Colles fracture is a specific distal radius fracture that occurs following a fall on an outstretched hand. The management of different types of distal radius fractures is discussed in the following article.
This article discusses only Colles fracture.
What is Colles Fracture?
Colles fracture is the most common type of distal radial fracture and one of the common fractures to be encountered in orthopedic practice. The fracture is most commonly seen in elderly women and is seen more commonly in elderly women because the bone is weakened by osteoporosis.
A Colles fracture is a complete transverse fracture of the radius bone and extra-articular [about 20-35 mm from articular surface.] That means the articular surface of the radius is not involved.
The fracture results in posterior or dorsal displacement and angulation leading to the peculiar dinner-fork deformity.
Colles fractures are low-energy fractures in the elderly often due to osteoporotic bones
Younger patients have stronger bone, and thus, more energy is required to create a fracture in these individuals. Therefore a severe trauma or fall is responsible for this fracture in young patients.
This fracture was first defined by Abraham Colles, an Irish surgeon.
Most of the Colles fractures are manageable with nonoperative methods.
Relevant Anatomy
The term Colles fracture is classically used to describe a fracture at the distal end of the radius, at its cortico-cancellous junction.
The distal radius articulates with the carpal bones of the wrist joint. It also articulates with the distal ulna to form the distal radioulnar joint where supination and pronation movement occurs.
Colles fracture occurs through distal metaphysis of the radius. The bony cortex at the distal radius is thinner than the bone proximal and distal. Therefore, it becomes a relatively weak region and can fracture easily, especially when osteoporosis decreases the bone density further.
Pathophysiology and Mechanism of Colles Fracture
Colles fracture occurs when a person falls on an outstretched hand with the forearm in pronation and wrist in dorsiflexion [The position that a falling person has to attempt to break forward fall.]
During the impact, the proximal row of wrist bones transfers energy to the distal radius, in the dorsal direction and along the long axis of the radius leading to angulation and impaction.
In addition, there is radial displacement and tilt. There could be a disturbance of the radial-ulnar articulation. The ulnar styloid may be fractured. Though by definition it is a transverse extraarticular fracture, extension to joint may be present.
Classical Colles fractures have the following characteristics
- Transverse fracture of the radius
- One inch (2.5 cm) proximal to the radiocarpal joint
- Dorsally displaced and dorsally angulated
Deformities in Colles Fracture
Classically, a Colles fracture will have combination of following. But not every fracture has every deformity.
- Dorsal angulation
- Radial shortening [impaction]
- Loss of radial inclination
- Ulnar angulation of the wrist
- Dorsal displacement of the distal fragment
- Comminution at the fracture site
- Associated fracture of the ulnar styloid may be present in 50% of the cases.
Presentation of Colles Fracture
There is a history of fall and the patient presents with pain and a typical deformity in the wrist called “dinner fork deformity”.
In elderly patients, in whom the fracture is common, the swelling is minimal because the fracture is low energy. However, in young patients, the swelling can be substantial as the injury required to break the bone is more and thus injury to associated soft tissues is also more.
On examination, the region is tender and bruises may be present. There is pain in movement.
Differential Diagnoses
- Smith fracture
- Also called reverse Colles as the only difference is volar angulation instead of dorsal
- Barton fracture
- Involves rim of radius articular surface
- Cna be dorsal or volar
- Radial styloid fracture
- Also called Hutchinson or Chauffer fracture
- Often caused by direct trauma
Imaging
Plain films usually suffice, although if there is a concern of intra-articular extension, then CT may be beneficial.
X-rays
Anteroposterior and lateral views are often sufficient.
Oblique views are sometimes needed.
The fracture is typically extra-articular and about 25-30 cm from joint margin of radius. Typically the fracture is proximal to the radioulnar joint. In addition, look for the following
- Angulation
- Dorsal angulation is present in Colles [the fracture with volar angulation is called Smith fracture]
- Severe angulation leads to dinner fork deformity
- Impaction
- Impaction leads to shortening
- An associated ulnar styloid fracture is present in up to 50% of cases
- Displacement
- Degree
- Direction
- Dorsal
- Volar
- Involvement of radioulnar joint
- Fractures proximal to radioulnar articulation do not affect radioulnar joint
- Presence of intra-articular fractures
- Associated fractures
- Ulnar styloid
- Carpal bones
Treatment of Colles Fracture
Most of the Colles’ fractures are treated by closed reduction and cast immobilization. The cast extends from below the elbow to the metacarpal heads and holds the wrist somewhat flexed and in ulnar deviation. The cast is called Colle’s cast.
In elderly, below elbow cast is enough but in young patients above elbow cast is recommended. This is because fractures in adults are high energy fractures and need greater immobilization.
Open reduction and internal fixation should be considered in the case of
- Unstable fracture
- Failure of closed reduction
Decision for surgery is also based on the age and physical demands of the patient.
Various surgical options available are
- Closed reduction and external fixation
- Open reduction and internal fixation
- Plating
- Pins
Complications of Colles Fracture
Malunion
Colles fracture almost always unite. An unreduced or insufficiently reduced fracture would go into malunion and result in dinner fork deformity. These patients also may develop tears of extensor pollicis longus due to increased friction.
Reflex Sympathetic Dystrophy
It is also known as complex regional pain syndrome and is characterized by severe pain, swelling, and changes in the skin in the involved region. Nerve involvement may or may not be present.
Carpal Tunnel Syndrome
This occurs due to constriction of space around the median nerve in the wrist following trauma.
References
- MacDermid JC, Roth JH, Richards RS. Pain and disability reported in the year following a distal radius fracture: a cohort study. BMC Musculoskeletal Disord. 2003;4:24.
- Dionyssiotis Y, Dontas IA, Economopoulos D, Lyritis GP. Rehabilitation after falls and fractures. J Musculoskelet Neuronal Interact. 2008;8(3):244-50.
