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140 Orthopaedic Nursing • March/April 2008 • Volume 27 • Number 2

displacement of the distal fragment is defined as theSmith’s fracture.

To add more confusion, a distal radial fracture mayalso be termed a Barton’s fracture, which may be usedfor “subluxation of the wrist consequent to a fracturethrough the articular surface of the carpal extremity ofthe radius” (Barton, 1838, p. 365). The mechanism forthis type of injury is described as a force encountered bythe palm of the hand that forces the carpal bonesagainst the dorsal edge of the radial dorsal surface thatcauses a dorsal fracture and subluxation of the carpus.

Mechanism of InjuryThe most frequent injury for a distal radial fracture oc-curs when the hand and arm are extended and placeddown to prevent a fall. The wrist is often hyperextended,and the blunt force impacted on the wrist upon contactwith the floor (or other surface) is very intense at the pointof contact (see Figure 3). This is still an issue with thoseover the age of 50, especially those with osteoporosis,which is a condition of low bone density. The older gener-ation tends to be more unstable with ambulation andhave a high risk of falling, and fracture is more commonin an elderly patient with osteoporosis or osteopenia.

A distal radial fracture can also be caused by any-thing that forces dorsiflexion of the wrist without at-tempting to prevent a fall. The density of the bone isvery low and the bone tissue is not as strong as thenonosteoporotic bone tissue.

The actual type of injury depends on the position ofthe wrist on impact and the magnitude and direction ofthe force on impact. When a fall occurs and the out-stretched hand has the wrist in a 40� to 90� dorsiflexion,a fracture of the distal radius occurs with dorsal dis-placement (Frykman, 1967). A fracture of the ulnar sty-loid in a Colles’ fracture results from the force throughan intact triangular fibrocartilage complex. A distal ra-dial fracture with palmar displacement can also occurwith an impact on the back of a hand that is flexed. This

Many people “slip and fall,” especially in the icy areas of thewinter season. To prevent an injury to the head, most peo-ple put their hand out to hit the ground first, so the wristusually gets injured. The most frequent injury from this typeof “intervention” is a fracture to the distal radius and/orulna, which is frequently called a “Colles’ fracture.”

Why is a distal radius fracture called a “Colles’fracture”? Originally, in 1814, Dr. AbrahamColles, an Irish surgeon and anatomist, de-fined a distal radial fracture as a low-

energy, extra-articular fracture to the distal radius inthe elderly population. Since that time, several aspectsof Dr. Colles’ definition have changed. It is no longerconsidered a low-energy injury and is not specific tobeing an extra-articular fracture. In addition, the elderlyis not the only population with high incidence of Colles’fracture. In the younger population, the number of dis-tal radial fractures has increased because of the sportsactivities that have been incorporated into the juniorand senior high school curricula.

In general, the radius is the most common fracturedbone in the arm and the distal radius, and is a very com-mon site. The ulna, a parallel bone with the radius, isfrequently fractured with a distal radial fracture be-cause of the similar location and force impact site (seeFigure 1).

The basic goal of treatment in a Colles’ fracture is torestore the anatomic position of the distal radius withthe full range of motion of the wrist that is painless.Each fracture is assessed individually because Colles’fractures differ according to the angulation, fragmenta-tion, and stability of the fracture.

The distal radius includes triangular and biconcavecontours with hyaline cartilage coverage (see Figure 2).The cortical bone in the distal radial metaphysic is thinand susceptible to fracture with heavy force. The distalradius fracture is sometimes defined by two differentnames. A Colles’ fracture is a fracture of the distal radiuswithin 2 cm of the distal radius including dorsal dis-placement of the distal fragment. The confusing situa-tion of a distal radial fracture is when another termmay be used. This may occur when a fracture withinthe distal 2 cm of the radius with palmar and proximal

Linda L. Altizer, MSN, RN, ON, CLNC, Armed Forces Medical Examiner’s office.

The author has no significant interest, financial or otherwise, to anycompany that might have an interest in the publication of this educational activity.

Colles’ FractureLinda L. Altizer

ORTHOPAEDIC ESSENTIALS

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Orthopaedic Nursing • March/April 2008 • Volume 27 • Number 2 141

most frequently occurs with the forearm supinated atthe time of fall.

Because of the confusion with identifying all thetypes of Colles’ fractures, Frykman developed and pub-lished a comprehensive classification of the Colles’ frac-tures that were based on the types of fractures of the dis-tal radius and ulna (Frykman, 1967) (see Table 1).

The Frykman system of identifying the type of Colles’fracture has clarified many of the previous questions. Itdoes not specify the direction or extent of the fracturedisplacement.

The most recently published system also classifiesstable versus unstable patterns of Colles’ fractures, aswell as associated lesions and children injuries (seeTable 2 and Table 3).

AssessmentComplete assessment is vital in extremity injuries, andaccurate diagnosis defines the proper treatment. Thesensation in the distal digits should be continuouslymonitored. If the patient is alert, it is possible to de-tect whether the sensory level is decreasing. The me-dian nerve status gets prime attention. If the patienthas an extremely edematous wrist with an obviousdecrease in median nerve function, carpal canal pres-sures are evaluated and used to determine the diagno-sis of median nerve contusion or acute compressiveneuropathy. If the diagnosis is median nerve contu-sion, it would require continuous monitoring. If acute

FIGURE 1. Anteroposterior radiograph of distal radius fracturesuitable for percutaneous pinnin. From Chapman, M.W.Chapman’s Orthopaedic Surgery, 3rd edition. Philadelphia,Lippincott Williams, and Wilkins, 2001; 1421. Reprinted withpermission.

FIGURE 3. Falling with the wrist hyperextended, with pressureon the distal radius and ulna.

FIGURE 2. Anterior distal end of the radius and ulna. FromKaplan EB, Taleisnik J. The Wrist. In Spinnter M, ed. Kaplan’sFunctional and surgical Anatomy of the Hand, 3rd ed.Philadelphia: JB Lippincott, 1984. Reprinted with permission.

TABLE 1. FRYKMAN’S CLASSIFICATION OF COLLES’ FRACTURE

Type Fracture

I Extra-articular radial fractureII Extra-articular radial fracture with an ulnar fractureIII Intra-articular fracture of the radiocarpal joint

without an ulnar fractureIV Intra-articular fracture of the radius with an ulnar

fractureV Fracture of the radioulnar jointVI Fracture into the radioulnar joint with an ulnar

fractureVII Intra-articular fracture involving radiocarpal and

radioulnar jointsVIII Intra-articular fracture involving radiocarpal and

radioulnar joints with an ulnar fracture

ON270209_140-145.qxp 3/14/08 1:20 AM Page 141


TAB

LE2.

A P

RA

CTIC

AL,

TR

EATM

ENT-

OR

IEN

TED

CLA

SSIF

ICA

TIO

NO

FFR

ACT

UR

ESO

FTH

ED

ISTA

LR

AD

IUS

AN

DA

SSO

CIA

TED

DIS

TAL

RA

DIO

ULN

AR

JOIN

TLE

SIO

NS.

BY

DIE

GO

L. F

ERN

AN

DEZ

Stab

ility

/As

soci

ated

Les

ions

In

stab

ility

: C

arpa

l Lig

amen

t,H

igh

Risk

of

Frac

ture

s, M

edia

n,

Seco

ndar

y U

lnar

Ner

ve,

Frac

ture

Typ

es

Dis

plac

emen

t Te

ndon

s, L

psila

t.,

(Adu

lts)

Bas

ed o

n C

hild

ren

Afte

r In

itial

fx

Upp

er E

xtre

mity

, th

e M

echa

nism

Fr

actu

re

Adeq

uate

D

ispl

acem

ent

Num

ber

of

Com

part

men

t Re

com

men

ded

of In

jury

Eq

uiva

lent

Re

duct

ion

Patt

ern

Frag

men

ts

Synd

rom

e Tr

eatm

ent

Not

e. F

rom

Cha

pman

, M.W

. Cha

pman

’sO

rtho

paed

ic S

urge

ry, 3

rd e

ditio

n. P

hila

delp

hia,

Lip

pinc

ott

Will

iam

s, a

nd W

ilkin

s, 2

001;

141

7. R

eprin

ted

with

per

mis

sion

.

Type

IBe

ndin

g fr

actu

re o

f th

e m

etap

hysi

s

Type

IISh

earin

g fr

actu

re o

f th

e jo

int

surf

ace

Type

III

Com

pres

sion

fr

actu

re o

f th

ejo

int

surf

ace

Type

IVA

vuls

ion

frac

ture

s,

radi

o ca

rpal

fr

actu

re

disl

ocat

ion

Type

V

Dis

tal f

orea

rmFr

actu

re

Salte

r II

Salte

r IV

Salte

r III

, IV

, V

Ver

y ra

re

Com

bine

d fr

actu

res

(I-II-

III-IV

)hi

gh-v

eloc

-ity

inju

ry

Stab

le

Uns

tabl

e

Uns

tabl

e

Stab

le

Uns

tabl

e

Uns

tabl

e

Ver

y ra

re

Non

-dis

plac

edD

orsa

lly (C

ol-le

s-Po

utea

u)V

olar

ly (S

mith

)Pr

oxim

alC

ombi

ned

Dor

sal

Radi

alV

olar

Prox

imal

Com

bine

d

Non

-dis

plac

edD

orsa

lRa

dial

Vol

arPr

oxim

alC

ombi

ned

Dor

sal

Radi

alV

olar

Prox

imal

Com

bine

d

Uns

tabl

e

Alw

ays

2 m

ain

frag

men

ts �

vary

ing

degr

eeof

met

aphy

seal

com

min

utio

n(In

stab

ility

)

Two-

part

Thre

e-pa

rt

Com

min

uted

Two-

part

Thre

e-pa

rtFo

ur-p

art

Com

min

uted

Two-

Part

(rad

ial

styl

oid

ulna

rst

yloi

d)Th

ree-

part

(vol

ar,

dors

al m

argi

n)C

omm

inut

ed

Dor

sal

Radi

alV

olar

Prox

imal

Com

bine

d

Unc

omm

on

Less

unc

omm

on

Com

mon

Freq

uent

Com

min

uted

an

d/or

bon

elo

ss (f

requ

ently

intr

aart

icul

arop

en, s

eldo

mex

traa

rtic

ular

)

Con

serv

ativ

e (s

tabl

e fx

s)Pe

rcut

aneo

us p

inni

ng

(ext

ra-

or in

traf

ocal

)Ex

tern

al fi

xatio

n (e

xcep

tiona

lly b

one

graf

t)

Ope

n Re

duct

ion

Scre

w-p

late

fixa

tion

Con

serv

ativ

e cl

osed

, lim

ited,

art

hros

copi

cas

sist

ed, o

r ex

tens

ileop

en r

educ

tion

Perc

utan

eous

pin

s co

mbi

ned

exte

rnal

and

inte

rnal

fixa

tion

bone

gra

ft

Clo

sed

or o

pen

redu

ctio

n Pi

n or

scr

ew fi

xatio

nTe

nsio

n W

iring

Alw

ays

pres

ent

Com

bine

d m

etho

d

ON270209_140-145.qxp 3/14/08 1:20 AM Page 142

TAB

LE3.

FRA

CTU

RE

OF

THE

DIS

TAL

RA

DIU

S: A

SSO

CIA

TED

DIS

TAL

RA

DIO

ULN

AR

JOIN

T(D

RU

J) L

ESIO

NS D

egre

e of

Jo

int S

urfa

ce

Path

o-An

atom

y of

the

Lesi

on

Invo

lvem

ent

Prog

nosi

s Re

com

men

ded

Trea

tmen

t

Not

e. F

rom

Cha

pman

, M.W

. Cha

pman

’s O

rtho

paed

ic S

urge

ry, 3

rd e

ditio

n. P

hila

delp

hia,

Lip

pinc

ott

Will

iam

s, a

nd W

ilkin

s, 2

001;

141

8. R

eprin

ted

with

per

mis

sion

.

Type

I

Stab

le

(fol

low

ing

redu

ctio

n of

the

rad

ius

the

DRU

J is

con

gruo

us

and

stab

le)

Type

II

Uns

tabl

e

(sub

luxa

tion

or

disl

ocat

ion

of t

he

ulna

r he

ad

pres

ent)

Type

III

Pote

ntia

lly u

nsta

ble

(sub

luxa

tion

poss

ible

)

A Avu

lsio

n fr

actu

re

tip u

lnar

st

yloi

d

A Subs

tanc

e te

ar o

f TF

CC

and

/or

palm

ar a

nd

dors

al c

apsu

lar

ligam

ents

A Intr

aart

icul

ar

frac

ture

of

the

sigm

oid

notc

h

B Stab

le f

ract

ure

ulna

r ne

ck

B Avu

lsio

n fr

actu

re

base

of

the

ulna

r st

yloi

d

B Intr

aart

icul

ar

frac

ture

of

the

ulna

r ha

nd

Non

e

Non

e

Pres

ent

Goo

d

•C

hron

ic in

stab

ility

•Pa

infu

l lim

itatio

nof

sup

inat

ion

ifle

ft u

nred

uced

•Po

ssib

le la

tear

thrit

ic c

hang

es

•D

orsa

l sub

luxa

tion

poss

ible

tog

ethe

rw

ith d

orsa

lly d

is-

plac

ed d

ie p

unch

or d

orso

ulna

rfr

agm

ent

•Ri

sk o

f ea

rly

dege

nera

tive

chan

ges

and

se-

vere

lim

itatio

n of

fore

arm

rot

atio

n if

left

unr

educ

ed

A �

B

A A A �

B

A B

Func

tiona

l aft

er t

reat

men

tEn

cour

age

early

pro

natio

n-su

pina

tion

exer

cise

s

Clo

sed

trea

tmen

tRe

duce

sub

luxa

tion,

sug

ar t

ong

splin

t in

45�

of s

upin

atio

nfo

ur t

o si

x w

eeks

Ope

rativ

e tr

eatm

ent

Repa

ir TF

CC

fix

ulna

r st

yloi

d w

ith t

ensi

on b

and

wiri

ngIm

mob

ilize

wris

t an

d el

bow

in

supi

natio

n (c

ast)

or

tran

sfix

ulna

/rad

ius

with

k-w

ire a

ndfo

rear

m c

ast

Ana

tom

ic r

educ

tion

of p

alm

ar

and

dors

al s

igm

oid

notc

hfr

agm

ents

. If

resi

dual

su

blux

atio

n te

nden

cy

pres

ent

imm

obili

ze a

s in

ty

pe II

inju

ryFu

nctio

nal a

fter

tre

atm

ent

to

enha

nce

rem

odel

ling

oful

nar

head

If D

RUJ

rem

ains

pai

nful

: par

tial

ulna

r re

sect

ion,

Dar

rach

or

Sauv

e-K

apan

dji p

roce

dure

at

a la

ter

date

Not

e: E

xtra

artic

ular

uns

tabl

efr

actu

res

of t

he u

lna

at t

he m

etap

hyse

al le

vel

or d

ista

l sha

ft r

equi

re s

tabl

e pl

ate

fixat

ion


ON270209_140-145.qxp 3/14/08 1:20 AM Page 143


carpal tunnel syndrome is determined, immediateoperative decompression would be the treatment ofchoice.

Neurovascular (N/V) assessment should be per-formed on the entire hand including all digits. This in-cludes radial and ulna pulses and the ability to flex andextend each interphalangeal joint. The fingers shouldalso have the ability to abduct and adduct. The sensa-tion at the tip of each finger and the thumb is also as-sessed. If the patient is hospitalized, the finding of N/Vassessment is documented and the trends of change areevident.

An x-ray film of the wrist will display the direction ofdisplacement, degree of shortening, and comminution,compression, and involvement of the articular surface.

TreatmentTreatment outcomes are based on goals of achievinganatomical alignment of the injured area and maintain-ing that alignment until the fracture is healed, and dur-ing that healing time, maintaining the innervations ofthe nerves supplying motion and sensation to the ex-tremity. When the wrist is put in a cast, an x-ray film isobtained 2 weeks later to make sure the fracture has notbeen displaced while in the cast. Sometimes displace-ment does occur in the cast, and the fracture requiresrepeat reduction and stabilization.

Colles’ fractures that are noncomminuted and arenondisplaced are usually managed with a splint. Smith’sfractures are sometimes casted or splinted in supination.

Percutaneous pinning is sometimes used to maintainalignment if traction reduces the fracture to proper po-sition. If the fracture is comminuted and cannot be re-duced and maintained in proper position with a cast,the choice of treatment may be external fixation.External fixation often restores the length and intra-ar-ticular alignment of the fracture (see Figure 4).

Open reduction and internal fixation are sometimesnecessary to manage a displaced intra-articular fracturewith palmar dislocation of the carpus. This fracturetends to be very unstable and is difficult to reduce andstabilize. Internal fixation can be performed with pinsor a plate or both (see Figure 5).

An arthroscopically assisted reduction via externalor internal fixation of the fraction can be another op-tion. There is less ability with the scope to visualize thesurrounding ligaments that may also be injured (seeTable 4).

FIGURE 4. External fixation for Colles’ fracture. From Altizer-Salvagno Center for Joint Surgery.

FIGURE 5. Open reduction, internal fixation for Colles’ fracture.From Altizer-Salvagno Center for Joint Surgery.

TABLE 4. UNIVERSAL CLASSIFICATION OF DISTAL RADIUS

FRACTURES

Classification of Fracture Treatment Preference

I. Nonarticular, nondisplaced Cast immobilizationII. Nonarticular, displaced

A. Reducible, stable Cast immobilizationB. Reducible, unstable Percutaneous pinsC. Irreducible Open reduction/external

fixationIII. Articular, nondisplacedIV. Articular, displaced

A. Reducible, stable Closed reduction, percutaneous pin (K-wires)

B. Reducible, unstable Closed reduction, external fixation (� percutaneous pins)

C. Irreducible ORIF � percutaneous pinsD. Complex ORIF; plate fixation � bone

graft (� percutaneous pins)

Note. From “Fractures of the Distal Radius. A Modern Treatment-based Classification,” W. Cooney, 1993, Orthopaedic Clinic, 24,p. 211.

ON270209_140-145.qxp 3/14/08 1:20 AM Page 144

Postreduction InstructionsRegardless of how a Colles’ fracture is treated, all pa-tients are instructed to elevate the hand above the elbowand move their fingers frequently. The application of icefor the first 24 hr is helpful to reduce pain and decreaseedema. A complete teaching session should be given tothe patient to educate them regarding the “red flags”that may occur and need physician notification immedi-ately. These symptoms include the following:

• discoloration of nail beds• edema• “tingling or numbness” in fingers• decreased motion ability• decreased sensation in fingers• severe pain

Physical therapy is used when the fracture is healed,and activity in the hand can strengthen the muscles andligaments associated with the hand and increase rangeof motion. Therapy is designed for the severity of thefracture, the age of the patient, any functional demandsthat are required by his or her occupation or activities athome, and to accommodate any postinjury problemsthat he or she may have.

Many patients heal well post-Colles’ fracture with nocomplications, but some may not regain full range of mo-tion of the affected wrist. A ligament injury may also

occur with the Colles’ fracture and will be the main causeof chronic wrist pain. Other possible complications mayinclude arthritis or median nerve damage/compression,which usually leads to carpal tunnel syndrome.

Any patient with a Colles’ fracture who is older than50 should be recommended to be screened for osteo-porosis because the earlier this disease is recognized, thebetter the outcome. Osteoporosis has been shown to be afactor in approximately 250,000 cases of wrist fractures.If there is a known risk for osteoporosis in addition toColles’ fracture, screening is extremely important.

REFERENCESAltizer-Salvagno Center for Joint Surgery, Robinwood

Medical Center, Hagerstown, MD.Barton, J. (1838). Views and treatment of an important in-

jury to the wrist. Medical Examiner, 1, 365.Chapman, M. (2001). Chapman’s operative orthopaedic

surgery (Vol. 2, 3rd ed). Philadelphia: Lippincott,Wilkins & Williams.

Cooney, W. (1993). Fractures of the distal radius. A moderntreatment-based classification. Orthopaedic Clinic, 24, 211.

Frykman, G. (1967). Fractures of the distal end of theradius, including sequelae—shoulder, hand, fingersyndrome, disturbance in the distal radioulnar jointand impairment of nerve function: A clinical and ex-perimental study. Acta Orthopaedica Scandinavica,108(Suppl.), 1.


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