colles fracture

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Colles' Fracture

Definition

A Colles' fracture is a transverse fracture of the distal radial metaphysis within 2-2.5 cm of the articular surface, characterized by dorsal angulation, dorsal and proximal displacement, and radial deviation of the distal fragment. It is the most common wrist fracture in adults.

Pye's Surgical Handicraft, p. 189
Rosen's Emergency Medicine, p. 611

Mechanism

Fall on an outstretched, extended hand (FOOSH)
Compression forces on the dorsal side produce dorsal comminution
Most common in postmenopausal women (often a pathological fracture on an osteoporotic background)

Radiographic Appearance

$Colles' Fracture X-ray: (A) PA view showing radial shortening, intraarticular extension, ulnar styloid fracture; (B) Lateral view showing the dinner-fork deformity with dorsal displacement and angulation$

Fig. Colles' Fracture. (A) PA view: fracture with radial shortening, intraarticular extension, ulnar styloid fracture. (B) Lateral view: dorsal displacement and angulation - the classic "dinner fork" deformity. - Rosen's Emergency Medicine, p. 612

$Distal radius fracture patterns: A = Colles' (dorsal), B = Colles' with ulnar styloid, C = radial styloid, D = intraarticular with ulnar styloid$

Fig. Distal radius fracture patterns. A = extra-articular Colles', B = with ulnar styloid fracture, C/D = intraarticular variants. - Pfenninger & Fowler's Procedures, p. 1321

PA view findings:

Distal metaphyseal radius fracture, often shortened
Radial displacement of the carpus
Ulnar styloid fracture (present in ~60% of cases)
Intraarticular extension into radiocarpal or radioulnar joints possible

Lateral view findings (best for diagnosis):

Dorsal angulation and displacement of radial fragment
Loss of normal volar tilt of the distal radial articular surface

Clinical Features

Feature	Detail
Deformity	"Dinner fork" (lateral view)
Swelling & tenderness	Over distal radius
Radial deviation	Lower end of ulna becomes prominent
Paresthesias	Palmar - median nerve compression

Radiology: Criteria for Instability / Reduction

Reduction is indicated when:

Dorsal angulation >20 degrees on lateral view
Radial shortening - radius shorter than ulna on PA view (positive ulnar variance)
Intraarticular involvement with step-off
Marked comminution, or >1 cm shortening

The lateral view line test (Pye's): Draw a line between the anterior and posterior lips of the radial articular surface. If tilted backwards relative to the radial shaft or displaced radially, reduction is needed. If tilted slightly forwards or at right angles, reduction is likely unnecessary.

Management

Non-Operative (Stable Fractures)

Extra-articular, non-displaced: double sugar-tong splint (one from elbow to wrist, second from elbow to axilla) for 3-5 days, then short-arm cast for 4-6 weeks
Follow-up radiographs at 1, 2, and 6 weeks to ensure no displacement

Closed Reduction Technique

Anesthesia: Hematoma block - inject 5-10 mL of 1% lidocaine (±bupivacaine) via 22-gauge needle into the dorsal fracture hematoma. Bier block (IV regional anesthesia) or regional nerve blocks (median, radial, ulnar, brachial plexus) are alternatives.
Finger traps: Applied to relax deforming forces from muscle spasm; may achieve reduction alone and hold position during splinting.
Traction: While the forearm is held firmly, push the fragment distally and palmarly.
Goal: Restore volar tilt (at minimum, neutral/zero degrees), radial inclination, and proper radial length.
Splint: Sugar-tong splint post-reduction. Avoid circumferential casting for ≥24 hours due to post-reduction edema.
Post-reduction: Urgent orthopedic follow-up within 2-3 days.

Operative Indications

Unstable fractures (>20° angulation, marked comminution, intraarticular)
Fractures not amenable to or not maintained by closed reduction
Open fractures
Neurovascularly compromised fractures
High-demand patients (dominant wrist, young/active)

CT scan is helpful when significant intraarticular extension, comminution, or distal radioulnar joint (DRUJ) instability is suspected.

Associated Injuries

Ulnar styloid fracture (~60%) - may indicate triangular fibrocartilage complex (TFCC) injury and DRUJ disruption (a significant source of long-term morbidity)
Carpal instability
Median nerve injury (most common nerve, ~17%)
TFCC tears
Radiocarpal/radioulnar instability

Complications (occur in 6-80% of cases)

Complication	Notes
Carpal tunnel syndrome	Most common; immediate or delayed; from nerve damage or swelling
Median nerve injury	~17%; from contusion, traction, compression, or cast
Malunion	Especially with inadequate reduction
DRUJ instability	From TFCC injury / ulnar styloid fracture
Post-traumatic arthritis	Especially with intraarticular extension
Stiffness & weakness	Particularly in elderly
Reflex sympathetic dystrophy (CRPS)	Rare but debilitating
Iatrogenic	Extreme wrist flexion in splint can cause median nerve damage; thin skin may convert closed to open fracture

Red flags for poor outcome: dorsal angulation ≥20°, radial shortening ≥5 mm.

Comparison with Related Fractures

Fracture	Displacement	Deformity
Colles'	Dorsal	"Dinner fork"
Smith's (reverse Colles')	Volar	"Garden spade"
Barton's	Volar or dorsal articular fragment + carpal shift	Intraarticular

Sources: Tintinalli's Emergency Medicine, p. 1847-1848 | Rosen's Emergency Medicine, p. 611-612 | Pfenninger & Fowler's Procedures for Primary Care, p. 1321 | Pye's Surgical Handicraft, p. 189

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