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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
FRACTURES OF THE DISTAL RADIUS IN ADULTS
The distal end of the radius is subject to many different types of fracture, depending on factors
such as age, transfer of energy, mechanism of injury and bone quality. With any of these
fractures, the wrist also can suffer substantial ligamentous injury causing instability to the carpus
or distal radio-ulnar joint. These injuries are easily missed because the x-rays may look normal.
COLLES’ FRACTURE
The injury that Abraham Colles described in 1814 is a transverse fracture of the radius
just above the wrist, with dorsal displacement of the distal fragment.
It is the most common of all fractures in older people, the high incidence being related to
the onset of postmenopausal osteoporosis.
Thus the patient is usually an older woman who gives a history of falling on her
outstretched hand.
Mechanism of injury and pathological anatomy
Force is applied in the length of the forearm with the wrist in extension.
The bone fractures at the corticocancellous junction and the distal fragment collapses
into extension, dorsal displacement, radial tilt and shortening.
Clinical features
We can recognize this fracture (as Colles did long before radiography was invented) by
the ‘dinner-fork’ deformity, with prominence on the back of the wrist and a depression in
front.
In patients with less deformity there may only be local tenderness and pain on wrist
movements.
X-ray There is a transverse fracture of the radius at the corticocancellous junction, and
often the ulnar styloid process is broken off. The radial fragment is impacted into radial
and backward tilt. Sometimes there is an intra-articular fracture; sometimes it is severely
comminuted.
Treatment
UNDISPLACED FRACTURES
If the fracture is undisplaced (or only very slightly displaced), a dorsal splint is
applied for a day or two until the swelling has resolved, then the cast is completed.
An x-ray is taken at 10–14 days to ensure that the fracture has not slipped; if it has,
surgery may be required; if not, the cast can usually be removed after four weeks to
allow mobilization.
DISPLACED FRACTURES
Displaced fractures must be reduced under anaesthesia (haematoma block, Bier’s
block or axillary block).
Maneuver : The hand is grasped and traction is applied in the length of the bone
(sometimes with extension of the wrist to disimpact the fragments); the distal
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
fragment is then pushed into place by pressing on the dorsum while manipulating the
wrist into flexion, ulnar deviation and pronation.
The position is then checked by x-ray.
If it is satisfactory, a dorsal plaster slab is applied, extending from just below the
elbow to the metacarpal necks and two-thirds of the way round the circumference of
the wrist. It is held in position by a crepe bandage. The arm is kept elevated for the
next day or two; shoulder and finger exercises are started as soon as possible.
If the fingers become swollen, cyanosed or painful, there should be no hesitation in
splitting the bandage.
At 7–10 days fresh x-rays are taken; re-displacement is not uncommon and should be
treated, if the patient’s functional demands are high, by re-manipulation and internal
fixation.
However, in some elderly patients with low functional demands, modest degrees of
displacement should be accepted because
The fracture unites in about 6 weeks and, even in the absence of radiological proof of
union, the slab may safely be discarded and exercises begun.
Complications
EARLY
Circulatory problems The circulation in the fingers must be checked; the bandage
holding the slab may need to be split or loosened.
Nerve injury Direct injury is rare, but compression of the median nerve in the carpal
tunnel is fairly common. If it occurs soon after injury and the symptoms are mild,
they may resolve with release of the dressings and elevation. If symptoms are severe
or persistent, the transverse ligament should be divided.
Reflex sympathetic dystrophy This condition is probably quite common, but
fortunately it seldom progresses to the full-blown picture of Sudeck’s atrophy. There
may be swelling and tenderness of the finger joints, a warning not to neglect the daily
exercises. In about 5 per cent of cases, by the time the plaster is removed the hand is
stiff and painful and there are signs of vasomotor instability. X-rays show
osteoporosis and there is increased activity on the bone scan.
TFCC injury
LATE
Malunion
Delayed union and non-union
Stiffness of the shoulder, elbow and fingers from neglect is a common complication.
Tendon rupture Rupture of extensor pollicis longus occasionally occurs a few weeks
after an apparently trivial undisplaced fracture of the lower radius. The patient should
be warned of the possibility and told that operative treatment is available.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
SMITH’S FRACTURE
Smith (a Dubliner, like Colles) described a similar fracture about 20 years later.
In this injury the distal fragment is displaced anteriorly (which is why it is sometimes
called a ‘reversed Colles’).
It is caused by a fall on the back of the hand.
Clinical features
The patient presents with a wrist injury, but there is no dinner-fork deformity. Instead,
there is a ‘garden spade’ deformity.
X-ray There is a fracture through the distal radial metaphysis; a lateral view shows that
the distal fragment is displaced and tilted anteriorly – the opposite of a Colles’ fracture.
The entire metaphysis can be fractured, or there can be an oblique fracture exiting at the
dorsal or volar rim of the radius.
Treatment
The fracture is reduced by traction, supination and extension of the wrist, and the forearm
is immobilized in a cast for 6 weeks.
X-rays should be taken at 7–10 days to ensure the fracture has not slipped.
Unstable fractures should be fixed with percutaneous wires or a plate.
COMMINUTED INTRA-ARTICULAR FRACTURES IN YOUNG ADULTS
In the young adult, a comminuted intra-articular fracture is a high energy injury.
A poor outcome will result unless intra-articular congruity, fracture alignment and length
are restored and movements started as soon as possible.
The simplest option is a manipulation and cast.
If the anatomy is not restored, then an open reduction may be necessary.
The medial complex must be anatomically reduced, which may require open reduction
through dorsal and palmar approaches and a combination of wires, plates, screws and
bone grafts.
COMPLICATIONS OF RADIO-CARPAL FRACTURES
Associated injuries of the carpus must be excluded
Re-displacement There is a strong tendency for Barton’s fracture to re-displace if it is
held in a cast; hence our preference for internal fixation.
Carpal instability The patient may present years later with chronic carpal instability.
Secondary osteoarthritis Fractures into the joint and carpal instability may eventually lead
to secondary osteoarthritis.
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DR.JAMAL AL-SAIDY
M.B.CH.B..…… F.I.C.M.S