Colles Fracture

Original Editor - Stacy S Stone

Top Contributors - Emma Guettard, Carina Therese Magtibay, Admin, Adam Vallely Farrell, Kim Jackson, Stacy S Stone, Laura Ritchie, Rachael Lowe, Anne-Laure Vanherwegen, Nikhil Benhur Abburi, Lauren Lopez, Lucinda hampton, Priyanka Chugh, Benjamin Desmedt, WikiSysop, Scott Buxton, Claire Knott, Anas Mohamed and Evan Thomas - Emma Guettard as part of the Vrije Universiteit Brussel Evidence-based Practice Project

Introduction

A Colles Fracture is a fracture of the distal radius resulting in an upward (posterior) displacement of the radius and obvious deformity. It is commonly called a “broken wrist” in spite of the fact that the distal radius is the location of the fracture, not the carpal bones of the wrist.

The Colles fracture is named after Abraham Colles, an Irish surgeon, who first described it in 1814 by simply looking at the classical deformity before the advent of X-rays.

Clinical Relevant Anatomy

When weightbearing through the hand, the distal radius is responsible for 80% of axial load bearing, making it a common site for injuries. It articulates with two proximal carpal bones (scaphoid and lunate) and distal ulna. These articulations divide the distal radius in 3 columns:

1. Radial column
   • includes radial styloid and scaphoid fossa
   • attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament
2. Intermediate column
   • includes lunate fossa
   • main role is transmitting load from the carpus to the forearm.
3. Ulnar column
   • includes distal ulna and TFCC
   • responsible for distal radioulnar joint stability and forearm rotation

Mechanism of Injury

Fall on outstretched hand or “FOOSH” is the most common cause of Colles fracture. The bending and compressive forces through the wrist result to dorsal displacement and comminution of distal radius. The position of the wrist and the amount of traumatic force determine the severity of the injury.

Epidemiology

Colles fractures are among the most commonly seen orthopaedic cases in the emergency department. High impact trauma usually cause this fracture in younger population while low-energy trauma such as falling is common in older population .

Risk factors:

• post-menopausal women
• sporting activities
• motor vehicle accidents
• obesity
• osteoporosis

Clinical Presentation

The typical clinical presentation of Colles fracture are as follows:

• "Dinner Fork" Deformity - posterior displacement of the distal fragment of radius
• History of fall on an outstretched hand
• Pain at level of wrist
• Numbness
• Limited wrist range of motion
• Swelling
• Decreased grip strength
• Pain with palpation at the anatomic snuff box may indicate scaphoid fracture
• Associated injuries that may also be present - Tenderness in the carpal bones, hand, elbow or shoulder

Diagnosis

Xray is the gold standard diagnostic tool for Colles fracture and other distal radius fractures. The standard xray views taken are lateral and posteroanterior.

CT scan has much higher accuracy in assessing joint involvement, providing a view of the radiocarpal and distal radioulnar joints. It is used to assist in surgical planning.

MRI is not often used in initial assessment but it is helpful in evaluating ligamentous and soft tissue injuries e.g TFCC, scapholunate, lunotriquetral ligament injuries.

Differential Diagnosis

• Carpal Tunnel Syndrome
• Scaphoid fracture
• Ulnar styloid fracture
• TFCC injury
• CRPS
• Carpal ligament injury (Scapholunate ligament, lunotriquetral ligament injuries)
• Compartment syndrome
• DRUJ (Distal Radial Ulnar Joint) Instability
• Smith fracture (also known as 'reverse Colles fracture', involves volar angulation of radius instead of dorsal)
• Galeazzi fracture (fracture to the distal third of the radius with injury of the distal radioulnar joint)
• Barton's fracture (fracture in the intra-articular rim of distal radius)
• Die-punch fractures (intra-articular fracture through the lunate interface of the radius)
• Hutchinson/Chauffer fracture (intra-articular radial styloid fractures)
• Monteggia fracture (ulnar fracture with of radial head dislocation)

Outcome Measures

Physical Objective Measures:

• Range of Motion
• Grip Strength

Self-Reported Outcome Measures:

• Disability of the Arm, Shoulder and Hand questionnaire (DASH)
• Visual Analogue Scale (VAS)
• Patient Rated Wrist Evaluation (PRWE)
• Michigan Hand Outcomes Questionnaire (MHQ)

Medical Management

The treatment of Colles fractures will depend on the type of Colles fracture present, the age and activity level of the patient, the surgeon’s preference, and the patient’s desires regarding immobilisation and return to activity. The ultimate goal is to return the wrist to its prior level of functioning.

Conservative Management

Common treatment for stable, nondisplaced or minimally displaced fractures includes reduction with immobilisation for 6-8 weeks, regularly followed-up by x-ray to ensure bone union.

Colles fractures managed with closed reduction and casting generally heal well provided the following parameters are met:

• articular step off <2 mm
• angulation <5 degrees
• shortening <5 mm

Surgical Treatment

Surgery is indicated when the fracture is unstable, displaced, extends to the joint and is comminuted. Displacement of the fracture after reduction often requires operative treatment.

Surgical options include external fixation, internal fixation, bone grafts and percutaneous pinning.

Physical Therapy Management

The rehabilitation management will depend whether the fracture was treated conservatively or operatively. In a systematic review by Handoll and Elliott, which studied 26 randomised controlled studies, early rehabilitation– starting as soon as possible after the injury – shows potential for better outcomes.

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During immobilisation, instructions for self-care is the minimum standard of care. This includes general advice on immobilisation (eg. not lifting heavier than a teacup), education on pain management, swelling control and home exercises of uninvolved joints such as the neck, shoulder, elbow, thumb and fingers.

After immobilisation, decreasing oedema, restoring range of motion and gradually strengthening the wrist are the goals of rehabilitation.

• Both hot and cold application can be used for swelling and pain management.
• Wrist range of motion exercises: flexion-extension, radioulnar deviation, pronation-supination motions are done actively then passively to optimize functional recovery.
• Scar management: As soon as the wound close, scar mobilisation is recommended to minimise tissue adhesion that can result to tightness.
• Strength exercises: Progressive strengthening of wrist and hand will help restore muscle strength that was weakened by immobilisation.
• Functional activities: exercises should be focused on regaining use of wrist and hand in daily activities. In older patients, a study suggests that resuming activities of daily living early may be as effective as formal therapy.