What is Colles Fracture?
The Colles fracture, named after Abraham Colles who documented this type of wrist fracture in 1814, is a common injury. It accounts for roughly 17.5% of all adult fractures treated in the emergency room. A Colles fracture happens in the wrist’s radius bone, and it’s specifically defined by multiple fractures along the back of the wrist, a shortened radius bone, and often a fractured ulnar styloid bone.
People often use the term ‘Colles fracture’ to refer to any fracture at the end of the radius, usually with the wrist bent backwards. These types of fractures usually occur when someone falls on an outstretched hand, bending the wrist back, creating stress in the front of the wrist and leading to fractures along the back.
The radius bone in the wrist carries about 80% of the load. It connects to other bones like the scaphoid, lunate, and the ulna. The radius bone is divided into three segments: the radial, the intermediate, and the ulnar columns.
The radial column, where the scaphoid bone and wrist ligaments attach, prevents the wrist from moving towards the ulna (the larger bone of the forearm). It also helps distribute the load evenly across the wrist and supports the wrist when it moves towards the ulna.
The intermediate column, where the lunate bone attaches, helps transfer the pressure from the wrist to the forearm.
The ulnar column, where the triangular fibrocartilage complex (TFCC) and the distal ulna are located, helps with wrist stability and forearm rotation.
What Causes Colles Fracture?
A Colles fracture typically happens when someone falls and lands on an outstretched hand with the wrist bent back. This is often called a “fall on outstretched hand injury,” or “FOOSH injury” for short. How serious the injury is usually depends on the position of the wrist at the time of the fall and how forceful the trauma was. If there’s tension on the underside of the wrist, this can result in bending and squeezing forces.
Because of these forces acting on the wrist, the part of the wrist towards the back of the hand can be displaced, meaning it shifts from its normal position. This can also result in the bone getting crumbled or fragmented, a condition called comminution.
Risk Factors and Frequency for Colles Fracture
Distal radius fractures, or breaks in the wrist, can happen to anyone, but they’re found more in women. There are generally two main groups at risk: young athletes who might get these fractures from high-energy activities such as sports or car accidents, and elderly people who can get them from simple accidents because their bones may be fragile. Interestingly, these fractures are least common in people between the ages of 19 and 49.
As people age, they are more at risk of getting these fractures due to a condition called osteoporosis, which makes bones less dense and more fragile. This is especially common in women over the age of 50. Therefore, if a woman over 50 gets a wrist fracture, a DEXA scan, which measures bone density, would be recommended to check the quality of her bones.
- Distal radius fractures happen more often in females.
- Young athletes and elderly people are more likely to experience these fractures.
- The fractures are rare in people from 19 to 49 years old.
- Older individuals and women are more at risk due to a condition called osteoporosis.
- A woman over 50 who experiences a distal radius fracture should get a DEXA scan to check her bone quality.
Signs and Symptoms of Colles Fracture
When dealing with fractures of the wrist bone (also known as distal radius fractures), a thorough check-up of the injured and the healthy limb is crucial for the diagnosis and treatment of the injury. Some of the common signs that a person might exhibit include wrist pain and tenderness, a particular bend in the wrist (colloquially known as a “dinner fork” deformity), bruising and swelling. It’s also important to make sure that the skin isn’t broken, as this could indicate an open fracture.
The person may also have a limited range of movements due to the injury, but this should still be checked by the doctor whenever possible. Making sure that the part of the limb beyond the injury has proper blood supply and sensation, as well as the ability to move, is also very important. To assess these things, a detailed checkup of pulse, sensation, and motor function in the affected limb is needed.
Another crucial step in evaluating wrist fractures is checking the joints above and below the injury for potential additional injuries.
Testing for Colles Fracture
Radiographs, or X-rays, are commonly used in the initial evaluation and management of forearm injuries. It’s important to get both a front-to-back view (referred to as PA) and a side view to assess the type and extent of the injury and to distinguish between different types of forearm fractures.
A common wrist fracture is the Colle’s fracture, which can typically be seen in both front-to-back and side views of the wrist.
When a doctor looks at the X-ray of your wrist, they consider certain measurements. In the front-to-back view:
– Radial height: This is usually 13 mm. If it’s less than 5 mm shorter than usual, it’s acceptable.
– Radial inclination: This typically is 23 degrees. A deviation less than 5 degrees from the norm is acceptable.
– Articular step-off: This refers to how well the joint surfaces align. A difference of less than 2 mm is considered acceptable.
In side views:
– Radial volar tilt: This is normally 11 degrees. A tilt less than 5 degrees or within 20 degrees of the opposite side is acceptable.
A CT scan is useful if the doctor needs to get a more detailed view of a fracture inside the joint or for planning surgery.
MRI is not typically used to diagnose these types of injuries initially. However, it can be used to evaluate potential injuries to the ligaments or soft tissue, such as the TFCC, scapholunate, or lunotriquetral ligaments.
Treatment Options for Colles Fracture
Distal radius fractures, or breaks in the forearm bone near the wrist, can be treated through two methods — non-operative and operative ones. The method chosen relies on the type of fracture and the patient’s health.
Non-operative Treatment
For minor fractures where the bone hasn’t shifted out of place by more than 5mm, or bent at an unusual angle, it can be repositioned using closed reduction. This involves anesthetizing the area, applying some pressure to the disjointed bone, and immobilizing the wrist with a splint or cast. To confirm if the bone has returned to its normal position, patients need to have an x-ray taken a week after the operation.
Treating the fracture without surgery requires exercise performed at home that matches the benefits of physical therapy. There’s a risk of developing a carpal tunnel syndrome if the wrist is excessively flexed or deviated while in a cast. It could also lead to the rupture of the tendon responsible for thumb extension.
Fractures with three or more risk factors can be less responsive to non-operative treatment. The risk factors, also known as LaFontaine’s predictors of instability, include excessive radial shortening and fragmentation on the backside of the radius bone.
In people aged 65 or older, non-operative treatment achieves similar health benefits as operative ones.
Operative Treatment
If the fracture is severe, surgery becomes necessary. There are several techniques of surgical treatment, including closed reduction and percutaneous pinning (CRPP) and open reduction and internal fixation (ORIF).
CRPP is mainly used for extraarticular distal radius fractures. This approach often has a high success rate, up to 90%, when administered correctly. However, it can sometimes lead to injury to the radial nerve or pin tract infection.
ORIF is best for fractures that are unstable and those that deteriorate further after a closed treatment. This includes situations where the bone shifts away from its initial alignment after reduction. Other cases where ORIF is required are those with severe extraarticular fractures, such as Barton’s fractures and Smith’s fractures.
The type of ORIF method used depends on the nature of the fracture. For example, volar plating, placing a plate on the palm side of the fracture, tends to offer better support for the bones if performed accurately. However, volar plating can irritate both flexor and extensor tendons and lead to other complications.
External fixation, a temporary device that holds the broken bones together, can be used in open fractures and severe fractures that aren’t suitable for internal fixation or in patients who aren’t fit for long procedures. Notably, the use of external fixation alone doesn’t fully restore the bone’s alignment and may be used in conjunction with other fixation methods.
Regardless of the treatment method employed, complications can occur. These may include tendon rupture, screw misplacements, malunion and non-union, and nerve injuries. Despite these challenges, home exercises have been found to be as effective as therapist-directed physiotherapy in supporting recovery.
What else can Colles Fracture be?
When trying to diagnose Colles fractures (which are fractures at the end of the forearm), doctors also consider other forearm injuries. These can be differentiated with X-Ray imaging. Here are some other types of fractures:
- Smith fracture: Often called a “reverse Colles,” this fracture has the end of the radial bone (one of the two bones in the forearm) bending towards the front of the hand. It is usually caused by landing on an outstretched hand in certain positions.
- Barton fracture: This is another type of forearm fracture, and it involves the back rim of the radial bone near the wrist, with the break occurring inside the joint.
- Hutchinson or Chauffer fracture: These are fractures to the end of the radial bone (near the thumb), often caused by direct impact. They present as oblique or transverse fractures.
- Galeazzi fracture: This fracture happens on the inner or distal part of the radial bone near the wrist, typically with associated dislocation of the joint between the two forearm bones.
- Monteggia fracture: This involves a fracture of the ulna shaft (the other forearm bone) along with a dislocation of the radial head (the end of the radial bone near the elbow).
- Essex Lopresti lesion: This is a rare combination of Galeazzi and Monteggia fractures. It involves a radial head fracture at the elbow with a dislocation at the wrist, and disruption of the membranous tissue connecting both forearm bones.
What to expect with Colles Fracture
How well a person recovers from a Colles fracture, or a break in the wrist, depends on how serious the break is, and whether or not any complications occur from the injury. Problems can be avoided if the fracture is quickly and properly treated. This involves realigning the bone, and then using a splint or cast, followed by regular check-ups with a bone specialist (orthopedist).
Very serious injuries, such as an open fracture, or one that damages nerves and blood vessels or causes pressure to build up in the muscles (compartment syndrome), require immediate attention from a specialist and often need surgery.
Recovery also depends on the patient’s age. Younger patients tend to recover really well, as their bones have a great capacity to remodel and heal. Older patients, unfortunately, might not have such positive outcomes.
Possible Complications When Diagnosed with Colles Fracture
Problems that can occur after a Colles fracture, a break in the bone near the wrist, can happen right away or develop over time. These issues can vary widely, from minor to major, and could even result in long-term difficulties or disabilities.
Immediately after the fracture, common complications can include compartment syndrome, or high pressure in an arm or leg that can damage nerves and muscles, injury to the median nerve (one of the main nerves in the arm), and injuries to blood vessels.
Less immediate and longer-lasting complications can be conditions like carpal tunnel syndrome, when the median nerve is pinched as it passes through a narrow area in the wrist, and osteoarthritis, a condition that causes joints to become painful and stiff.
If the fracture does not properly heal in alignment (a situation referred to as malunion), it can lead to injury of tendons, the fibrous tissues that connect muscles to bones, and may result in persistent wrist pain.
Common Complications:
- Compartment syndrome
- Median nerve injury
- Vascular injury
- Carpal tunnel syndrome
- Osteoarthritis
- Malunion
- Tendon injury
- Chronic wrist pain
Preventing Colles Fracture
People who’ve injured their wrists, especially if they suspect a fracture, should get medical help straight away. A common type of wrist injury is a Colles fracture, where the lower part of the radius bone in the arm gets displaced towards the back. Such injuries need to be promptly corrected, followed by supporting the wrist using splints and casts. It’s important to regularly see a bone specialist (an orthopedist) to ensure the wrist is healing correctly. In severe cases, surgery might even be necessary.
Patients need to know how to manage their splints and casts correctly, which includes continuously monitoring the state of nerves and blood vessels in their hand. Undue swelling or tightness of the cast can lead to severe pain, numbness, or a tingling sensation in the fingers. These symptoms, along with any discoloration of the fingers, are warning signs that require immediate medical help. With the right treatment, management, and regular follow-ups, these injuries can be fully healed, and normal hand function can be regained.