Colles Fracture Notes
Colles Fracture
A Colles fracture is not just a fracture of the lower end of the radius but also a fracture-dislocation of the inferior radioulnar joint.
The fracture typically occurs about 1½ inches (approximately cm) above the carpal extremity of the radius.
Following the fracture, some deformity may persist throughout life, but pain usually decreases, and movements gradually improve.
A Colles fracture is a complete fracture of the radius bone in the forearm, near the wrist, resulting in an upward (posterior) displacement of the radius and a visible deformity.
Dinner Fork Deformity
The fracture results in a characteristic "dinner fork" deformity.
Mechanism of Injury
The most common cause is a fall on an outstretched hand with dorsiflexion ranging from to degrees (average degrees).
Other causes include road traffic accidents, falls from stairs, and other forms of trauma.
Types of Colles’ Fracture
Extra-articular: The fracture does not extend into the joint.
Intra-articular: The fracture extends into the joint.
Clinical Presentation
"Dinner Fork" Deformity is a key sign.
Patients will typically report a history of falling on an outstretched hand.
Dorsal wrist pain is common.
Swelling of the wrist is usually present.
Increased angulation of the distal radius can be observed.
Patients may experience an inability to grasp objects.
Other symptoms include pain, numbness, tenderness, bruising, and deformity of the wrist.
Classification of Colles’ Fractures
Type I: Transverse metaphyseal fracture (includes both Colles and Smith fractures as angulation is not a feature).
Type II: Type I + ulnar styloid fracture.
Type III: Fracture involves the radiocarpal joint (includes both Barton and reverse Barton fractures, and Chauffeur fractures).
Type IV: Type III + ulnar styloid fracture.
Type V: Transverse fracture involves the distal radioulnar joint.
Type VI: Type V + ulnar styloid fracture.
Type VII: Comminuted fracture with involvement of both the radiocarpal and radioulnar joints.
Type VIII: Type VII + ulnar styloid fracture.
Complications
Malunion: This is the most common complication, where the fracture heals in a non-anatomical position.
Rupture of extensor pollicis longus (EPL) tendon: This can occur due to the tendon rubbing over sharp fracture surfaces.
Sudeck’s osteodystrophy (Complex Regional Pain Syndrome): This is due to an abnormal sympathetic response causing vasodilatation and osteoporosis at the fracture site.
Frozen shoulder/hand syndrome: This develops due to unnecessary immobilization of the shoulder, leading to stiffness. Patients may mentally "amputate" the limb by keeping it still.
Carpal tunnel syndrome: Malunion of the Colles’ fracture can compress the median nerve within the carpal tunnel.
Nonunion: This is extremely rare due to the cancellous nature of the bone, which promotes good fracture healing.
Rehabilitation Program
The rehabilitation program aims to achieve specific orthopedic and functional goals.
Orthopedic Goals
To restore the radial length and palmar tilt.
To provide a stable, pain-free wrist.
Normally, the ulna is about cm shorter than the radius (negative ulnar variance). In a Colles’ fracture, this is reversed (positive ulnar variance) due to radial shortening. Rehabilitation aims to restore the negative ulnar variance.
Rehabilitation Goals
To restore the range of motion of the wrist and digits, either fully or to a functional range.
To improve muscle strength in the wrist, thumb, digit flexors and extensors, hypothenar, thenar, lumbricals, and interossei muscles.
Functional Goals
To restore hand functions such as grip, grasp, and pincer grip.
Vital Facts
Bone healing typically takes place in weeks.
The duration of rehabilitation is approximately weeks.
Casts act as stress-sharing devices, while plates act as stress-shielding devices.
The First Week of Rehabilitation
Conservative treatment involves using above or below-elbow casts for undisplaced or slightly displaced, non-comminuted Colles’ fractures.
Closed reduction and casting (above-elbow for intra-articular, below-elbow for extra-articular fractures) is a common treatment method.
Plaster Care
The plaster should fit snugly and not cross the proximal palmar crease and head of the metacarpals dorsally.
The plaster should be regularly checked for tightness, looseness, softening, cracks, and swelling. If any of these are present, the cast needs to be changed.
The sling should be checked for slackness and padding near the neck.
Dependent edema should be treated with hand elevation and retrograde massage, “milking” the swelling from the fingertips to the palm.
Range of Motion
Active range of motion exercises are encouraged for the uninvolved joints (digits, thumb, elbow, and shoulder) to prevent stiffness.
Wrist movements, supination, and pronation are generally not encouraged during the first week.
Isometric exercises for the hand muscles are initiated.
Activities of daily living are carried out with the unaffected hand, and no weight-lifting is allowed with the affected arm.
The Second Week of Rehabilitation
Conservative recasting is advised if the cast is loose, cracked, or slipped distally. An X-ray is taken to check the fracture alignment.
Continue range of motion exercises for the shoulder, elbow, digits, and thumb.
External fixators: Pin sites should be evaluated for signs of infection. Active supination and pronation, along with previously mentioned exercises, are permitted.
Open reduction and internal fixation: The cast/splint is removed, the wound is inspected, and sutures are removed. If fixation is rigid, further immobilization may not be necessary.
Fourth to Sixth Weeks of Rehabilitation
Conservative methods: The cast is removed, and the wrist is checked for stability, tenderness, and range of motion. An X-ray is taken to assess fracture status.
If there is tenderness, motion at the fracture site, or poor callus formation on X-ray, a short arm cast is reapplied.
If these findings are absent, the cast can be discontinued, and full active range of motion exercises can be encouraged.
Methods of Wrist Mobilization
Step 1: To reduce pain, edema, and discomfort, hydrotherapy or thermotherapy may be used in the initial stages.
Step 2: Active wrist mobilization is initiated. The patient sits with the forearm in midpronation over a table, and with the unaffected hand to fix the affected forearm, the patient actively flexes and extends the wrist with gravity eliminated.
Step 3: Self-assisted passive wrist mobilization is begun after about days of active mobilization. The patient sits with the affected hand resting on the edge of the table. Fixing it with the normal hand, the affected arm is lowered below the table (palmar flexion) and raised above the table (dorsiflexion) periodically.
Step 4: Pronation and supination exercises are carried out.
Step 5: Exercises through activity, such as turning keys, doorknobs, scooping beans, and putting them in a box, are helpful in returning the patient to normal function.
Step 6: To improve grip and writing skills, ulnar deviation exercises are encouraged.
Step 7: To regain muscle strength, gentle resistive exercises like ball squeezing are encouraged.
Instruct the patient to carry out day-to-day functional activities with the affected hand. Night splints can be used in cases of pain and discomfort.
Sixth to Eighth Weeks of Rehabilitation
Conservative method: The cast is removed, and a vigorous exercise regimen is carried out.
External fixator: If the fracture is stable, the pins are removed, and the exercise regimen is carried out. However, if the fracture is unstable, a short arm cast is applied for another four weeks.
Term 1: What is a Colles Fracture?
Definition 1: Not just a fracture of the lower end of the radius but also a fracture-dislocation of the inferior radioulnar joint. Typically occurs about 1½ inches (approximately cm) above the carpal extremity of the radius.
Term 2: What is Dinner Fork Deformity?
Definition 2: A characteristic deformity resulting from a Colles fracture.
Term 3: What is the most common cause of Colles’ Fracture?
Definition 3: A fall on an outstretched hand with dorsiflexion ranging from to degrees (average degrees).
Term 4: What are the two main types of Colles’ Fracture?
Definition 4: Extra-articular: The fracture does not extend into the joint. Intra-articular: The fracture extends into the joint.
Term 5: What are common clinical presentations of Colles’ Fracture?
Definition 5: "Dinner Fork" Deformity, dorsal wrist pain, swelling, increased angulation of the distal radius, and inability to grasp objects.
Term 6: What is a Type I Colles’ Fracture?
Definition 6: Transverse metaphyseal fracture (includes both Colles and Smith fractures as angulation is not a feature).
Term 7: What is the most common complication of Colles’ Fracture?
Definition 7: Malunion: where the fracture heals in a non-anatomical position.
Term 8: What are orthopedic goals in the rehabilitation of Colles
Definition 8: To restore the radial length and palmar tilt, and to provide a stable, pain-free wrist. Rehabilitation aims to restore the negative ulnar variance.