Introduction
A Colles' fracture is an extra-articular fracture of the distal radius with dorsal angulation of the distal radius fragment.
It is a common fracture, affecting 15% of people during their lifetime. Colles' fractures typically occur due to a fall on an outstretched hand (FOOSH) and most commonly affect people with osteoporosis. Complications of Colles' fractures include median nerve palsy and malunion.
It is a common fracture, affecting 15% of people during their lifetime. Colles' fractures typically occur due to a fall on an outstretched hand (FOOSH) and most commonly affect people with osteoporosis. Complications of Colles' fractures include median nerve palsy and malunion.
Epidemiology
- Incidence: 180.00 cases per 100,000 person-years
- Peak incidence: 70+ years
- Sex ratio: more common in females 2:1
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Aetiology
Colles' fractures most commonly affect older females with osteoporosis. In this age group, they are associated with low-energy trauma such as a FOOSH. Due to their strong association with osteoporosis, they are commonly known as a 'fragility fracture'. As such, the main risk factors for sustaining a Colles' fracture are related to osteoporosis and include:
In younger people, Colles' fractures tend to occur due to high-energy trauma.
- Female gender
- Being post-menopausal confers a higher risk of osteoporosis
- Increasing age
- Prolonged steroid use
- Smoking
- Low BMI
In younger people, Colles' fractures tend to occur due to high-energy trauma.
Clinical features
Colles' fracture typically occur in older people after a fall on an outstretched hand (FOOSH) with the forearm pronated in dorsiflexion. They can also occur in younger people, typically after high-energy trauma such as road traffic accidents.
Typical presenting symptoms of a Colles' fracture are:
Typical presenting symptoms of a Colles' fracture are:
- Wrist pain and swelling
- Pain and swelling usually occur immediately after the fracture is sustained
- Movement at the wrist is painful
- Wrist deformity
- Colles' fractures typically cause a 'dinner-fork' deformity of the wrist, caused by dorsal displacement of the distal fragment of the radius.
- Paresthesia and weakness
- If the fracture causes neurological damage this may result in paraesthesia and weakness of the wrist and/or fingers
- The median nerve is the most common nerve to be damaged by a Colles' fracture, affecting up to 12% of cases caused by low-energy trauma and up to 30% of cases caused by high-energy trauma
Investigations
If a Colles' fracture is suspected, the gold standard investigation for diagnosis is a plain radiograph using 2 views. Typically, an AP (anteroposterior) and lateral view are sufficient for diagnosis although oblique views are sometimes included.
Features of a Colles' fracture on a plain radiograph are:
CT/MRI scans may be performed for complex fractures or if a more detailed image is required for preoperative planning.
Features of a Colles' fracture on a plain radiograph are:
- Transverse fracture of the distal radius.
- The fracture is typically 2.5cm proximal to the radio-carpal (wrist) joint.
- Dorsal displacement and angulation of the distal fragment of the radius.
- In some cases the distal fragment of the radius is comminuted.
- There may be an associated ulnar styloid fracture.
CT/MRI scans may be performed for complex fractures or if a more detailed image is required for preoperative planning.
Differential diagnosis
Colles' fractures account for 90% of all distal radius fractures, however, other distal radius fracture types may share similar clinical features therefore imaging is important to differentiate them. Other types of distal radius fracture include:
In addition, other types of injury to the forearm or wrist may share symptoms and clinical features with a Colles' fracture:
- Smith's fracture
- In this type of distal radius fracture, there is volar angulation of the distal radius fragment as opposed to dorsal angulation as seen in Colles' fractures
- There may or may not be concomitant volar displacement
- Smith's fractures are typically sustained after a fall onto a flexed wrist, rather than an extended wrist as seen in Colles' fractures
- There may be a 'garden-spade deformity' on clinical examination
- Barton's fracture
- This is similar to a Colles' fracture, however, a Barton's fracture is intra-articular with dislocation of the radio-carpal joint
- Barton's fractures can be volar or, less commonly, dorsal, depending on which margin of the radius is affected
In addition, other types of injury to the forearm or wrist may share symptoms and clinical features with a Colles' fracture:
- Galeazzi fracture
- This is a fracture of the radius which usually occurs at the junction of the middle and distal third of the radial shaft
- This injury is typically caused by a FOOSH with the elbow in flexion
- Typically affects children rather than adults, with a peak incidence of age 9-12 years
- Wrist dislocation
- The most common carpal bone dislocation is perilunate dislocation
- This injury is typically sustained by a FOOSH
- Carpal dislocations are commonly missed on imaging
- Carpal bone fracture
- The most common carpal bone fracture is a fracture of the scaphoid bone
- This type of fracture is caused by a FOOSH
- Although this can affect any age, young adults are most commonly affected
- There is typically pain in the anatomical snuffbox
Management
Choice of management of a Colles' fracture depends on the severity of the fracture. The most common treatment method is closed reduction with immobilisation with a plaster cast.
If certain circumstances, open reduction and internal fixation (ORIF) or external fixation may be required, such as:
Colles' fractures typically unite by 6 weeks and repeat X-rays should be performed to ensure adequate union.
If certain circumstances, open reduction and internal fixation (ORIF) or external fixation may be required, such as:
- Unstable fracture
- Significant angulation of the distal fragment of the radius
- Usually defined as >10 degrees dorsal angulation
- Closed reduction is unsuccessful
- Comminuted fracture
Colles' fractures typically unite by 6 weeks and repeat X-rays should be performed to ensure adequate union.
Complications
Complications of a Colles' fracture include:
- Malunion
- If a fracture heals in a non-anatomical position, this is known as malunion
- Malunion is a relatively common complication of a Colles' fracture and is estimated to affect up to 33% of cases
- Malunion of a Colles' fracture can lead to a 'dinner-fork' deformity, pain, loss of strength and a limited range of movement
- Revision surgery may be required
- Median nerve damage
- It is important to assess for neurovascular damage in a patient who has a suspected or confirmed Colles' fracture
- The median nerve is the most common nerve to be damaged in a Colles' fracture
- Median nerve neuropathy occurs in approximately 1-12% of low energy fractures and 30% of high energy fractures
- Damage to the median nerve may cause median nerve palsy and post-traumatic carpal tunnel syndrome
- Symptoms of median nerve damage include paresthesia, weakness and pain in the wrist and/or fingers
- Decompression surgery may be required
- Rupture of the extensor pollicis longus (EPL) tendon
- This is an uncommon but important complication of a Colles' fracture
- An EPL tendon rupture is more likely to occur if the Colles' fracture is non-displaced and is due to mechanical attrition or tendon ischaemia
- Clinical features of an EPL tendon rupture include the inability to extend the interphalangeal joint of the thumb
- Surgical treatment is required
- Secondary osteoarthritis of the radio-carpal joint
- Although secondary osteoarthritis is more common in intra-articular fractures of the distal radius, it can sometimes occur due to Colles' fractures
- Post-traumatic osteoarthritis can lead to pain and reduced range of movement at the wrist joint