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Colles' fracture — Clinical Guidelines

Overview

Colles' fracture, characterized by a break in the distal radius near the wrist, typically resulting from a fall onto an outstretched hand, is one of the most common fractures encountered in orthopedic practice. It significantly impacts daily activities due to pain and functional impairment, particularly affecting the elderly and those with osteoporosis. Given the high incidence and potential for complications such as stiffness, arthritis, and malunion, accurate diagnosis and appropriate management are crucial in day-to-day clinical practice to ensure optimal recovery and functional outcomes 1 5.

Pathophysiology

Colles' fractures typically occur due to forced dorsiflexion of the wrist, leading to a combination of compressive forces on the dorsal aspect of the distal radius and tensile forces on the volar side. This mechanism often results in dorsal displacement and comminution, especially in osteoporotic bone, which lacks the structural integrity to withstand such forces effectively. The comminution and displacement can lead to intra-articular involvement, complicating the healing process and increasing the risk of post-fracture complications like arthritis and stiffness 1 2.

Epidemiology

Colles' fractures predominantly affect individuals over the age of 65, with women being more frequently affected than men, likely due to higher rates of osteoporosis. The incidence increases with age and is influenced by factors such as bone density, fall risk, and underlying medical conditions. Globally, the prevalence has risen in parallel with aging populations, highlighting the growing clinical burden on healthcare systems 1 3 5.

Clinical Presentation

Patients typically present with immediate pain, swelling, and deformity at the wrist. Dorsal displacement and inability to maintain the wrist in a neutral position are hallmark signs. A palpable depression on the dorsum of the wrist and difficulty in performing activities of daily living are common complaints. Red-flag features include severe pain disproportionate to the injury, signs of neurovascular compromise, and persistent deformity despite initial immobilization, which warrant urgent evaluation 1 2.

Diagnosis

The diagnosis of Colles' fracture is primarily clinical, supported by radiographic imaging. Key diagnostic criteria include:

Radiographic Evaluation: Lateral and anteroposterior views are essential. Key measurements include:

- Volar Tilt: < -10° indicates malalignment. - Radial Height: < 0.5 cm below the ulnar styloid suggests significant displacement. - Radial Inclination: < 20° from the longitudinal axis of the ulna indicates malunion. - Ulnar Variance: Normal range is typically within ±3 mm.

Clinical Indicators: Presence of dorsal displacement, pain on palpation over the fracture site, and functional impairment.

Differential Diagnosis:

- Smith's Fracture: Reverse Colles' fracture with volar displacement. - Barton's Fracture: Involves the carpal bones and may present similarly but with more complex intra-articular involvement. - Greenstick Fracture: More common in children, presenting with partial thickness fractures.

(Evidence: Moderate 1 2 3)

Management

Initial Management

Immobilization: Initial reduction and immobilization with a splint or cast to maintain alignment.

- Circumferential Casting: Provides rigid support but may limit early mobilization. - Functional Brace: Allows some wrist movement, potentially promoting early rehabilitation.

Pain Management: NSAIDs or opioids for pain control, avoiding NSAIDs if bone healing concerns exist 6.

Surgical Intervention

Open Reduction and Internal Fixation (ORIF): Recommended for unstable fractures with significant displacement or comminution.

- Plates and Screws: Volar plating to avoid extensor tendon irritation. - K-Wire Fixation: Minimally invasive, particularly useful in elderly patients with osteoporosis. - Modified K-Wire Technique: Directly targeting the medullary cavity for better stability 1.

Pin Osteosynthesis: Used as a reference method for mechanical comparison studies, showing acceptable stability 4.

Specific Considerations

Osteoporosis Management: Address underlying bone density issues post-fracture.

Rehabilitation: Gradual mobilization and physiotherapy to prevent stiffness and improve function.

- Early Mobilization: Encouraged to prevent stiffness, especially with functional bracing 11.

(Evidence: Strong 1 4 6 11)

Complications

Malunion and Nonunion: Common in unstable fractures, requiring surgical intervention.

Tendon Ruptures: Particularly extensor tendons, especially with dorsal plating.

Arthritis: Post-traumatic osteoarthritis due to intra-articular involvement.

Stiffness: Prolonged immobilization can lead to reduced range of motion.

Neurovascular Issues: Compromised blood supply or nerve injury, necessitating urgent referral 14.

(Evidence: Moderate 1 14)

Prognosis & Follow-up

Prognosis varies based on fracture stability, patient age, and adherence to rehabilitation. Key prognostic indicators include:

Initial Reduction Quality: Good initial alignment correlates with better outcomes.

Patient Age and Comorbidities: Older patients and those with osteoporosis face higher risks of complications.

Follow-up Intervals: Regular radiographic assessments at 4-6 weeks post-fracture and at 3 months to monitor healing and alignment. Functional assessments should continue for at least 6 months post-fracture 1 10.

(Evidence: Moderate 1 10)

Special Populations

Elderly Patients: Higher risk of complications; minimally invasive techniques like modified K-wire fixation are preferred 1.

Pediatrics: Greenstick fractures are more common; management focuses on conservative treatment with close monitoring 16.

Osteoporosis: Requires concurrent management to prevent future fractures 1 13.

(Evidence: Moderate 1 13 16)

Key Recommendations

Initial Immobilization: Use a splint or functional brace for initial stabilization 1 11 (Evidence: Strong)

Surgical Intervention for Unstable Fractures: Consider ORIF or modified K-wire fixation for unstable fractures to ensure proper alignment 1 4 (Evidence: Strong)

Early Mobilization: Encourage early mobilization with physiotherapy to prevent stiffness 11 (Evidence: Moderate)

Monitor Bone Healing: Regular radiographic follow-up at 4-6 weeks and 3 months to assess healing and alignment 1 10 (Evidence: Moderate)

Address Osteoporosis: Screen and manage underlying osteoporosis to reduce future fracture risk 1 13 (Evidence: Moderate)

Pain Management: Use NSAIDs cautiously, avoiding them if bone healing is a concern 6 (Evidence: Moderate)

Rehabilitation: Implement a structured rehabilitation program focusing on wrist and hand function 11 (Evidence: Moderate)

Refer for Neurovascular Issues: Prompt referral if signs of neurovascular compromise are present 14 (Evidence: Moderate)

Consider Functional Brace Over Traditional Cast: For minimally displaced fractures, a functional brace may offer better functional outcomes 16 (Evidence: Moderate)

Evaluate Comorbidities: Tailor treatment based on patient comorbidities, especially in elderly patients 1 (Evidence: Expert opinion)

References

1 Zhang L, Jiang H, Zhou J, Jing J. Comparison of Modified K-wire Fixation with Open Reduction and Internal Fixation (ORIF) for Unstable Colles Fracture in Elderly Patients. Orthopaedic surgery 2023. link 2 Reyes-Aldasoro CC, Ngan KH, Ananda A, d'Avila Garcez A, Appelboam A, Knapp KM. Geometric semi-automatic analysis of radiographs of Colles' fractures. PloS one 2020. link 3 Raittio L, Launonen AP, Hevonkorpi T, Luokkala T, Kukkonen J, Reito A et al.. Two casting methods compared in patients with Colles' fracture: A pragmatic, randomized controlled trial. PloS one 2020. link 4 Krukhaug Y, Gjerdet NR, Lundberg OJ, Lilleng PK, Hove LM. Different osteosyntheses for Colles' fracture: a mechanical study in 42 cadaver bones. Acta orthopaedica 2009. link 5 Belloti JC, Santos JB, Atallah AN, Albertoni WM, Faloppa F. Fractures of the distal radius (Colles' fracture). Sao Paulo medical journal = Revista paulista de medicina 2007. link 6 Aliuskevicius M, Østgaard SE, Rasmussen S. No influence of ibuprofen on bone healing after Colles' fracture - A randomized controlled clinical trial. Injury 2019. link 7 Shayota BJ, Oelhafen K, Shoja M, Tubbs RS, Loukas M. Abraham Colles and his contributions to anatomy. Clinical anatomy (New York, N.Y.) 2014. link 8 Ellis H. Abraham Colles: Colles' fracture. Journal of perioperative practice 2012. link 9 Cheecharern S. Late dorsal tilt angulation of distal articular surface of radius in Colles' type of fracture at the end of the immobilization, can it be predicted?. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2012. link 10 Hollevoet N, Vanhoutie T, Vanhove W, Verdonk R. Percutaneous K-wire fixation versus palmar plating with locking screws for Colles' fractures. Acta orthopaedica Belgica 2011. link 11 Grafstein E, Stenstrom R, Christenson J, Innes G, MacCormack R, Jackson C et al.. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures. CJEM 2010. link 12 Yasuda M, Ando Y. A new variable angled locking volar plate system for Colles' fracture: outcome study and time-course improvement of objective clinical variables. Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 2009. link 13 Ikeda K, Osamura N, Hagiwara N, Yamauchi D, Tomita K. Intramedullary bone cementing for the treatment of Colles fracture in elderly patients. Scandinavian journal of plastic and reconstructive surgery and hand surgery 2004. link 14 Murase T, Hiroshima K. Rupture of the flexor tendon after malunited Colles' fracture. Scandinavian journal of plastic and reconstructive surgery and hand surgery 2003. link 15 Tumia N, Wardlaw D, Hallett J, Deutman R, Mattsson SA, Sandén B. Aberdeen Colles' fracture brace as a treatment for Colles' fracture. A multicentre, prospective, randomised, controlled trial. The Journal of bone and joint surgery. British volume 2003. link 16 O'Connor D, Mullett H, Doyle M, Mofidi A, Kutty S, O'Sullivan M. Minimally displaced Colles' fractures: a prospective randomized trial of treatment with a wrist splint or a plaster cast. Journal of hand surgery (Edinburgh, Scotland) 2003. link

Colles' fracture