Colles' Fracture

Definition

Mechanism

• Fall on an outstretched, extended hand (FOOSH)
• Compression forces on the dorsal cortex produce dorsal comminution
• The fracture line may extend into the radioulnar or radiocarpal joint ("die-punch" fracture)

Radiographic Findings

• Distal metaphyseal fracture of radius, often appearing shortened
• Intraarticular extension may be visible (radiocarpal or radioulnar joint)
• Radial displacement of the carpus
• Associated ulnar styloid fracture is common (suggests triangular fibrocartilage complex injury)

• Dorsal angulation and displacement - the "dinner fork" deformity
• Loss of normal volar tilt of the distal radial articular surface

Distal Radius Fracture Patterns (Diagram)

Clinical Features

Instability Criteria (higher likelihood of requiring surgery)

• Dorsal angulation > 20 degrees
• Intra-articular involvement
• Marked comminution
• Radial shortening > 1 cm
• Distal radioulnar joint instability
• Radiocarpal instability patterns

Management

Stable, Nondisplaced, Extra-articular Fractures

• Double sugar-tong splint for 3-5 days (allows swelling)
• Followed by short-arm cast for 4-6 weeks
• Follow-up X-rays at 1, 2, and 6 weeks to ensure no displacement

Displaced / Angulated Fractures - Closed Reduction

• Hematoma block (first-line, easy, effective): 22-gauge needle into dorsum of distal radius, aspirate hematoma, instill 5-10 mL of 1% or 2% lidocaine ± bupivacaine
• IV regional anesthesia (Bier block)
• Regional nerve blocks (median, radial, ulnar, brachial plexus)
• Procedural sedation

1. Apply finger traps for traction - relaxes deforming muscle spasm, may perform reduction alone
2. Push the distal fragment distally and palmarly while holding the forearm firmly
3. Goal: restore volar tilt, radial inclination, and radial length
4. Acceptable minimum: neutral (0 degrees) volar tilt; ideally restore anatomic volar tilt (~11°)
5. Periosteal entrapment: re-create then reverse the mechanism under traction

• Double sugar-tong splint (NOT circumferential cast - edema risk)
• Splint must immobilize wrist but allow finger movement
• Avoid circumferential casting for at least 24 hours
• Urgent orthopedic follow-up within 2-3 days

Indications for Emergent Reduction

• Neurovascular compromise
• Significant deformity
• Soft tissue tenting

Indications for Surgery

• Unstable, severely comminuted, or intra-articular fractures not amenable to closed reduction
• Fractures in the dominant wrist of high-demand active patients
• All open fractures
• Neurovascularly compromised fractures

Complications (occur in 6-80% of cases)

Comparison: Colles' vs. Smith's Fracture

Colles' Fracture - Bailey & Love's Short Practice of Surgery (28th Ed.)

What Is It?

Named after Abraham Colles, an Irish surgeon who described it in 1814 - before X-rays existed.

How It Happens

• Fall on an outstretched hand (FOOSH)
• Compressive force drives the distal radius upward and backward (dorsally)
• Very common in older, osteoporotic women

Classic Deformity

• The distal fragment displaces dorsally (backward)
• Associated swelling, tenderness, and restricted wrist movement

X-ray Findings

• Distal radius displaced proximally and dorsally
• Possible ulnar styloid fracture (associated)
• Possible extension into radiocarpal or radioulnar joints ("die-punch" fracture)

Treatment (as per Bailey & Love)

1. Stable / Undisplaced Fractures

• Below-elbow plaster cast until healed (4-6 weeks)
• Keep elbow and shoulder moving to prevent stiffness

2. Displaced Fractures - Closed Reduction + Cast

• Most Colles' fractures (dorsal displacement) can be reduced closed and held in a cast
• However: fractures with significant initial displacement or dorsal comminution are at risk of re-collapsing ("slipping") in the cast
• These need close review with X-rays in the first few weeks

3. Unstable / At-Risk Fractures - Surgery

4. Intra-articular Fractures (Types B & C)

• Require anatomical reduction of the joint surface
• Gap/step of < 2 mm is acceptable
• Treated with closed reduction + K-wires, plate fixation, or external fixation

In Children

• Usually a Salter-Harris Type 2 physeal fracture or metaphyseal fracture
• Closed manipulation + below-elbow cast works well
• X-ray checks weekly for 3 weeks - if re-displacement occurs, use K-wires
• Growth arrest is rare

Key Points (Bailey & Love Summary)

1. Colles' fracture = dorsal displacement of the distal radius
2. Most can be treated with closed reduction + cast
3. Unstable or comminuted ones need K-wires or plating
4. Intra-articular fractures need anatomical joint reduction (< 2 mm step)
5. After treatment - move elbow and shoulder to prevent stiffness while in cast
6. Opposite injury = Smith's fracture (volar/forward displacement) - usually needs a plate

Greenstick Fracture

Bailey & Love's Short Practice of Surgery, 28th Ed.

Definition

Named after the way a "green" (living, sap-filled) stick breaks - it snaps and splinters on one side but does not break all the way through. (Bailey & Love, Fig. 32.8)

Why It Occurs in Children (Not Adults)

Types of Incomplete Paediatric Fractures (Bailey & Love)

Key Features

• Age: Children and adolescents only
• Cortex: One cortex broken (tension side); one intact (compression side)
• Periosteum: Usually intact on compression side - acts as a hinge
• Fracture line: Incomplete - does not cross the whole bone
• Deformity: Angulation present but no complete displacement
• Radiograph: Fracture line visible on one cortex only; opposite side shows bending

Treatment

• Closed reduction under anaesthesia - the deforming force is reversed
• Some surgeons "complete" the fracture intentionally to prevent re-angulation (the intact periosteum can spring back if not fully corrected)
• Immobilised in a plaster cast until healed
• Prognosis is excellent - children's bones remodel well

Important Distinction