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ORTHOPAEDIC ESSENTIALS

Colles Fracture
Linda L. Altizer

Many people slip and fall, especially in the icy areas of the winter season. To prevent an injury to the head, most people put their hand out to hit the ground rst, so the wrist usually gets injured. The most frequent injury from this type of intervention is a fracture to the distal radius and/or ulna, which is frequently called a Colles fracture.

hy is a distal radius fracture called a Colles fracture? Originally, in 1814, Dr. Abraham Colles, an Irish surgeon and anatomist, dened a distal radial fracture as a lowenergy, extra-articular fracture to the distal radius in the elderly population. Since that time, several aspects of Dr. Colles denition have changed. It is no longer considered a low-energy injury and is not specic to being an extra-articular fracture. In addition, the elderly is not the only population with high incidence of Colles fracture. In the younger population, the number of distal radial fractures has increased because of the sports activities that have been incorporated into the junior and senior high school curricula. In general, the radius is the most common fractured bone in the arm and the distal radius, and is a very common site. The ulna, a parallel bone with the radius, is frequently fractured with a distal radial fracture because of the similar location and force impact site (see Figure 1). The basic goal of treatment in a Colles fracture is to restore the anatomic position of the distal radius with the full range of motion of the wrist that is painless. Each fracture is assessed individually because Colles fractures differ according to the angulation, fragmentation, and stability of the fracture. The distal radius includes triangular and biconcave contours with hyaline cartilage coverage (see Figure 2). The cortical bone in the distal radial metaphysic is thin and susceptible to fracture with heavy force. The distal radius fracture is sometimes defined by two different names. A Colles fracture is a fracture of the distal radius within 2 cm of the distal radius including dorsal displacement of the distal fragment. The confusing situation of a distal radial fracture is when another term may be used. This may occur when a fracture within the distal 2 cm of the radius with palmar and proximal
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displacement of the distal fragment is defined as the Smiths fracture. To add more confusion, a distal radial fracture may also be termed a Bartons fracture, which may be used for subluxation of the wrist consequent to a fracture through the articular surface of the carpal extremity of the radius (Barton, 1838, p. 365). The mechanism for this type of injury is described as a force encountered by the palm of the hand that forces the carpal bones against the dorsal edge of the radial dorsal surface that causes a dorsal fracture and subluxation of the carpus.

Mechanism of Injury
The most frequent injury for a distal radial fracture occurs when the hand and arm are extended and placed down to prevent a fall. The wrist is often hyperextended, and the blunt force impacted on the wrist upon contact with the oor (or other surface) is very intense at the point of contact (see Figure 3). This is still an issue with those over the age of 50, especially those with osteoporosis, which is a condition of low bone density. The older generation tends to be more unstable with ambulation and have a high risk of falling, and fracture is more common in an elderly patient with osteoporosis or osteopenia. A distal radial fracture can also be caused by anything that forces dorsiexion of the wrist without attempting to prevent a fall. The density of the bone is very low and the bone tissue is not as strong as the nonosteoporotic bone tissue. The actual type of injury depends on the position of the wrist on impact and the magnitude and direction of the force on impact. When a fall occurs and the outstretched hand has the wrist in a 40 to 90 dorsiexion, a fracture of the distal radius occurs with dorsal displacement (Frykman, 1967). A fracture of the ulnar styloid in a Colles fracture results from the force through an intact triangular brocartilage complex. A distal radial fracture with palmar displacement can also occur with an impact on the back of a hand that is exed. This
Linda L. Altizer, MSN, RN, ON, CLNC, Armed Forces Medical Examiners office. The author has no signicant interest, nancial or otherwise, to any company that might have an interest in the publication of this educational activity.

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FIGURE 3. Falling with the wrist hyperextended, with pressure

on the distal radius and ulna.

The Frykman system of identifying the type of Colles fracture has claried many of the previous questions. It does not specify the direction or extent of the fracture displacement. The most recently published system also classies stable versus unstable patterns of Colles fractures, as well as associated lesions and children injuries (see Table 2 and Table 3). FIGURE 1. Anteroposterior radiograph of distal radius fracture suitable for percutaneous pinnin. From Chapman, M.W. Chapmans Orthopaedic Surgery, 3rd edition. Philadelphia, Lippincott Williams, and Wilkins, 2001; 1421. Reprinted with permission.

Assessment
Complete assessment is vital in extremity injuries, and accurate diagnosis defines the proper treatment. The sensation in the distal digits should be continuously monitored. If the patient is alert, it is possible to detect whether the sensory level is decreasing. The median nerve status gets prime attention. If the patient has an extremely edematous wrist with an obvious decrease in median nerve function, carpal canal pressures are evaluated and used to determine the diagnosis of median nerve contusion or acute compressive neuropathy. If the diagnosis is median nerve contusion, it would require continuous monitoring. If acute

most frequently occurs with the forearm supinated at the time of fall. Because of the confusion with identifying all the types of Colles fractures, Frykman developed and published a comprehensive classication of the Colles fractures that were based on the types of fractures of the distal radius and ulna (Frykman, 1967) (see Table 1).

TABLE 1. FRYKMANS CLASSIFICATION OF COLLES FRACTURE

Type I II III IV V VI Fracture Extra-articular radial fracture Extra-articular radial fracture with an ulnar fracture Intra-articular fracture of the radiocarpal joint without an ulnar fracture Intra-articular fracture of the radius with an ulnar fracture Fracture of the radioulnar joint Fracture into the radioulnar joint with an ulnar fracture Intra-articular fracture involving radiocarpal and radioulnar joints Intra-articular fracture involving radiocarpal and radioulnar joints with an ulnar fracture

FIGURE 2. Anterior distal end of the radius and ulna. From

Kaplan EB, Taleisnik J. The Wrist. In Spinnter M, ed. Kaplans Functional and surgical Anatomy of the Hand, 3rd ed. Philadelphia: JB Lippincott, 1984. Reprinted with permission.

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TABLE 2. A PRACTICAL, TREATMENT-ORIENTED CLASSIFICATION OF FRACTURES OF THE DISTAL RADIUS AND ASSOCIATED DISTAL RADIOULNAR JOINT LESIONS. BY DIEGO L. FERNANDEZ

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Children Fracture Equivalent Displacement Pattern Uncommon Number of Fragments Distal forearm Fracture Unstable Salter II Stable Stability/ Instability: High Risk of Secondary Displacement After Initial Adequate Reduction Recommended Treatment Associated Lesions Carpal Ligament, Fractures, Median, Ulnar Nerve, Tendons, Lpsilat., fx Upper Extremity, Compartment Syndrome Non-displaced Dorsally (Col-lesPouteau) Volarly (Smith) Proximal Combined Two-part Three-part Comminuted Common Less uncommon Always 2 main fragments varying degree of metaphyseal comminution (Instability) Conservative (stable fxs) Percutaneous pinning (extra- or intrafocal) External xation (exceptionally bone graft) Open Reduction Screw-plate xation Salter IV Unstable Dorsal Radial Volar Proximal Combined Salter III, IV, V Unstable Stable Non-displaced Dorsal Radial Volar Proximal Combined Two-part Three-part Four-part Comminuted Conservative closed, limited, arthroscopic assisted, or extensile open reduction Percutaneous pins combined external and internal xation bone graft Two-Part (radial styloid ulnar styloid) Three-part (volar, dorsal margin) Comminuted Dorsal Radial Volar Proximal Combined Unstable Very rare Dorsal Radial Volar Proximal Combined Frequent Closed or open reduction Pin or screw xation Tension Wiring Very rare Unstable Combined fractures (I-II-III-IV) high-velocity injury Comminuted and/or bone loss (frequently intraarticular open, seldom extraarticular) Always present Combined method

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Fracture Types (Adults) Based on the Mechanism of Injury

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Type I Bending fracture of the metaphysis

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Type II Shearing fracture of the joint surface

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Type III Compression fracture of the joint surface

Type IV Avulsion fractures, radio carpal fracture dislocation

Type V

Note. From Chapman, M.W. Chapmans Orthopaedic Surgery, 3rd edition. Philadelphia, Lippincott Williams, and Wilkins, 2001; 1417. Reprinted with permission.

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TABLE 3. FRACTURE OF THE DISTAL RADIUS: ASSOCIATED DISTAL RADIOULNAR JOINT (DRUJ) LESIONS

Patho-Anatomy of the Lesion A Avulsion fracture tip ulnar styloid B Stable fracture ulnar neck None Good A B

Degree of Joint Surface Involvement Prognosis

Recommended Treatment

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Stable (following reduction of the radius the DRUJ is congruous and stable) None Chronic instability Painful limitation of supination if left unreduced Possible late arthritic changes A B A A

Functional after treatment Encourage early pronationsupination exercises Note: Extraarticular unstable fractures of the ulna at the metaphyseal level or distal shaft require stable plate xation

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Type II

Unstable

(subluxation or dislocation of the ulnar head present)

A Substance tear of TFCC and/or palmar and dorsal capsular ligaments

B Avulsion fracture base of the ulnar styloid

Closed treatment Reduce subluxation, sugar tong splint in 45 of supination four to six weeks

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Operative treatment Repair TFCC x ulnar styloid with tension band wiring Immobilize wrist and elbow in supination (cast) or transx ulna/radius with k-wire and forearm cast Present A

A Intraarticular fracture of the sigmoid notch B Intraarticular fracture of the ulnar hand Dorsal subluxation possible together with dorsally displaced die punch or dorsoulnar fragment B Risk of early degenerative changes and severe limitation of forearm rotation if left unreduced Anatomic reduction of palmar and dorsal sigmoid notch fragments. If residual subluxation tendency present immobilize as in type II injury Functional after treatment to enhance remodelling of ulnar head If DRUJ remains painful: partial ulnar resection, Darrach or Sauve-Kapandji procedure at a later date

Type III

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Note. From Chapman, M.W. Chapmans Orthopaedic Surgery, 3rd edition. Philadelphia, Lippincott Williams, and Wilkins, 2001; 1418. Reprinted with permission.

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Treatment
Treatment outcomes are based on goals of achieving anatomical alignment of the injured area and maintaining that alignment until the fracture is healed, and during that healing time, maintaining the innervations of the nerves supplying motion and sensation to the extremity. When the wrist is put in a cast, an x-ray lm is obtained 2 weeks later to make sure the fracture has not been displaced while in the cast. Sometimes displacement does occur in the cast, and the fracture requires repeat reduction and stabilization. Colles fractures that are noncomminuted and are nondisplaced are usually managed with a splint. Smiths fractures are sometimes casted or splinted in supination. Percutaneous pinning is sometimes used to maintain alignment if traction reduces the fracture to proper position. If the fracture is comminuted and cannot be reduced and maintained in proper position with a cast, the choice of treatment may be external xation. External xation often restores the length and intra-articular alignment of the fracture (see Figure 4). Open reduction and internal xation are sometimes necessary to manage a displaced intra-articular fracture with palmar dislocation of the carpus. This fracture tends to be very unstable and is difcult to reduce and stabilize. Internal xation can be performed with pins or a plate or both (see Figure 5). An arthroscopically assisted reduction via external or internal fixation of the fraction can be another option. There is less ability with the scope to visualize the surrounding ligaments that may also be injured (see Table 4).

FIGURE 4. External xation for Colles fracture. From AltizerSalvagno Center for Joint Surgery.

carpal tunnel syndrome is determined, immediate operative decompression would be the treatment of choice. Neurovascular (N/V) assessment should be performed on the entire hand including all digits. This includes radial and ulna pulses and the ability to ex and extend each interphalangeal joint. The ngers should also have the ability to abduct and adduct. The sensation at the tip of each nger and the thumb is also assessed. If the patient is hospitalized, the nding of N/V assessment is documented and the trends of change are evident. An x-ray lm of the wrist will display the direction of displacement, degree of shortening, and comminution, compression, and involvement of the articular surface.

TABLE 4. UNIVERSAL CLASSIFICATION OF DISTAL RADIUS FRACTURES

Classication of Fracture I. Nonarticular, nondisplaced II. Nonarticular, displaced A. Reducible, stable B. Reducible, unstable C. Irreducible III. Articular, nondisplaced IV. Articular, displaced A. Reducible, stable Treatment Preference Cast immobilization Cast immobilization Percutaneous pins Open reduction/external xation

B. Reducible, unstable

C. Irreducible D. Complex

Closed reduction, percutaneous pin (K-wires) Closed reduction, external xation ( percutaneous pins) ORIF percutaneous pins ORIF; plate xation bone graft ( percutaneous pins)

FIGURE 5. Open reduction, internal xation for Colles fracture.

From Altizer-Salvagno Center for Joint Surgery.

Note. From Fractures of the Distal Radius. A Modern Treatmentbased Classication, W. Cooney, 1993, Orthopaedic Clinic, 24, p. 211.

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Postreduction Instructions
Regardless of how a Colles fracture is treated, all patients are instructed to elevate the hand above the elbow and move their ngers frequently. The application of ice for the rst 24 hr is helpful to reduce pain and decrease edema. A complete teaching session should be given to the patient to educate them regarding the red ags that may occur and need physician notication immediately. These symptoms include the following: discoloration of nail beds edema tingling or numbness in ngers decreased motion ability decreased sensation in ngers severe pain

occur with the Colles fracture and will be the main cause of chronic wrist pain. Other possible complications may include arthritis or median nerve damage/compression, which usually leads to carpal tunnel syndrome. Any patient with a Colles fracture who is older than 50 should be recommended to be screened for osteoporosis because the earlier this disease is recognized, the better the outcome. Osteoporosis has been shown to be a factor in approximately 250,000 cases of wrist fractures. If there is a known risk for osteoporosis in addition to Colles fracture, screening is extremely important.

REFERENCES
Altizer-Salvagno Center for Joint Surgery, Robinwood Medical Center, Hagerstown, MD. Barton, J. (1838). Views and treatment of an important injury to the wrist. Medical Examiner, 1, 365. Chapman, M. (2001). Chapmans operative orthopaedic surgery (Vol. 2, 3rd ed). Philadelphia: Lippincott, Wilkins & Williams. Cooney, W. (1993). Fractures of the distal radius. A modern treatment-based classication. Orthopaedic Clinic, 24, 211. Frykman, G. (1967). Fractures of the distal end of the radius, including sequelaeshoulder, hand, finger syndrome, disturbance in the distal radioulnar joint and impairment of nerve function: A clinical and experimental study. Acta Orthopaedica Scandinavica, 108(Suppl.), 1.

Physical therapy is used when the fracture is healed, and activity in the hand can strengthen the muscles and ligaments associated with the hand and increase range of motion. Therapy is designed for the severity of the fracture, the age of the patient, any functional demands that are required by his or her occupation or activities at home, and to accommodate any postinjury problems that he or she may have. Many patients heal well post-Colles fracture with no complications, but some may not regain full range of motion of the affected wrist. A ligament injury may also

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