Colles' fracture results most often from falls on the outstretched hand. This mechanism produces a distal radial metaphysis fracture that is dorsally angulated and displaced. Compression forces on the dorsal side often produce dorsal comminution of bone. The fracture line may also comminute and extend into the radioulnar or radiocarpal joint ("die-punch" fracture). A fracture of the ulnar styloid is often present and may be suggestive of injury to the triangular fibrocartilage complex ( Fig. 2.6.2-12).
The wrist has the characteristic dorsiflexion, or "silver-fork," deformity. These individuals may complain of palmar paresthesias from tension or pressure on the median nerve. Anteroposterior radiographs reveal a distal metaphyseal fracture of the radius that often appears shortened from the angulation or comminution of the bone. The lateral view provides the best view of the dorsal angulation and comminution. In general, potentially unstable fractures have more than 20 degrees of angulation, intra-articular involvement, marked comminution, or more than a centimeter of shortening. These injuries are more likely to develop loss of reduction, distal radioulnar joint instability, radiocarpal instability patterns, and subsequent arthritis.
Stable fractures may be treated with a compression dressing and splint until they can be evaluated by an orthopedic surgeon. Otherwise, closed reduction is performed, with traction provided by finger traps while the fracture fragment is pushed distal and palmar while the patient's forearm is firmly held. The goal is to restore the volar tilt, radial inclination, and proper length to the radius. This is particularly important in younger patients. The volar tilt ideally should be restored to its normal position, but a minimum of neutral or zero degrees of angulation may be acceptable. Although most Colles' fractures can be treated with closed reduction and cast immobilization, those that are unstable, severely comminuted, or intra-articular may require casting with pinning, external fixation with possible bone grafting, or open reduction and internal fixation. Good to excellent results are achieved in 56 to 81 percent of patients with these more aggressive treatment alternatives. All open and neurovascularly compromised fractures require prompt evaluation by the orthopedic surgeon.
Complications include malunion, median nerve injuries, triangular fibrocartilage complex injuries, secondary radioulnar and radiocarpal instability patterns, and arthritis. These can produce a weak, stiff, and painful wrist.
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