Colles’ original 1814 description is reported to be a low-energy extra-articular fracture of the distal radius, as described earlier, occurring in elderly individuals. It may be associated with an ulnar styloid or triangular fibrocartilage complex (TFCC) injury. A die punch fracture is a depression of the lunate fossa from impaction of the lunate into the distal radius. A Barton’s fracture is an unstable volar or dorsally displaced intra-articular fracture- subluxation of the distal radius with displacement of the carpus along with the fracture fragment. A Smith’s fracture is referred to as a reverse Colles’ fracture (i.e., with volar angulation and displacement). A chauffeur’s fracture features an intra-articular shear fracture of the distal radius fracture where the fragment includes the radial styloid, which displaces with the carpus (Fig. 75.1).1,2 Dorsal fracture VOLAR Barton’s fracture Smith’s fracture Volar fracture Colles’ fracture Die punch/lunate load fracture DORSAL Fig. 75.1 Types of fractures. (Adapted from Berger RA, Weiss APC. Hand Surgery. Philadelphia: Lippincott Williams & Wilkins, 2004.)
2. Wong PK, Hanna TN, Shuaib W, Sanders SM, Khosa F. What’s in a name? Upper extremity fracture eponyms (Part 1). Int J Emerg Med 2015;8(1):75 The quality of a lateral radiograph can be assessed in part by referencing the relative position of the pisiform to the distal pole of the scaphoid. In a true lateral view, they will overlap by 50%. A rough guide to interpretation of distal radius fracture radiographs is given by the “Rule of 11’s”: Average volar tilt: 11 degrees (not dorsal) Average radial height: 11 mm Average radial inclination: 22 degrees (e.g., double 11) Radial height refers to the distance that the radial styloid projects beyond the sigmoid notch (at the distal tip of ulnar articulation) and is usually 11 to 12 mm. Ulnar variance describes the position of the transverse distal ulnar joint surface relative to the distal radius joint surface at the wrist. Positive variance is present if the ulnar sits greater than 2 mm more distally than the radius, and in negative variance if the ulnar surface sits greater than 2 mm more proximally (Fig. 75.2). Most surgeons consider a 1-mm intra-articular step-off to be sufficient to indicate intervention.1,2 12° 23° 90° 90° 12 mm 90° Lateral view Volar tilt PA view Radial inclination PA view Radial height Sigmoid notch/DRU joint Ulnar variance +2 to -2 mm Fig. 75.2 Normal anatomic parameters of the distal radius. (DRU, distal radioulnar; PA, posteroanterior.) (Adapted from Smith DW, Brou KE, Henry MH. Early active rehabilitation for operatively stabilized distal radius fractures. J Hand Ther 17:43–49, 2004.)
correct? management. Attrition rupture of the extensor pollicis longus tendon can occur with either operative or nonoperative management of distal radius fractures. It may be due to ischemia from pressure within the rigid tunnel under extensor retinaculum, or direct trauma from a fracture spike/ridge. A Colles fracture is an extra-articular injury. All displaced extra-articular fractures would normally be manipulated and placed in a splint in the first instance. If the position is satisfactory following this, a trial of nonoperative management is warranted. If the fracture is behaving in an unstable fashion at 1 week, particularly in a fairly young, active patient, it should be formally stabilized rather than making further attempts at nonoperative management (Fig. 75.3).1,2
While dorsal angulation greater than 10 degrees and radial shortening greater than 3 mm after reduction are usually an indication for intervention, up to 20 degrees dorsal angulation and 5 mm shortening can be tolerated in elderly inactive patients. K-wire fixation in osteoporotic bone is not sufficiently stable to allow early mobilization. Furthermore, it would usually be supplemented with an external fixator. Four weeks of splint age, either in the form of a plaster splint or external fixator, would be insufficient for healing. A minimum of 6 weeks is required.1,2
Conventional spanning plates rely on purchase into the far cortex, whereas locking plates may be adequate with only the near cortex. Volar plating is preferred to dorsal plating because there are fewer associated complications, and there is a more favorable surface contour to the radius. Bone grafting with autologous or substitute materials is important where there are metaphyseal defects following disimpaction. This can be useful in osteoporotic bone where additional strength may be conferred by use of a substitute.1
A sugar-tong splint is sometimes required following surgery to prevent forearm rotation when the distal radio-ulnar joint needs to be immobilized, for example, if there has been an associated triangular fibrocartilage complex (TFCC) injury. This interferes with elbow movements and can lead to stiffness, which usually settles with physiotherapy. Although chronic regional pain syndrome has been reported to be as high as 40% with distal radius fractures in the past, it is currently thought to be less common at a rate of less than 3% after surgery.1 Internal fixation with plates is generally avoided in children because of potential problems with subsequent growth. Wrist strength may continue to improve over the first year with physiotherapy. Patients should always be aware that malunion and nonunion can both still occur despite surgical intervention.
Restoring volar cortical continuity may best predict final carpal alignment.1 Volar locking plate open reduction internal fixation has been shown to give superior functional outcomes to percutaneous pinning.2 When reduction and casting was compared to external fixation, all patients achieved union.3 Locking plates can reduce the requirement for bone graft.4 Locking plates have superior purchase to nonlocking plates in osteoporotic bone. Extra-articular fractures in patients with good bone stock will often do well with manipulation and splinting, or a variety of fixations, and there is no conclusive evidence to mandate one option over another. The treatment is tailored to the patient’s requirements, their health status, and the skill set of the treating surgeon. For a treatment algorithm for distal radius fractures, see Fig. 75.3).