Distal Radius Fracture

Aka: Distal Radius Fracture, Colles Fracture, Colles' Fracture

1. Epidemiology
   1. Most Common Wrist Injury
   2. Represents one sixth of all Fractures overall
   3. More common at extremes of age
      1. Young: High energy injury (e.g. skateboarding, Inline Skating, Downhill Skiing)
      2. Old: Low impact injury (e.g. fall)
2. Mechanism
   1. Fall on an outstretched hand
3. Signs
   1. Distal Radius Fracture
      1. Displacement ("Dinner Fork" Deformity)
      2. Dorsal Angulation with volar prominence
      3. Shortening
      4. Radial Deviation of hand
   2. Ulnar styloid Injury often associated (60%)
   3. Thumb Ulnar Collateral Ligament Injury often associated
4. Complications
   1. Compartment Syndrome
      1. Significantly increased pain after reduction despite analgesia may suggest Compartment Syndrome
   2. Median Nerve Injury
      1. Most common nerve injury after angulated, displaced Distal Radius Fracture
      2. Presents with thumb and index finger Muscle Weakness and sensory deficit
5. Imaging: Wrist XRay
   1. See Wrist XRay
6. Management: Anesthesia
   1. Conscious Sedation
      1. First-line Anesthesia unless skilled with hematioma block
      2. Fracture >4 hours prior (Hematoma Block less likely to be effective)
   2. Local Anesthetic (sufficient if recent Fracture within prior 4 hours)
      1. Hematoma Block
         1. Needle inserted dorsally into Fracture hematoma
         2. Aspirate to confirm needle within hematoma
         3. Inject 5-10 ml local Anesthetic
      2. Inject tip of ulna as well
7. Management: Manual Reduction (Technique 1)
   1. Assistant Position
      1. Grasps Forearm for countertraction
   2. Surgeon Position
      1. Grasps hand of affected wrist
      2. Thumb of other hand is placed on distal fragment
   3. Break up Impaction
      1. Wrist is hyperextended
   4. Dorsal Displacement and rotation is corrected
      1. Apply traction and countertraction
      2. Continue Thumb pressure on distal fragment
      3. Distal fragment dorsal cortex apposed with proximal
   5. Radial and Dorsal Angulation Corrected
      1. Apply Ulnar and Volar pressure over distal fragment
   6. Assess if Length is Restored
      1. Palpate radial styloid
8. Management: Finger Trap Reduction (Technique 2)
   1. Anesthesia as above
   2. Break up Impaction by hyperextending wrist
   3. Place Index finger and thumb in finger traps
   4. Apply counterweight to upper arm
   5. Manipulate Fracture as above
9. Management: Immobilization with Sugar Tong Splint
   1. Fluoroscopy (C-Arm) confirms alignment during Splinting
   2. Assistant applies steady traction at hand
   3. Wrist in slight pronation
   4. Avoid volar flexion of wrist
      1. Risk of Median Nerve Compression (Carpal Tunnel)
   5. Apply cast padding from MCP heads to above elbow
   6. Apply felt pad to volar surface of proximal fragment
   7. Splint with 10 cm wide, 12 plaster plies around elbow
   8. Dorsal half ends at MCP heads
      1. Mold over the distal fragment
   9. Volar half ends 1-2 cm distal to Fracture
   10. Maintain wrist in ulnar deviation
       1. Wrap a strip of plaster around distal splint
       2. Include distal MCP
       3. Keep strip proximal to distal palmar crease
   11. ACE Wrap Sugar Tong in place
10. Management: Isolated Distal Radius Fracture
    1. Non-displaced Distal Radius Fracture (torus Fracture, buckle Fracture)
       1. Immobilize in a Short Arm Cast for 3 weeks
       2. Removable splints have been used with similar outcomes to Casting
          1. Williams (2013) Pediatr Emerg Care 29(5):555-9 +PMID:23603644 [PubMed]
    2. Displaced and overlapping Distal Radius Fracture
       1. Ulna Fracture also
          1. See Colles Fracture management above
       2. Ulna greenstick Fracture
          1. Complete ulna Fracture for adequate reduction
          2. Manage as Colles Fracture
       3. Ulna intact or greenstick Fracture
          1. Do not re-Fracture
          2. Reduction may be quite difficult
             1. Maximally supinate wrist
             2. Digital pressure to replace the distal radius
          3. Alignment is paramount
             1. Re-align as best as possible
          4. Apposition is secondary to alignment
             1. Bayonet apposition is acceptable
11. Management: Discharge Instructions
    1. Ice for 72 hours
    2. Elevation
    3. Maintain active Range of Motion of fingers and Shoulder
    4. Shoulder Sling
       1. Do not use longer than 2-3 days
       2. Risk of Shoulder stiffness
12. Management: Orthopedic referral indications
    1. Distal radius dorsal angulation >5 to 10 degrees
    2. Radial Inclination change >5-10 degrees
    3. Radial Height shortening >2 mm
    4. Young athletes, or those with occupation or hobby requiring highly functional hand and wrist
    5. Rotational deformity tolerated (criteria contingent on 50% apposition or greater)
       1. Age >8 years: Refer for >10 degrees rotational deformity
       2. Age <8 years: Refer for 15-20 degrees rotational deformity
13. Management: Follow-Up
    1. Days 1-2
       1. Phone: Is Splint too tight?
    2. Days 5-7
       1. Repeat Wrist XRay
          1. Strongly consider weekly XRay for first 3 weeks
       2. Apply Short Arm Cast
          1. Do not limit motion of the elbow or the metarcarpophalangeal joints
       3. Anticipate mal-union after swelling decreases
          1. Elderly
             1. Mal-union may be acceptable
             2. Re-manipulation may result in greater morbidity
          2. Young
             1. Malunion unacceptable
                1. Radial head shortening results in dysfunction
             2. Correction of mal-union
                1. Re-manipulation and closed reduction
                2. Open reduction and internal fixation (ORIF)
                3. External fixator
    3. Weeks 4-6
       1. Cast may be removed
    4. Weeks 7-9
       1. Wrist support or cast until pain subsides
14. References
    1. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
    2. Krishnan (2002) Orthopedics 25(2): 175-9 [PubMed]