European Journal of Cardiovascular Medicine

Abraham Colles from Dublin, Ireland, in 1814, was the first to describe what is now known as Colles' fracture. He noted its distinctive features, such as the absence of crepitus and anomalous movement, distinguishing it from other fractures. Historically, distal radius fractures were predominantly seen in the elderly and postmenopausal women. Recently, there has been a rise in occurrences among younger individuals due to high-velocity injuries and road traffic accidents. [1,2]
During the late 18th and early 19th centuries, incapacity resulting from improperly healed distal radius fractures was deemed tolerable. Patients would become accustomed to the remaining deformity, restricted range of motion, and reduced grip strength. Due to evolving management trends, improved access to advanced treatment methods, and patients' unwillingness to accept deformities, the goal is to attain near-normal wrist function.[3]

Extra-articular distal radius fractures can be treated using methods such as internal fixation with plate and screws after open reduction, ligamentotaxis after closed reduction, percutaneous K-wire fixation, or closed reduction followed by plaster cast application. Orthopaedic surgeons most commonly perform the latter two procedures for Colles’ fracture. [3-5].We have considered many factors before settling on the treatment method. For patients with minimal functional demand, advanced age, injury to the non-dominant hand, and extra-articular fractures along the metaphyseal area, immobilization in a plaster of Paris cast can be done following closed reduction.[6,7] The pin and plaster approach involves using a K-wire to enhance stability following closed reduction of a distal radius fracture. The coordinates are (8,9). Due to poor bone quality and increased risk of fracture in elderly individuals, percutaneous K-wire pinning provides additional support to preserve the fracture in the appropriate alignment and position until edema decreases.[7,10]

In addition to the fracture, the dorsal comminution, fracture pattern, intra-articular extension of the fracture, association with ulnar fracture, and the degree of primary displacement of the fracture, including dorsal tilt exceeding 20 degrees and radial shortening over 5 mm, are significant risk factors for instability. These complex fractures will require more aggressive treatment.[11-13] This study is conducted to evaluate the functional and anatomical outcome following closed reduction and cast immobilization of extra-articular distal radius fractures (Colles’ type) in ‘dorsiflexion’.

The study was carried out in the orthopedic department of a tertiary care hospital located in Central India. All patients, regardless of gender, who were above the age of 20 and had a closed fracture of the distal end of the radius were included in the study if they met the specified inclusion and exclusion criteria during the study period. The study included all patients, regardless of sex, who were over the age of 20 and had isolated metaphyseal fractures of the radius and near fractures. The study excluded cases of pathological fractures, underlying neuromuscular diseases, open fractures, and other fractures in the same limb. A comprehensive history, including details of the mechanism of damage, and a thorough examination were conducted. Radiographs were obtained in both the injured and uninjured wrists, including both AP and lateral views. The patients were provided with an explanation regarding the treatment, and an extra radiograph of the unaffected side was taken for the purpose of comparison. To minimize swelling, the limb will be initially immobilized with a dorsal POP slab for a period of 4-5 days. During this time, the arm will be elevated and vigorous finger movements will be encouraged.

The closed reduction procedure was performed using a hematoma block and c-arm control. Following successful reduction, a cast was inserted below the elbow to maintain the reduction. While the plaster was solidifying, the helper carefully moved the wrist to a dorsiflexion angle of 150 degrees and slightly deviated it towards the ulnar side, all while keeping the traction intact. The surgeon consistently applied palmar flexion pressure to the distal piece in order to sustain its palmar tilt throughout the procedure. This also guaranteed the movement of bending the hand upwards at the wrist and not at the location of the broken bone. The plaster was skillfully shaped around the wrist. After the fracture was realigned, a cast made of plaster of Paris (POP) was placed on the lower part of the arm, extending below the elbow, and left in place for a duration of 4 weeks. X-rays were promptly collected in both anteroposterior and lateral views immediately after the application of the plaster. The confirmation of fracture reduction was obtained. Finger and thumb workouts were initiated immediately after the plaster was applied.

The patient received instruction on performing exercises to engage the elbow and shoulder joints. Their data was gathered via a proforma. At the one-week, four-week, and three-month follow-up visits, a repeat X-ray was performed and radiological parameters were recorded. PRWE scores were recorded at the time of the injury and at the final follow-up. The variables (dorsal tilt, radial shortening, and loss of radial inclination) were assessed at multiple time points: before reduction, immediately after reduction, one week, four weeks, and three months after the procedure. The radiological findings were computed using the Lindstrom classification.The functional score is assessed using the PRWE score. Utilizing the unpaired t-test. A χ2 test was used to conduct multivariate analysis. A significance level of p<0.05 was used.

The distribution of age, gender, and mode of injury among the patients studied revealed a varied demographic profile. In terms of age, the majority of patients fell within the 60-69 age range, comprising 40% of the total, followed by individuals aged 30-39 and 50-59, each representing 20%. The mean age of the patients was 50.30 years with a standard deviation of 16.05. Gender distribution showed a slight predominance of females, constituting 60% of the sample, while males accounted for the remaining 40%. Regarding the mode of injury, the most common cause was falls on an outstretched hand, affecting 40% of the patients, followed by road traffic accidents (30%), falls from height (20%), and direct injuries (10%). Statistical analysis revealed non-significant p-values for age distribution (p = 0.83), gender distribution (p = 0.525), and mode of injury (p = 1.000). Overall, the study depicted a diverse cohort of patients with various age groups, genders, and mechanisms of injury.

At three months follow-up, a study assessing loss of radial length in cases categorized by radius height revealed that 30% of the cases had a radius height of less than 3 mm, 50% fell within the 3-6 mm range, and 20% had heights between 7 and 11 mm. None of the cases had a radius height exceeding 12 mm. The total number of cases assessed was 30, representing the entire cohort. These findings suggest a varied distribution of radial length loss across different height categories, with a significant proportion falling within the 3-6 mm range.

At the three-month mark, an evaluation of the loss of radius angle revealed distinct distributions across various inclination categories. Among the cases assessed, 43.33% exhibited an inclination within the 0-4 degrees range, while 36.66% fell within the 5-9 degrees range. Only a small proportion, 8.33%, showed inclinations ranging from 10 to 14 degrees. Additionally, 11.66% of cases had inclinations exceeding 15 degrees. The total number of cases evaluated amounted to 30, encompassing the entire sample. These findings underscore the diverse patterns of radius angle loss observed, with a notable portion exhibiting inclinations within the 0-9 degrees range.

After a three-month period, radiological assessment of volar tilt demonstrated varied results across different tilt ranges. Among the cases evaluated, 53.33% exhibited a volar tilt ranging from 0 to +8 degrees, while 13.33% displayed a tilt within the range of 0 to -5 degrees. Additionally, 15.0% of cases showed tilts between -6 to -10 degrees, and 18.34% had tilts falling within the -11 to -18 degrees range. The total number of cases assessed was 30, representing the entire cohort. These findings highlight a diverse distribution of volar tilt deviations, with a significant portion of cases demonstrating positive tilts within the 0 to +8 degrees range.

Based on the Lindstrom criteria, the distribution of patients yielded varying grades of outcomes. Among the cases evaluated, 43.33% were categorized as excellent, while 36.66% were deemed good. A smaller proportion, 8.33%, fell into the fair category, while 11.66% were classified as poor. The total number of cases assessed amounted to 30, encompassing the entire sample. These findings underscore the diverse range of outcomes observed following the criteria set forth by Lindstrom, with a notable portion of cases achieving excellent or good grades.

The distribution of patients based on the PRWE (Patient-Rated Wrist Evaluation) score indicates varying levels of functional outcomes. Among the cases assessed, 40% achieved an excellent score, falling below 20 on the PRWE scale. Additionally, 36.6% were classified as good, with scores ranging from 21 to 40. A smaller proportion, 13.3%, fell into the fair category, scoring between 41 and 60. Furthermore, 10% of cases were categorized as poor, with scores ranging from 61 to 80. Notably, no cases fell into the worst category, scoring between 81 and 100. The total number of cases evaluated was 30, representing the entire sample. These findings illustrate a varied distribution of functional outcomes based on the PRWE score, with a substantial portion of patients achieving excellent or good scores.

Close reduction and cast immobilization is a common treatment strategy for distal radius fractures. The anatomical success of plaster cast immobilization for distal radius fractures is widely believed to depend on stability.  Fractured Maintaining reduction of a Colles' fracture is challenging due to its proximity to the wrist joint, which contains many carpal bones, and a lack of clear understanding of the fracture mechanism.

The primary force-bearing column of the wrist consists of the distal radial articular surface, the lunate, the proximal two-thirds of the scaphoid, the capitate, the trapezoid, and the joints of the second and third metacarpals. The wrist flexors and extensors attach to the base of the second and third metacarpal bones, affecting their movement and position.

Charnley detailed the technique of three-point fixing for applying a molded plaster.[14] The fracture is realigned and a plaster cast is put on. The plaster is shaped to exert pressure both at the fracture site and on areas near the fracture.  Sarmiento categorized and detailed fractures of the distal epiphyseal radius.[15] He suggested immobilizing the arm in a cast that covers from the base of the fingers to above the elbow, with the joint held at a 90-degree flexion, the forearm in pronation, and the wrist slightly flexed and deviated towards the ulnar side.

Serminto pinpointed the brachioradialis muscle as the primary force causing the fracture to lose its alignment. The brachioradialis muscle, which is connected to the lower part of the radius bone, acts as an elbow flexor when the forearm is facing downward. Stimulation of this muscle can effectively correct a fracture, especially if the fracture shows signs of instability along its axis. It was determined that stabilizing the fracture in a supinated position after reduction was preferable to stabilizing it in a pronated position.

A forearm brace was created to allow bending of the elbow while restricting the rotation of the forearm and limiting the extension of the elbow in the final fifteen degrees. The device allows for minimal wrist flexion but restricts wrist dorsiflexion. It prevents any radial deviation.

Gupta et al. said that following a Colles' fracture, the carpal extensors contribute to posterior displacement of the fracture in all wrist positions, whereas the wrist flexors work towards over-reduction.[16] The radial extensors of the wrist have greater strength compared to the radial flexors, as stated by Von Lanz and Wachsmuth. Optimal immobilization position with balanced forces is dorsiflexion, placing the wrist extensors at a mechanical disadvantage.

The periosteal hinge on the concave, dorsal side of a Colles’ fracture plays a crucial role in stabilizing the injury. When intact, it prevents excessive reduction and can be utilized by maintaining small volar angulation at the fracture under tension. To maintain tension in the periosteal hinge, shape the plaster in the direction of over correction.

Flexing at the fracture site optimizes the dorsal periosteal hinge, however the flexed position should not be sustained at the wrist joint. When the wrist is flexed downward, the dorsal carpal ligament is attached.  The dorsal ligament primarily restricts flexion of the proximal carpal row towards the back of the triquetrum. This causes most bending towards the palm to occur at the mid-carpal joint, which lacks a dorsal ligament .

The absence of regulation at the mid-carpal level enables the powerful radial extensors of the wrist to turn the proximal row of the carpus, together with the distal radial fragment, into extension, resulting in a loss of reduction. When the wrist is bent backward, the volar radiotriquetral and radiocapitate ligaments tighten, stabilizing both rows of carpal bones in relation to the radius.

They also counteract any pressures that could cause deformity by pulling on the distal fracture fragment from the front. Furthermore, forces exerted on the dorsiflexed carpus line up in a way that decreases the likelihood of a fracture. During palmar flexion, these pressures exert a tendency to increase displacement in the specified direction (Figure 3a and 3b).

Minimizing collapse in a badly comminute fracture can be achieved by immobilizing the wrist in dorsiflexion. Figure 4 illustrates that the collapse or impaction, particularly of the dorsal cortex, is more likely to occur in a straight or smoothly curved tube than in a tube with a double curve in a 'S' form. After manipulating a Colles' fracture, immobilizing the wrist in dorsiflexion might help maintain the reduction. The fracture will most readily collapse within a straight tube.

When the wrist is dorsiflexed, the plaster molds into a tube with a double bend in a 'S' shape. The most crucial radiographic measure for evaluating fracture instability is the decrease of radial height. The "Other" category encompasses the presence or absence of a decreased volar cortex.8 Advanced age, osteoporosis, and dorsal comminution contribute to higher fracture instability.[17,18] 

Not all parameters are equally preserved after applying a plaster cast. Retaining radial height is the most challenging, whereas volar tilt is somewhat kept and radial angle falls between loss of radial height and volar tilt.[19,20]

The average loss in radial height in our study is 4.11 mm at the final follow-up. The study by Gupta et al found that the highest loss of radial length occurred following immobilization in the neutral position, whereas those immobilized in dorsiflexion saw the least loss.10 Baruah et colleagues reported that 81.82% of patients with a radial length decrease exceeding 7 mm experienced unfavorable functional outcomes.[21] Rajan et al. discovered that 65% of patients with DF had a normal radial height, whereas only 40% of patients with PF had the same.[22] The study found an average loss in radial inclination of 6.85 degrees at the last follow-up. Gupta et al found that the loss of radial inclination was consistent across all three wrist positions. Baruah et al. found that 81.62% of patients (40 out of 49) with a radial angulation loss of less than 9 degrees demonstrated excellent to good functional outcomes.[18] Rajan et al. found that 7 out of 34 patients with distal radius fractures had a loss of radial inclination, while 16 out of 30 patients with proximal fractures experienced the same.[19]

The mean decrease in volar tilt is 7.06 mm at the end of our study. Gupta et al found that the least amount of volar tilt loss occurred when the wrist was in dorsiflexion rather than plantar flexion.[16] Baruah et al found that 88.10% of the 42 patients with residual dorsal angulation of less than 10 degrees had excellent or good functional outcomes.[21] Rajan et al found that 10 out of 34 patients had dorsal flexion loss of palmar tilt, while 19 out of 30 had palmar flexion.[22]
Our study found that 93% of patients achieved excellent to fair results based on the Lindstrom criteria, consistent with the findings of Rajan et al (91% good results), Baruah et al (76% results), and Gupta et al (99% results).

It is determined that immobilizing the wrist in dorsiflexion yields superior outcomes compared to immobilization in plantar flexion. Patients with dorsiflexion exhibit improved hand function and less residual deformity.

1. Porter M, Stockley I. Fractures of distal radius: intermediate and end results in relation to radiographic parameters. Clin Orthop. 1987; 220:241-52.
2. Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles fractures fractures. J Bone Joint Surg (Am). 1980; 62-A:613-19.
3. Jupiter JB. Fractures of distal end of radius. J Bone Joint Surg (Am). 1991; 73-A:461-9.
4. Ring D, Jupiter JB. Percutaneous and limited open fixation of fractures of distal end of radius. Clinical Orthop. 2000; 375:105-15.
5. Cooney WP, Lindscheid R, Dobyns J. External pin fixation for unstable Colles fracture. J Bone Joint Surg (Br). 1979; 61-B:840-5.
6. Azzopardi T, Coultan T. A prospective randomized study of immobilization in cast versus supplementary percutaneous pinning. J Bone Joint Surg. 2005; 87:837.
7. Wong TC, Chiu Casting versus percutaneous pinning for extra-articular fractures of distal radius in an elderly Chinese population. J Hand Surg Eur. 2010; 35(3);202-8.
8. Rayhack JM. The history and evolution of percutaneous pinning of distal radius fractures. Orthop Clin North Am. 1993; 24:287-300.
9. Simic PM, Weiland AJ. Fractures of the distal radius: changes in treatment over past two decades. J Bone Joint Surg (Am). 2003; 85:552-64.
10. Young BT, Ryan GM. Outcome following non operative treatment of displaced distal radius fractures in low demand patients older than 60 years. J Hand Surg (Am). 2000; 25:19-28.
11. Walton NP, Brammar TJ. Treatment of unstable distal radius fractures by intrafocal, intramedullary K-wires. 2001; 32:383-9.
12. Kurup HV, Madalia V. Variables affecting stability of distal radius fractures fixed with K-wires ; a radiological Eur J Orthop Surg Traumatol. 2005; 15:135-139.
13. Egol KA, Walsh M. Distal radius fractures in operative versus non operative treatment. J Bone Joint Surg. 2010; 92:1851-7.
14. Charnley J. The closed treatment of common fractures. 3rd ed. E. & S. Livingstone Ltd, London; 1963: 139-140.
15. Sarmiento A, Latta LL. Colles' fractures: functional treatment in supination. Acta Chir Orthop Traumatol Cech. 2014;81(3):197-202.
16. Gupta A. The treatment of Colles' fracture. Immobilisation with the wrist dorsiflexed. J Bone Joint Surg Br. 1991;73(2):312-5.
17. Phillips AR, Al-shawi A. Restoration of the volar cortex: predicting instability after manipulation of distal radial Injury. 2014;45(12):1896-9.
18. Leone J, Bhandari M, Adili A, Mckenzie S, Moro JK, Dunlop Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. Arch Orthop Trauma Surg. 2004;124(1):38-41.
19. Wadsten MÅ, Sayed-noor AS, Englund E, Buttazzoni GG, Sjödén GO. Cortical comminution in distal radial fractures can predict the radiological outcome: a cohort multicentre study. Bone Joint J. 2014;96(7):978-83.
20. Hove LM, Solheim E, Skjeie R, Sörensen Prediction of secondary displacement in Colles' fracture. J Hand Surg Br. 1994;19(6):731-6.
21. Baruah RK, Islam M, Haque R. Immobilisation of extra-articular distal radius fractures (Colles type) in The functional and anatomical outcome. J clin orthopaedics trauma. (2015);6(3):167-72.
22. Rajan S, Jain S, Ray A, Bhargava P. Radiological and functional outcome in extra-articular fractures of lower end radius treated conservatively with respect to its position of Indian journal of orthopaedics. (2008);42(2):201-7.