The term Colles fracture is classically used to describe a fracture at the
distal end of the radius, at its cortico-cancellous junction. However, now the
term tends to be used loosely to describe any fracture of the distal radius,
with or without involvement of the ulna, that has dorsal displacement of the
fracture fragments.
[3]
Classical Colles fractures have the following characteristics:
• Transverse fracture of the radius
• 1 inch (2.5 cm) proximal to the radio-carpal joint
• dorsal displacement and angulation
Typical Plain Film Findings
• Dorsal tilt
• Radial shortening
• Loss of ulnar inclination
• Radial angulation of the wrist
• Dorsal displacement of the distal fragment
• Comminution at the fracture site
• Associated fracture of the ulnar styloid process in more than 60% of
cases.
• A Barton's fracture is an intra-articular fracture of the distal radius
with dislocation of the radiocarpal joint.
[1]
• There exist two types of Barton's fracture - dorsal and palmar, the
latter being more common. The Barton's fracture is caused by a fall
on an extended and pronated wrist increasing carpal compression force
on the dorsal rim. Carpal displacement distinguishes this fracture from
a Smith's or a Colles' fracture. Treatment of this fracture is usually
done by open reduction and internal fixation with a plate and screws,
but occasionally the fracture can be treated conservatively.
Barton's Fracture
• Intra-articular fracture of the dorsal margin of the distal radius
• Extends into radio-carpal joint
A chauffeur's fracture is an is an oblique fracture of the radial styloid process
with extension into the radiocarpal joint. It is named for the fracture sustained by
chauffeurs (french for someone who warms the car engine) who had to hand-
crank their engines. These tended to backfire and deliver a force to the thenar
aspect of the wrist under ulnar deviation and supination.
Examination
Swelling, deformity, tenderness and loss of wrist motion are normal features
on examination of a patient with a distal radius fracture. Examination should
rule out a skin wound which might suggest an open fracture. It is imperative
to check for loss of sensation, loss of circulation to the hand, and more
proximal injuries to the forearm, elbow and shoulder.
[edit] Injuries associated
The most commonly associated injury is to the ulnar styloid. Styloid
fractures can occur either to the very tip of the styloid or at the base.
Because the triangular fibrocartilage (TFCC) attaches to the base of the ulna
styloid, displaced fractures can result in instability of the distal radio-ulnar
joint. Carpal bone fractures such as those to the scaphoid have been
described, whereas instability or dislocations of the wrist are seen with
certain types of distal radius and ulna fractures. Injuries to the elbow,
humerus and shoulder are also common after a FOOSH (fall on out-
stretched hand). Swelling and displacement can cause compression on the
median nerve across the wrist, an acute carpal tunnel syndrome. Very rarely
is pressure on the muscle components of the hand or forearm sufficient to
create a compartment syndrome.
[edit] Diagnosis
Diagnosis may be evident clinically when the distal radius is deformed but
should be confirmed by x-ray. The differential diagnosis includes scaphoid
fractures and wrist dislocations, which can also co-exist with a distal radius
fracture. Occasionally, fractures may not be seen on x-rays immediately after
the injury. Delayed x-rays, CT scan, or MRI will confirm the diagnosis.
Medical imaging
X-ray of the affected wrist is required if a fracture is suspected. CT scan is
often performed to investigate the articular anatomy of the fracture,
especially if surgery is considered. Investigation of a potential distal radial
fracture includes assessment of the lateral articular angle, radial length,
and subluxation of the distal radioulnar joint. Displacement of the articular
surface is the most important factor affecting prognosis and treatment.
[edit] Articular surface
The articular joint surface must be smooth for it to function properly.
Irregularity may result in radiocarpal arthritis, pain, and stiffness. More than
1 mm of incongruity places the patient at a high risk for posttraumatic
arthritis. Significant articular incongruity typically occurs in young patients
after high energy injuries (Figure 2). If the surface is very irregular and
cannot be reconstructed, then the only option may be a fusion.
Figure 2: X-ray of a displaced intra-articular distal radius fracture in an external
fixator. The articular surface is widely displaced and irregular.
[edit] Lateral articular angle
The lateral articular angle is the angle on an x-ray film between the axis of
the radius and the articular cup. Normally, the angle is turned down toward
the thumb (volar/ventral tilt) by 11°. As pressure is applied dorsally (to the
back of the wrist), malalignment may occur. Alignment up to 0° is still
considered to be functional, and does not require any intervention. However,
tilt away from the thumb (dorsal tilt) beyond this point (>11° deviation)
begins to create biomechanical changes that can lead to arthritis, pain, and
stiffness. When dorsal tilt beyond the acceptable threshold occurs, distal
radio-ulnar joint motion is altered, and forearm rotation becomes restricted.
The upper limit of an acceptable deformity after reduction of the fracture is
20° of dorsal tilt.
[edit] Radial length
Radial length is an important consideration in distal radius fractures. When
the fracture begins to shorten, there is relative lengthening of the ulna
because this is usually not fractured. With increasing relative lengthening of
the ulna, ulnar positive variance, ulnar impaction syndrome may occur.
Ulnar impaction is a degenerative tear of the TFCC and positive ulnar
variance (Figure 3).
Classification
In medicine, classifications systems are devised to describe patterns of injury
which will behave in predictable ways, to distinguish between conditions
which have different outcomes or which need different treatments. Most
wrist fracture systems have failed to accomplish any of these goals and there
is no consensus about the most useful one.
At one extreme, a stable undisplaced extra-articular fracture has an excellent
prognosis. On the other hand, an unstable, displaced intra-articular fracture is
difficult to treat and has a poor prognosis without operative intervention.
Eponyms such as Colles', Smith's, and Barton's fractures are discouraged.
Though the Frykman system has traditionally been used, there is little value
in its use because it does not help direct treatment. The Universal system is
descriptive but also does not direct treatment. Universal codes include:
o Type I: extra articular, undisplaced
o Type II: extra articular, displaced
o Type III intra articular, undisplaced
o Type IV: intra articular, displaced
The system that comes closest to directing treatment has been devised by
Melone:
o I Stable fracture
o II Unstable "die-punch"
o III "Spike" fracture
o IV Split fracture
o V Explosion injuries
However, an anatomic description of the fracture is the easiest way to
describe the fracture, decide on treatment, and make an assessment of
stability.
o Articular incongruity
o Radial shortening
o Radial angulation
o Comminution of the fracture (the amount of crumbling at the
fracture site
o Open (compound fracture) or closed injury
o Associated ulnar styloid fracture
o Associated soft tissue injuries
Treatment
Figure 4: Posttraumatic arthritis of the wrist. Degeneration of the articular
surface before and after resection.
Figure 5: X-rays of a wrist fusion.
Figure 6: X-rays of pins across a distal radius fracture. Notice the ulnar styloid
base fracture, which has not been fixed. This patient has instability of the DRUJ
because the TFCC is not in continuity with the ulna.
The type of treatment required depends on many factors, including
displacement and stability of the fracture fragments.
[edit] Non-operative
[2]
For torus fractures a splint may be sufficient and casting may be avoided.
Where the fracture is undisplaced and stable, non operative treatment
involves immobilization. Initially the wrist is splinted to allow swelling and
subsequently a cast is applied. Depending on the nature of the fracture, the
cast may be placed above the elbow to control forearm rotation.
In displaced fractures, the fracture may be manipulated under anaesthesia
and cast in a position to minimize the risk of re-displacement. Typically,
this involves injecting local anesthesia into the fracture (hematoma block)
possibly combined with intravenous medication. The general principle is to
reverse the mechanism of injury. The typical fracture has the articular
surface facing toward the back side of the hand (dorsal tilt) causing over-
extension of the wrist joint, often with some radial deviation. Therefore, the
preferred position for this type of injury, following reduction, is flexion and
ulnar deviation. This position is safe for only a brief period of time as it
places excess pressure on the median nerve (carpal tunnel syndrome) and
makes maintaining digital motion difficult.
During the period of follow-up, it is common practice to repeat x-rays at
about 1 week to make sure the position is still acceptable. Follow-up is also
needed to determine when the cast may be removed, when the fracture has
healed and when rehabilitation is complete. The critical time after injury is
between 2 and 3 weeks. The swelling will reduce during this time and the
fracture can displace. More than 3 weeks after injury, the fracture will start
to heal which makes options for treatment limited.
The length of time in the cast varies with different ages. Children heal more
rapidly, but may ignore activity restrictions. Three weeks in a cast and 6
weeks off sports may be appropriate for certain fractures. In adults, the risk
of stiffness of the joint increases the longer it is immobilized. If callus is
seen on x-ray at 4 weeks, the cast may be replaced by a removable splint.
However, many hand surgeons leave the patients in the cast for up to 6
weeks. In general, the x-rays will not show any callous until about a month
after the fracture is healed; therefore the cast is removed before the x-rays
confirm that it is healed.
Displaced fractures in the elderly or those physiologically unable to undergo
surgery are treated differently. When the fracture is displaced and there are
no plans for a surgery, a short arm cast is placed for only 4 weeks or until
the tenderness resolves. A larger cast placed for an extended period of time
only slows down recovery in this group of patients.
Following healing and cast removal a period of rehabilitation for recovery of
strength and range of motion is necessary. Patients will continue to improve
after the fracture for 4 to 12 months.
[edit] Reduction
Closed management of a distal radius fracture involves first anesthetizing the
affected area with a hematoma block, regional anesthesia, sedation or a
general anesthetic.
Manipulation generally includes first placing the arm under traction and
unlocking the fragments. The deformity is then reduced with appropriate
closed manipulations (depending on the type of deformity) reduction, after
which a splint or cast is placed and an X-ray is taken to ensure that the
reduction was successful. The cast is usually maintained for about 6 weeks.
Closed treatment is frequently unsuccessful in maintaining a good position in
adults, because there is frequently comminution of the fracture. Re-
displacement and deformity can reoccur with an unacceptable ultimate result.
[edit] Risks of non-operative treatment
Failure of non-operative treatment is common and is the largest risk of an
adverse outcome. Studies have shown that the fracture often re-displaces to
[3]
its original position even in a cast. Only 27% - 32% of fractures are in
[4]
acceptable alignment 5 weeks after closed reduction. In the long term this
increases the risk of stiffness and post traumatic osteoarthritis leading to
wrist pain and loss of function. It is because of these findings that most
surgeons recommend operative intervention if the fracture is displaced
enough to consider a reduction. Ultimately, the fractures that have a closed
reduction usually end up back in the position before the reduction is
attempted.
Stiffness of the wrist is universal following a fracture of the distal radius.
The degree of stiffness in the wrist is dependent on the type of fracture and
the period of mobilization. It is for this reason that an open reduction is
advantageous. It is also quite common for patients to develop digital
stiffness after a fracture of the distal radius. Aggressive movement of the
digits while immobilized or following operative treatment should minimize
the stiffness.
Other risks specific to cast treatment relate to the potential for compression
of the swollen arm causing carpal tunnel syndrome or compartment
syndrome. Carpal tunnel syndrome is related to the position of the wrist,
that is, excess flexion or excess distraction if the wrist is placed in an
external fixator. A compartment syndrome is swelling in the muscle
compartments, usually in the forearm, leading to severe pain, loss of nerve
function and a contracture. Finally, complex regional pain syndrome (reflex
sympathetic dystrophy) is a serious complication following injury and is
thought to be more common after cast immobilization than after surgery.
The provoking factors for regional pain syndromes, however, are very
complex but the condition often leads to chronic pain and stiffness.
[edit] Prognosis following non-operative treatment
In children the outcome of distal radius fracture treatment in casts is usually
very successful with healing and return to normal function expected. Some
residual deformity is common but this often remodels as the child grows. In
the elderly, distal radius fractures heal and may result in adequate function
following non-operative treatment. A large proportion of these fractures
occur in elderly people with limited expectations and little requirement for
strenuous use of their wrists. Some of these patients tolerate severe
deformities and minor loss of wrist motion very well even without reduction
of the fracture. In this low demand group only a short period of
immobilization is indicated as rapid mobilization improves functional
outcome.
In younger patients the injury requires greater force and results in more
displacement particularly to the articular surface. Unless an accurate
reduction of the joint surface is obtained, these patients are very likely to
have long term symptoms of pain, arthritis, and stiffness.}}
[edit] Surgery
Contemporary surgical options have developed that really have
revolutionized treatment of this common injury. Generally, techniques
include Open Reduction Internal Fixation (ORIF), external fixation,
percutaneous pinning, or some combination of the above. The greatest recent
advances have been with operative open reduction and internal fixation
ORIF. An entire market of surgical implants are available to treat this
specific fracture. The two most recent and promising developments have
been fragment specific fixation and fixed angle volar plating. These attempt
fixation rigid enough to allow almost immediate mobility, thus ultimately
less stiffness and greater function is possible. Although restoration of
radiocarpal alignment is of obvious importance, one must not overlook the
alignment of the distal radioulnar joint as this can be a source of a
frustrating pronation contracture down the road.
Each orthopaedic surgeon will treat the fracture according to what his/her
preferences are and what works best for him/her. The surgeon should be
open to discussion of the rationality of the decisions that are made.
Prognosis varies depending on dozens of variables. If the anatomy (bony
alignment)is not properly restored, function may remain poor even after
healing. Restoration of bony alignment is not a guarantee of success, as
there are significant soft tissue contributions to the healing process.
An arthroscope can be used at the time of fixation to evaluate for soft tissue
injury. Structures at risk include the triangular fibrocartilage complex and
the scapholunate ligament. Beware of scapholunate injuries in radial styloid
fractures where the fracture line exits distally at the scapholunate interval.
TFCC injuries causing obvious DRUJ instability can be addressed at the
time of fixation.
[edit] Incidence
Distal fracture of the radius is the most commonly occurring fracture in
adults. It is common in the elderly because of the frequent osteopenia and
osteoporosis in this age group. This is also a common injury in children
which may involve the growth plate. A similar fracture in children involving
the growth plate is called a Salter-Harris fracture. In young adults, the injury
is often very severe because it requires greater force to produce the injury.
References
• ^ Vilke GM (1999). "FOOSH injury with snuff box tenderness". J Emerg
Med 17 (5): 899–900. PMID 10499710.
• ^ "BestBets: Is a cast as useful as a splint in the treatment of a distal radius
fracture in a child". [Link]
• ^ Abbaszadegan H, von Sivers K, Jonsson U (1988). "Late displacement of
Colles' fractures". Int Orthop 12 (3): 197–9. doi:10.1007/BF00547163.
PMID 3182123.
• ^ Earnshaw SA, Aladin A, Surendran S, Moran CG (March 2002). "Closed
reduction of colles fractures: comparison of manual manipulation and finger-
trap traction: a prospective, randomized study". J Bone Joint Surg Am 84-A
(3): 354–8. PMID 11886903.
Fracture Distal Ulnar Fracture:
Absent Present
Extra articular I II
Intra articular involving radiocarpal joint III IV
Intra articular involving distal RU joint V VI
Intra articular involving both radiocarpal & VI VIII
distal radioulnar joints
- Discussion:
- Frykman classification considers involvement of radiocarpal & RU joint,
in addition to presnce or absence of frx of ulnar styloid process;
- classification does not include extent or direction of initial displacement,
dorsal comminution, or shortening of the distal fragment;
- hence, it is less useful in evaluating outcome of treatment;
Fracture of the Distal Radius Including Sequelae--Shoulder-Hand-Finger Syndrome, Disturbance in the Distal
Radio-Ulnar Joint and Impairment of Nerve Function. A Clinical and Experimental Study.
Frykman, Gosta:
Acta Orthop. Scandinavica, Supplementum 108, 1967.
