Colles Fracture

One of the most common fractures is called a Colles’ Fracture. This is a fracture of the distal radius, meaning that the radius (one of two bones that makes up the forearm with the other being the ulna) is fractured or broken towards the end where the radius meets the hand. This fracture occurs across a wide variety of age ranges all with different mechanisms and different complications. Because of its commonality, it is important for people to understand how this fracture develops, how it is diagnosed, and the implications of the different treatment options.

Many people would like to know just how common their fracture is. A study published in 2012 in the Hand Clinics journal revealed that Colles’ fractures are remarkably common. In fact, data over the past 40 years was reviewed and revealed that 25% of fractures in the elderly population are fractures of the distal radius and 18% of fractures in children are fractures of the distal radius. Furthermore, the incidence of these fractures has been rising. This is likely due to the significant increase in the number of kids playing sports and the number of elderly people who are remaining active well into their later years. Clearly, these fractures are common across all age groups.

There are a couple of different ways this fracture can develop; however, the most common mechanism is a fall on an outstretched hand. When people fall, they generally extend their arms in front of them in order to protect the vital organs in their chest and abdomen from impact. While this may protect those organs, it also exposes the bones of the hand, wrist, and forearm to impact. If people fall with their wrists extended (so that their palms hit the surface of the ground), the force is transmitted through the bones of their hand up their forearm into the wrist. In this mechanism, the radius receives the bulk of the impact and is prone to being fractured.

Another possible mechanism is an overuse injury. This type of fracture may be termed a stress fracture or a fatigue fracture. While this mechanism is relatively uncommon, it can be seen in people with diseases such as osteoporosis. Therefore, this mechanism is seen almost exclusively in the elderly or people who already have significantly weakened bones.

The diagnosis of a Colles’ Fracture is going to start with a history, where the physician will attempt to figure out how the injury occurred. The physician will look for many of the factors discussed in the preceding section. Then, the physician will perform a physical exam to get a better look at the injury. The physician will try to decide whether or not imaging studies are warranted to look for a fracture. Some of the physical exam findings of a Colles’ Fracture include:

Pain over the Distal Radius: When people suffer a bone fracture, they will develop pain and tenderness over the fracture site. The physician will palpate over the distal radius to see if this increases the pain. The physician will also palpate over other areas of the arm to see if the pain dissipates when they move away from the suspected fracture site.

Swelling near the Fracture Site: Swelling is also common with almost all bone fractures. When people suffer a fracture, the body senses the injury and will rush cells to the area to fight off any potential infection and start the healing process. With all of the cells in the area, the distal radius will start to swell. Physicians will look for this on exam.

A Dorsal Tilt of the Wrist: Because the patient has fallen on an outstretched hand, the bone has been broken in a way that gives the wrist a dorsal tilt, or a tilt of the bone towards the back of the hand away from the palm. If the physician sees this, their suspicion for a Colles’ Fracture will increase.

Apparent Shortening of the Radius: If the radius is fractured, the bones may be displaced. If the bones are displaced, the overall length of the radius may appear shortened. While the total length of the radius is still intact, it will appear shorter on exam because the bone is no longer completely straight. The physician will assess this on their physical exam.

Angulation of the Wrist toward the Radius: The muscles of the forearm attach to the bones. If the bones are broken, the muscles are going to pull on these fragments, causing a deviation of the hand in the direction of the bone fracture. This could appear as though the hand is being “pulled” in the direction of the fractured radius.

These are a few of the physical exam findings that physicians are going to look for if they suspect a Colles’ Fracture. While this list is not complete, there are a few of the common signs of this specific fracture. Other obvious signs and symptoms the physician may look for are bone fragments sticking out of the skin with an open fracture or serious bleeding if one of these fragments has damaged a blood vessel. If any of these serious symptoms are present, the physician will rush the patient to the operating room immediately.

After the physician has completed the history and the physical exam, the physician will need to decide whether or not there is enough suspicion to order imaging studies. If they deem these studies necessary, there are a couple of different imaging modalities that they will use.

X-Ray, AP and Lateral: This is the first and fastest study that the physician will order. X-rays are exceptional tools for looking at bone fractures. The physician will likely order x-rays from multiple different angles, such as the AP (anterior to posterior angle) and the lateral (side to side) angle. The purposes of ordering multiple different angles is to make sure that there isn’t anything that could be missed by only looking at the wrist from one angle. If the patient has suffered a Colles’ Fracture, the physician will see the fracture in the distal radius near the forearm. They may also be able to see other fractures that might accompany the Colles’ Fracture, such as an associated fracture of the ulnar styloid.

MRI: It’s unusual for patients to require an MRI for a Colles’ Fracture; however, the physician may believe that this is necessary if there is any suspicion for damage to associated nerves and blood vessels. There are many different nerves and blood vessels that run through the forearm that supply nutrients and innervation to the hand, such as the radial artery, radial nerve, and ulnar nerve. If the physician has any suspicion that these structures have been compromised, an MRI may be necessary to get a better look at these structures. If these have been damaged, the patient may require surgery to repair the structures.

Ultrasound: Some patients will bone fractures will be given an ultrasound scan in the emergency room. The ultrasound scan will be used if the physician is worried about damage to blood vessels. It is faster than an MRI scan and can be used to assess blood flow through a blood vessel. If there is blood leaking into the tissue space or if blood flow through a vessel has been cut off for any reason, the ultrasound scan can help to determine this.

These imaging studies are important for making a final diagnosis as well as identifying any damage to other structures and planning for treatment. Once all of the information has been collected, the physician can proceed with a treatment plan.

When the physician has all of the information, they are ready to move forward with a treatment plan. There are a couple of different options on the table.

Immediate Casting: Based on the imaging studies, the physician could determine that the fracture has not been displaced. If this is the case, then reduction is not required because the bones are still in their proper location. In this situation, the physician will place short-arm plaster cast on the forearm, immobilizing the wrist for around six weeks on average. This will give time for the bones to heal properly. Most patients regain full use of their wrist on the other side of the healing process.

Closed Reduction: If the bones have been slightly displaced, the physician could elect to go with a closed reduction procedure. This closed reduction procedure can be painful; however, anesthesia is given to reduce the pain and it is better than heading to the operating room. The physician or an assistant will brace one end of the arm while another physician “reduces” the fracture by placing traction near the fracture site. Then, the patient is placed in a plaster cast for around six weeks to give the fracture time to heal. It’s not uncommon for patients to require a reduction of a Colles’ Fracture.

While it is unusual for patients to require surgery to repair a Colles’ Fracture, there are some circumstances where it is required to facilitate the healing process.

Failed Closed Reduction: This is one of the reasons that patients could require surgery to repair their wrist fracture. After the closed reduction procedure, some patients can have their reduction “slip” out of place. If this happens, patients may require surgery to permanently reduce the fracture.

Open or Comminuted Fractures: In this scenario, patients have bone fragments sticking out of their skin (an open fracture) or a fracture that has splintered into many pieces (comminuted fracture). This means that there is no way to reduce the fracture in a closed manner. Patients will need to head to the operating to have their wrist put back together by a surgeon.

Damage to Surrounding Structures: When patients suffer a bone fracture, it is possible for a fragment of the bone to break off and damage blood vessels or nerves. These are important structures that must be put back together in order for patients to make a full recovery. Patients will need to head to the operating room to have these structures repaired.

Like most traumatic injuries, there are certain complications that could develop in a Colles’ Fracture that people need to be aware of.

Fracture of the Ulnar Styloid: It’s always possible for a patient to fracture more than one bone with any traumatic injury. In any fracture of the distal radius, it is possible for a patient to fracture the ulnar styloid as well. This is the distal end of the ulna, the other bone that makes up the forearm, and it can be fractured due to the same injury mechanism that fractures the radius. An associated fracture of the ulnar styloid is common with a Colles’ Fracture.

Fracture through the Epiphyseal Plate: This is an associated injury that is seen in young kids who fall on an outstretched hand. The epiphyseal plate is also called the growth plate and is assessed on every imaging study ordered with any concern for a fracture. If the epiphyseal plate is damaged, it can have important implications for the growth of a child. If a Colles’ Fracture is severe, it can damage the epiphyseal plate of children.

Risk of Infection: If a patient requires surgery, there is always a risk that the patient could acquire an infection during the procedure. While infections are uncommon, it can keep people in the hospital for an extended period of time as they receive antibiotics to clean out the fracture site.

I’m Ed Smith, a Sacramento Bone Fracture Attorney. A fracture of the distal radius is common and patients suffering a traumatic injury should feel free to reach out to me at (916) 921-6400 for friendly, free advice. I also have a toll-free line available at (800) 404-5400.

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