Distal Radius Fracture

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

II. 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)

III. Mechanism

  1. Fall on an outstretched hand

IV. 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

V. 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

VI. Imaging: Wrist XRay

  1. See Wrist XRay

VII. 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

VIII. 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

IX. 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

X. 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

XI. 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

XII. 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

XIII. 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

XIV. 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

XV. References

  1. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
  2. Krishnan (2002) Orthopedics 25(2): 175-9 [PubMed]

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Related Studies

Ontology: Colles' Fracture (C0009353)

Definition (MSH) Fracture of the lower end of the radius in which the lower fragment is displaced posteriorly.
Concepts Injury or Poisoning (T037)
MSH D003100
ICD10 S52.53
SnomedCT 157214000, 123971006
English Colles Fracture, Colles' Fracture, Fracture, Colles', Fracture Colles', Colles' Fracture [Disease/Finding], Fracture;Colles, colle fracture, colles fractures, colles fracture, colles' fracture, fracture of radius distal end colles', Colles' fracture (diagnosis), Colles' fracture, Colles' fracture (disorder), fracture; Colles, Colles; fracture, Colles
Dutch Colles-fractuur, Colles; fractuur, fractuur; Colles, Collesfraktuur, Fractuur, colles-
French Fracture de Colles, Fracture de Pouteau-Colles
Portuguese Fractura de Colles, Fratura de Colles
Japanese コーレス骨折, ｺｰﾚｽｺｯｾﾂ
Swedish Colles fraktur
Czech Collesova fraktura, Collesova zlomenina
Finnish Tyypillinen värttinäluun murtuma
Russian LUCHEVOI KOSTI PERELOM KLASSICHESKII, KOLLISA PERELOM, LUCHEVOI KOSTI PERELOM TIPICHNYI, КОЛЛИСА ПЕРЕЛОМ, ЛУЧЕВОЙ КОСТИ ПЕРЕЛОМ КЛАССИЧЕСКИЙ, ЛУЧЕВОЙ КОСТИ ПЕРЕЛОМ ТИПИЧНЫЙ
Polish Złamanie Collesa
Hungarian Colles-féle törés, Colle-törés
Norwegian Fractura radii typica
Spanish fractura de Colles (trastorno), fractura de Colles, Fractura de Colles
German Colles-Fraktur
Italian Frattura di Colles
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Fracture of distal end of radius (C0435585)

Concepts Injury or Poisoning (T037)
ICD10 S52.5
SnomedCT 208355005, 157217007, 263199001
English Frac distal end of radius, Fracture / lower end of radius, fracture of distal end of radius, fracture of radius distal end, Fracture of distal end of radius (diagnosis), Fracture of distal end of radius, Fracture of lower end of radius, Fracture of distal end of radius (disorder)
German Distale Fraktur des Radius
Korean 노뼈하단의 골절
Spanish fractura del radio distal (trastorno), fractura de radio distal (trastorno), fractura de radio distal, fractura del radio distal
Dutch Fractuur van ondereinde van radius
Derived from the NIH UMLS (Unified Medical Language System)

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