This fracture was described in detail by Abaham Colles in 1814 and has since been referred to as a Colles fracture. Colles fracture is one of the most common fractures, accounting for about 6.7% of all fractures. It occurs mostly in middle-aged and elderly people, and is more common in women.
I. Definition.
A distal radius fracture is a cancellous bone fracture within 2 cm from the articular surface of the distal radius and is the most common of all upper extremity fractures.Pouteau first described this fracture in 1783 and Colles described the characteristics of this fracture in detail in 1814 and named it after Colles fracture.Barton in 1838, Smith in 1854, 1887 Dupuytren again described in detail the characteristics of different types of distal radius fractures, respectively.
The AO typing has the advantages of wide applicability and guidance for treatment and prognosis, and it divides the fractures into three subgroups A, B, and C.27 Group A is extra-articular epiphyseal fractures, usually due to fracture stress injury, and the radial wrist and lower ulnar radial joint are not injured.Group B is fractures of the dorsal margin, palmar margin, radial tuberosity, or medial secondary margin of the articular surface of the distal radius, with partial articular surface involvement and the epiphysis remaining continuous, mostly due to shear Group C is a fracture of the epiphysis that affects the articular surface, mostly due to high-energy injuries, and is often comminuted.
Unstable fractures have a dorsal inclination of >20°, comminution of the dorsal edge of the fracture end, radial shortening of 5 mm or more, intra-articular comminuted fractures, and displacement of the articular surface of >2 mm.
II. Pathogenesis.
Mostly caused by indirect external forces, when falling, the elbow is straightened, the forearm is rotated forward, the wrist is dorsally extended, and the palm of the hand is on the ground. The stress acts on the distal radius and the fracture occurs. It is mostly transverse in shape. The crush shape is also not uncommon.
III. Clinical manifestations.
1. General manifestations.
The wrist is painful and swollen, especially with limited palmar flexion activities. If the fracture is severely displaced, it may appear as a fork-like deformity, i.e., dorsal wrist elevation and palmar prominence. The outline of the ulnar styloid process is lost. The wrist is widened and the hand is shifted to the radial side. The lower end of the ulna is prominent and the radial styloid process is superiorly displaced to or beyond the level of the ulnar styloid process. The distal end of the radius has pressure pain, and the fracture end displaced to the radial dorsum can be palpated, and bone rubbing sound can be palpated in crushed fractures.
2.Auxiliary examination.
Radiographs show typical displacement with the following.
(1) The fracture block of the distal radius is displaced dorsally.
2) Displacement of the distal radial fracture fragment to the radial side.
3) Radial shortening with dorsal cortical embedding at the fracture site or a comminuted fracture.
4) The fracture is angulated to the palmar side.
5) The distal radius bone is rotated posteriorly.
6) In addition, it shows a subluxation or total subluxation of the ulnar head and displacement of the distal radius fracture to the radial side indicating a tear of the triangular cartilage margin. It is often combined with an ulnar stem avulsion fracture. The palmar inclination angle and ulnar deviation angle are reduced or are negative.
IV. Treatment.
1. For nondisplaced fractures, a functional position plaster brace or small splint can be used for 4 weeks.
2. Displaced fractures require closed reduction. The operator pulls the patient’s palm and thumb along the long axis of the forearm to ulnarly deviate the wrist and rotate the forearm forward. Then the wrist is palmarly flexed and pushed palmarly and ulnarly on the distal fracture segment of the radius at the same time. Keep the wrist in the rotated forward and mild palmar flexion ulnar deviation position, apply forearm plaster brace or small splint fixation for 4 weeks, and change to neutral position for 4 weeks in 10 to 14 days.
3.Resetting criteria: (1) The radial styloid process is lower than the ulnar styloid process by 1~2 cm. (2) The distal radius must be flat and without bone protrusion on the dorsal side, and the palmar solitary depression is restored. (3) The hand is not radially deviated, the contour of the ulnar head is normal, and the affected fingers move well. (4) X-ray shows that the distal radius joint is tilted towards the palmar side.
4.When the unstable fracture is considered, manual repositioning and plaster fixation are often not effective, and the treatment should be timely based on the injury situation by percutaneous needle fixation, external fixation frame fixation or incisional repositioning internal fixation.
5.Imaging of unstable fracture.
A. Dorsal (palmar) cortical comminution. It is usually the key indicator of instability and is closely related to the negative angle of palmar tilt and radial shortening. The integrity of the dorsal cortex provides the necessary support for maintaining the palmar tilt angle by manipulation and cast fixation. It is also necessary to maintain radial length. Certain fractures caused by high-energy injuries can reach even the lower 1/3 of the radius.
B. Intra-articular comminuted fractures with intra-articular displacement Knirk and Jupiter recommend that when intra-articular displacement is greater than 2 mm in line with other principles of intra-articular fracture treatment, the articular surface should be restored to its integrity as much as possible. If the joint surface is severely damaged, the recovery is not satisfactory and has an impact on the functional recovery of the wrist, such as pain, stiffness, etc., and an increased incidence of traumatic arthritis. Therefore, the displacement of the joint surface should be controlled within 2 mm after the intra-articular fracture is reset. Severe intra-articular comminuted fractures and displacement are obvious signs of instability, but most injuries are not easy to judge. Progressive intra-articular displacement often occurs with separation of the intra-articular bone mass greater than 2 mm, and sustained intra-articular displacement is most commonly seen in ulnar block compression fractures of the distal metacarpal (dorsal) radius, where closed reduction is often ineffective. A central vertical compression fracture caused by the lunate bone impinging on the distal radius fossa is difficult to close and reset due to the absence of soft tissue attachment. A compression fracture or displaced fracture of the central bone block of the radial carpal joint involving the radial carpal joint and the lower ulnar radial joint is not only difficult to reposition but also suggests a more extensive injury.
C. Negative palmar tilt angle, radial deviation, rotation of the fracture fragment, and dislocation or subluxation. Under normal conditions, 82% of the axial load through the wrist joint is carried by the radial carpal joint. When the negative angle deformity of the palmar tilt angle is greater than 10°, it has a significant effect on all the motion moments of the wrist joint, and when it is greater than 20°, it will affect the normal load relationship of the wrist joint and lead to abnormal load transmission of the wrist joint. When the negative angle reaches 45° 65% of the axial load is transferred to the ulna and the rest of the load is concentrated on the dorsal side of the navicular fossa. The decrease in radial deviation angle increases the load through the lunate bone. This effect not only involves the radial carpal joint and the inferior ulnar radial joint, but when the displacement is severe, it even affects the alignment relationship with the proximal row of carpal bones with dislocation or subluxation, resulting in wrist instability. The fracture of the distal radius with dislocation or subluxation, regardless of the size of the fracture fragment, suggests extensive injury to the surrounding ligaments and joint capsule in addition to the fracture. cooney (1981) suggested that dorsal displacement of the fracture fragment with a negative angle of palmar tilt greater than 25° as one of the important criteria for instability. jenkins (1989), kenichi Kazuki (1993) found that the degree of dorsal (palmar The degree of dorsal displacement depends on the presence or absence of dorsal (palmar) cortical comminution and the degree of initial displacement, and the greater the degree of negative angle, the more obvious the degree of wrist joint restriction and the more obvious the abnormal wrist bone alignment. Therefore, the palmar declination angle should be at least free of negative angle after restoration. The radial deviation angle should be restored to 10°-15°. Due to the overlapping of fracture blocks, which interferes with the physician’s judgment of the degree of injury and when the patient cannot take radiographs in the required position due to pain, CT examination can be chosen to help determine the presence or absence of joint dislocation, intra-articular fracture displacement and compression.
D. Shortening. Radial shortening directly affects the relationship between the radial carpal joint and the lower ulnar radial joint, changing the alignment of the proximal row of carpal bones with the radial and ulnar bones, further affecting the conduction and distribution of load on the carpal joint, which can produce ulnar impingement syndrome and instability of the carpal joint in the long term. Shortening of the radius can affect the carpal dynamics and the triangular fibrocartilage complex and may cause tearing of the triangular fibrocartilage complex. CT is a more visual and accurate reflection of the intra-articular fracture than X-rays. The horizontal phase can clearly reflect the fracture comminution, displacement and rotation of the distal radius, and the presence of inferior ulnar radial dislocation; the coronal phase can reflect the fracture displacement, compression, integrity of the articular surface, navicular lunar separation, navicular fracture, inferior ulnar radial separation, ulnar deviation, and radial shortening; the sagittal phase can be used to determine the fracture displacement, compression, rotation, integrity of the articular surface, dorsal palmar cortical support, and palmar dislocation and subluxation of the radial carpal joint. The sagittal view is valuable in determining fracture displacement, compression, rotation, articular surface integrity, dorsal metacarpal cortical support, and palmar and wrist joint subluxation and subluxation.
Common surgical methods for unstable fractures of the distal radius.
1.External fixation frame.
2. Percutaneous needle fixation.
3. incision and repositioning.
The treatment of deformity healing is not considered if the deformity is mild and does not affect the function of the wrist. If the deformity is not too heavy and only has rotation disorder, ulnar head resection can be performed. For severe deformity without forearm rotation disorder, Campbell’s operation can be done, that is, partial resection of ulnar head and osteotomy of distal radius.
V. Complications.
1.Stiffness of shoulder and elbow joint Due to the failure of active activity in fracture management.
2.Sudeck’s bone atrophy or reflexive sexual sensory bone atrophy. It is characterized by swelling and stiffness of the wrist and fingers, red and thinning skin, and generalized bone atrophy. Sometimes the onset is sudden. It is often caused by the failure of active exercise after fracture.
3.Extension of the long thumb tendon rupture usually occurs 4 weeks or more after the injury, caused by the original injury, injury to the tendon blood flow, ischemic necrosis, or may be due to the fracture and Lister’s node, the tendon is often rubbed on the unsmooth bone groove and rupture.