Colles Fracture

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Clinically Relevant Anatomy

File:Colles fracture.JPG

Colles Fracture

Low energy extra-articular fracture of the distal radius.  Can be associated with ulnar styloid fracture, TFCC tear, scapholunate dissociation.

Mechanism of Injury / Pathological Process

MOI: forced dorsiflexion of the wrist (FOOSH injury)

• Fracture is typically dorsally displaced and angulated
• Dorsal surface undergoes compression, while volar surface undergoes tension
• Typically occurs in elderly individuals.
  

Clinical Presentation

• "Dinner Fork" Deformity
• History of fall on an outstretched hand
• Dorsal wrist pain
• Sweling of the wrist
• Increased angulation of the distal radius
• Inability to grasp object

Diagnostic Procedures

• Radiographic Imaging - dorsally angulated fracture of distal radial metaphysis
• CT Scan

Classifications of Distal Radial (Colles') Fracture

• Universal Classification of Dorsally Displaced Distal Radial Fractures Type I - undisplaced
• Universal Classification of Dorsally Displaced Distal Radial Fractures Type II - displaced
• Melone Type I - undisplaced and minimally comminuted
• Frykman Type I - distal radial fracture without distal ulnar fracture
• Frykman Type II - distal radial fracture with distal ulnar fracture

Outcome Measures

• DASH
• Patient (PRWE)
• Green Score
• O'Brian Score

Management / Interventions

Conservative Treatment

• Immobilization in cast/splint - typically positioned in slight flexion, pronation
• Percutaneous Pinning

Surgical Intervention

• ORIF

Differential Diagnosis

Must differentially diagnose a Colles' Fracture from:

• Carpal fracture/dislocation (particularly scaphoid and lunate)
• Distal ulnar fracture
• Metacarpal fracture

Key Evidence

Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M.  A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating.  J Orthop Trauma. 2009;23(4):237-42.
OBJECTIVES: To compare final functional and radiographic outcomes of closed reduction and casting (CAST) with open reduction and internal fixation (ORIF) with palmar locking plate for unstable Colles type distal radius fractures (DRFs) in low-demand patients older than 70 years. DESIGN: Retrospective, clinical study. SETTING: Level 1 university trauma center. PATIENTS: Over a mean period of 4 years and 7 months, 130 consecutive patients older than 70 years were treated for an unstable dorsally displaced DRF of which 114 or 87% were followed for 1 year or longer. INTERVENTION: ORIF (n = 53) using volar locking plate or closed reduction and casting (n = 61). MAIN OUTCOME MEASUREMENTS: Objective and subjective functional results (active range of motion; grip strength; disabilities of the arm, shoulder and hand (DASH) score; patient-rated wrist evaluation (PRWE) score; visual analog scale; and Green and O'Brien score) and radiographic assessment (dorsal tilt, radial inclination, radial shortening, fracture union, and posttraumatic arthritis) were assessed. RESULTS: At final follow-up, there was no significant difference between the 2 groups for mean ranges of motion, grip strength, DASH score, PRWE score, and Green and O'Brien score. Pain level was significantly less for the patients in the CAST group. An obvious clinical deformity was present in 77% of cast group and none in the ORIF group. At final follow-up, in the ORIF group, there was a mean loss of dorsal tilt of 1.3 degrees, radial inclination of 0.3 degrees, and radial length of 0.5 mm compared with the postoperative measurements. No primary acceptable reduction was achieved in 44% of the CAST group. At final follow-up, in the CAST group, dorsal tilt, radial inclination, and radial shortening averaged -24.4 +/- 12 degrees, 19.2 +/- 6.5 degrees, and +3.9 +/- 2.7 mm, respectively. Malunion occurred in 89% primarily reduced fractures. Dorsal tilt, radial inclination, and radial shortening were significantly better in the ORIF group. CONCLUSIONS: Radiographic results (dorsal tilt, radial inclination, and radial shortening) after unstable dorsally displaced DRFs are significantly better in patients treated by ORIF using a volar fixed-angle plate rather than those treated by cast immobilization (P < 0.05). At a mean follow-up time of 4 years and 7 months, the clinical outcomes of active range of motion, the PRWE, DASH, and Green and O'Brien scores do not differ between the 2 methods of treatment. The pain level was significantly less in the CAST group (P < 0.05), and this group experienced no complications. There was no difference between the subjective and functional outcomes for the surgical and the nonsurgical treatments in a cohort of patients older than 70 years. Unsatisfactory radiographic outcome in older patients does not necessarily translate into unsatisfactory functional outcome. Nonoperative treatment may be the preferred method of treatment in this age group.

Wright TW, Horodyski M, Smith DW.  Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation.  J Hand Surg Am. 2005;30(2):289-99.
PURPOSE: The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixed-angle implant and a standard external fixation (EF) method. METHODS: This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12-84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12-24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups. RESULTS: The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 degrees extension and 57 degrees flexion, compared with 63 degrees extension and 64 degrees flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 degrees volar tilt and 25 degrees radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 degrees volar tilt and 22 degrees radial inclination, with .5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and .4 mm in the ORIF group. CONCLUSIONS: The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction.

Handoll HH, Huntley JS, Madhok R.  External fixation versus conservative treatment for distal radial fractures in adults.  Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006194.
BACKGROUND: Fracture of the distal radius ('broken wrist') is a common clinical problem. It can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation. OBJECTIVES: To evaluate the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared external fixation with conservative treatment. DATA COLLECTION AND ANALYSIS: After independent study selection by all review authors, two authors independently assessed the included trials. Independent data extraction of new trials was performed by two authors. Pooling of data was undertaken where appropriate. MAIN RESULTS: Fifteen heterogeneous trials, involving 1022 adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. While all trials compared external fixation versus plaster cast immobilisation, there was considerable variation especially in terms of patient characteristics and interventions. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment.External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment: 7/356 versus 51/338 (data from 9 trials); relative risk 0.17, 95% confidence interval 0.09 to 0.32) and prevented late collapse and malunion compared with plaster cast immobilisation. There was insufficient evidence to confirm a superior overall functional or clinical result for the external fixation group. External fixation was associated with a high number of complications, such as pin-track infection, but many of these were minor. Probably, some complications could have been avoided using a different surgical technique for pin insertion. There was insufficient evidence to establish a difference between the two groups in serious complications such as reflex sympathetic dystropy: 25/384 versus 17/347 (data from 11 trials); relative risk 1.31, 95% confidence interval 0.74 to 2.32. AUTHORS' CONCLUSIONS: There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.

Gehrmann SV, Windolf J, Kaufmann RA.  Distal radius fracture management in elderly patients: a literature review.   J Hand Surg Am. 2008;33(3):421-9.

Distal radius fracture management in elderly patients remains without consensus regarding the appropriate treatment or anticipated outcome. Forty-one studies that included at least 10 patients with a minimum mean age of 65 years and that were indexed in Medline or Embase were reviewed. Treatment methods included pins and plaster, external fixation, K-wires, bone cement, and open reduction and internal fixation with plates. The methodological quality of each study was evaluated through use of a grading scale. Despite study heterogeneity, higher rates of infection were noted with external fixation and K-wire stabilization. Stratifying patients into low-demand and high-demand groups may improve the management of distal radius fractures in elderly patients. In sedentary patients with low demands, functional outcomes are good despite the presence of deformity. Patients with higher demands may benefit from fracture stabilization with locking volar plates. Volar plating with fixed-angle screws may be particularly suitable for elderly patients who may take longer to heal a fracture, be more susceptible to pin-track infection, and demonstrate earlier tendon irritation leading to rupture.

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