57 type Anatomical

reduction

RESULTS results.
the mean

The angulation

deformities
angulation

were

severe.
was

Before

dorsal

30#{176} (14#{176} to

41#{176}), mean
Table 1. Position of immobilisation the wrist and the type ofdisplaced fracture Type III Palmar flexion (n = 60) 75)
= 69)

radial

was 16#{176} to 20#{176}) mean (6#{176} and

of Colles

shortening volar tilt der Linden

of the radius was 13 mm (5 to 20). Normal is 10#{176} normal and radial angulation is 22#{176} (van and Ericson 1981).

of fracture IV 17 19 17 53 V 15 22 20 57

28 34 32 94

Table II shows the loss of position which occurred between the postoperative and the 10-day radiographs. Little difference was found between the 10-day and the latest follow-up films.

Neutral

(n

In type
least

IV and usually

V injuries maintained

the loss of volar

in dorsiflexion

tilt was
(Fig. 2).

Dorsiflexion(n Total
*

in fractures

immobilised

Volar

tilt was

in this

group

even

if

III, extra-articular IV, extra-articular v, intra-articular

no comminution with comminution

there was was almost tion. Loss

significant collapse. Loss of radial angulation the same in all three positions of immobilisaof radial length was greatest after immobilisa-

Table

H.

Loss

of position

in three

types

of displaced

Colles

fracture

after

immobilisation

of the

wrist

in different

positions
Volar

(mean

and range) Radial tilt (degrees)

V 10 0to32 6 Oto3O 3 Otoll III 2 Oto5 1 Oto3 2 Oto6 IV 5 Otol6 8 Otol7 5 ltol3 V 6 2tol4 8 2to18 4 Otol2 ShOrt ening HI 1 Oto6 2 Oto8 1 Oto3 ofradi IV 4 Otol4 6 Otol8 2 Oto us(mm) V 3 Otoll 8 Otol8 2 OtolO

lii t (degrees) IV 8 0to28 8 Oto3l 2 OtolO

Position of immobilisation Palmar flexion

III 2 Otoll 1 Oto I Oto

Neutral
Dorsiflexion

VOL.

73-B,

No. 2, MARCH

1991

314

A. GUPTA

tion in the neutral

position

and least
In the type position

in those

immobilised

in dorsiflexion (Table II). articular, no comminution)the

III fractures (extraof immobilisation criteria with of the

of the wrist
Functional Sarmiento

made

no significant

difference.

results. These et al (1975).

were assessed by the Fractures immobilised

wrist in dorsiflexion had the best results (Table III). Comparison of various joint movements with those on the uninjured side showed that fractures immobilised in palmar flexion had more joint stiffness, particularly of the metacarpophalangeal and interphalangeal joints. Even in Type III fractures, where the position of
immobilisation of the wrist did not significantly affect
Fig. 2a
Fig. 2b

the anatomical result, immobilisation provided the best recovery of function

in dorsiflexion (Table III).

DISCUSSION Colles fracture can be difficult to treat : the major problem is maintenance of reduction. This is partly due to its anatomical site, adjacent to the multilinked system of the carpus, and partly to our poor understanding of the mechanics of the fracture itself. The carpal bones transmit forces from the hand to the forearm, but are under no direct motor control. The main force-bearing column ofthe wrist includes the distal
radial articular ofthe surface, second and the lunate and the proximal (Weber two-

Fig.

2c

Fig. 2d

thirds
joints

of the scaphoid,

the capitate,
third

the trapezoid

and the
1984).
.

metacarpals

Colles fracture breaks the continuity of this column proximally, so the main muscle forces influencing displacement are those acting on the whole column. These are the wrist flexors and extensors inserted at the
bases of the second and third metacarpals.

After a Colles fracture, whatever the position of the wrist, the extensors of the carpus tend to increase the posterior displacement of the fracture while the wrist flexors act in the direction of over reduction. The radial extensors of the wrist are more powerful than the radial flexors (Von Lanz and Wachsmuth 1959). This implies that the best position for immobilisation with balanced
forces is dorsiflexion, where the wrist extensors are placed

Fig.2e

Fig.

2f

Radiographs of a type IV fracture. Figures 2a and b - Before reduction. Figures 2c and d - The wrist in dorsiflexion in a below-elbow cast. Correction of volar tilt has been possible only to 0#{176}. Figures 2e and f Final radiograph shows healing with no further deterioration in the volar tilt.

at a relative mechanical disadvantage. The periosteal hinge on the concave, dorsal side of a Colles fracture can be an important stabilising factor. When it is intact, it prevents over reduction ; it should be exploited by being kept under tension by slight volar angulation at the fracture. Tension can be maintained in the periosteal hinge by moulding the plaster in the direction of over correction. Flexion at the fracture site
is important since it makes the best use of the dorsal

Table

III.

Functional

results

in displaced

Colles group position F 7 8 5 20 27 P 1 3 411 8 11

fractures

after

immobilisation with number and percentage

Palmar Type of fracture III Iv V E 9 5 5 19 Percentage E, excellent; 34 G 11 5 4 20 33

the

wrist

in different
treatment Neutral

positions,

showing

of each flexion* F 7 3 2 12 20 P 1 4 4 9 13

Dorsiflexion E 20 9 G 8 6 5 40 58 19 28 F 4 20 31 9 13 1 1 P 0

E 13 4 6 23 30 P, poor

G 13 4 7 24 32

periosteal hinge, but the flexed position need not be maintained at the wrist joint. When the wrist is palmar flexed the dorsal carpal ligament, attached mainly to the dorsal aspect of the triquetrum, limits flexion of the proximal carpal row, so that most palmar flexion takes place at the mid-carpal

G, good;

F, fair,

THE

JOURNAL

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AND

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SURGERY

THE

TREATMENTOF

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FRACTURE

315

Radius Raduu1 . \ carpal ligament Dorsal Volar radiotriquetral ligament

Distal carpal row carpal Proximal

Radiocapitate ligament

row Deforming forces PALMAR FLEXION DORSIFLEXION

Fig. 3b lack of an parallel, in anteriorly.

Fig. 3a

In palmar flexion the dorsal carpal ligament is taut, but cannot stabilise the fracture because of its attachment to distal carpal row. The deforming forces and the potential displacement of the fracture are the same direction. In dors(flexion, the volar ligaments are taut and tend to pull the fracture fragment The deforming forces act at an angle which tends to reduce the displacement of the fracture.

radius, and resist any deforming volar pull on the distal fracture Moreover, forces applied in the

forces by providing a fragment (Fig. 3b). line of the dorsiflexed

carpus
Palmar flexion

act at an angle which tends to reduce the fracture. In palmar flexion these forces act in a direction tending to increase displacement (Figs 3a and 3b). In a grossly comminuted fracture some collapse is probably inevitable, but this is likely to be minimised when the wrist is immobilised in dorsiflexion. Figure 4 shows that collapse or impaction, especially of the dorsal cortex, is more likely inside a straight or smoothly curved

Neutral

tube

than

in a tube

with

a double

curve

in an 5 shape.

Conclusion.

After

manipulation

of a Colles

fracture,

immobilisation to provide better and evaluation

party

of the wrist maintenance are required.

have been

in dorsiflexion ofreduction.

would appear Further trials

No benefits
commercial
article.

in any form
related

received
or indirectly

or will be received
to the subject

from
of this

directly

Dorsiflexion
Fig. 4

The fracture will collapse most easily inside a straight tube. When the wrist is dorsiflexed, the plaster forms a tube with a double curve in an S shape.

REFERENCES Bacorn RW, Kurtzke from the New Bone Joint Surg JF. Colles fracture : a study of two thousand cases York State Workmans Compensation Board. J [Am] 1953 ; 35-A :643-58. CW. Evaluation of healed 1951 ; 33-A :895-907. Colles fractures. fractures: 1975 ; 57its J J

Gartland JJ Jr, Werley BoneJoint Surg[AmJ

articulation, This lack radial the carpus, extension, radiotriquetral these

VOL.

where of control ofthe

there is no dorsal ligament at mid-carpal level allows wrist to rotate the proximal

(Fig. 3a). the strong row of into

Sarmiento A, functional A:31l-7.

Pratt GW, Berry NC, Sinclair WF. Colles bracing in supination. J Bone Joint Surg [Am]

extensors

van

together with with consequent

the distal radial fragment, loss of reduction.

der Linden W, Erlcson R. Colles fracture : how should displacement be measured and how should it be immobilized? BoneJoint Surg[Am] 1981 ; 63-A:l285-8. Lanz T, Wachsmuth Springer-Verlag, 1959. ER. segment Concepts of the W. Praktische Anatomic. 2nd ed. Berlin:

By contrast,
and both stabilise

when
rows
1991

the wrist

is dorsiflexed
ligaments with respect

the volar
become taut: to the

Von Weber

radiocapitate

of the carpus

governing the rotational carpus. Orthop C/in North

shift of the intercalated Am 1984; 15:2:193-207.

73-B, No. 2, MARCH