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). 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 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 12mm 1mm circumference of the
wrist. It is held in position by a crepe bandage. Extreme positions of flexion and ulnar deviation must be
avoided; 20 degrees in each direction is adequate. 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 (a) outcome in these patients is not so
dependent upon anatomical perfection, and (b) fixation of the fragile bone can be very difficult. 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.

IMPACTED OR COMMINUTED COLLES’ FRACTURES

With substantial impaction or comminution in osteoporotic bone, manipulation and plaster

immobilization alone may be insufficient. The fracture can sometimes be reduced and held with
percutaneous wires, but if impaction is severe even this may not be enough to maintain length; in that
case, an external fixator is used to neutralize the compressive force of the 25 tendons crossing the wrist,
and bone graft or bone substitute is placed into the gap. The fixator is attached to the distal radius and
the second metacarpal shaft. It should be used only as a neutralizing device; too much distraction will
lead to stiffness. The fixation is removed after 5–6 weeks and exercises begun. Plate fixation is
increasingly being used for some Colles’ fractures. The so-called ‘volar locking plate’ is applied to the
front of the radius through the bed of f lexor carpi radialis. The screws are fixed to the plate itself and
are passed into the relatively stronger subchondral bone distally. These devices, which are flourishing in
the orthopaedic marketplace, allow stable f ixation and thus early mobilization of the forearm. Other
devices, such as a locked intramedullary nail or crossed K-wires, are also suitable for the distal radius.
Outcome As Colles himself recognized, the outcome of these fractures in an older age group with lower
functional demands is usually good, regardless of the cosmetic or the radiographic appearance. Poor
outcomes can often be improved by performing a corrective osteotomy. The amount of displacement
that can be accepted depends on patient factors such as age, comorbidity, functional demands,
handedness, and quality of bone, and treatment factors such as surgical skill and implants available. As a
rule, shortening of more than 2 mm at the distal radio-ulnar joint, dorsal tilt of more than 10 degrees
and dorsal translation of more than 30 per cent are likely to lead to a poor outcome and early correction
should be considered. This advice applies to older osteopaenic fractures; in younger patients the
tolerances are far less! 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