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1991 B ritish Ed ito r ia l S oc ie ty ofB one and Jo in t S urge ry030l-6 20X /9 1 /2082 $2 .00JBoneJo in tSurg[Br] 1991; 73-B:312-5 . ___________

31 2 THE JOURNAL OF BONE AND JO INT SURGERY

THE TREATM ENT O F COLLES FRACTUREIMMOB IL ISA T ION W ITH THE W R IST DORSIFLEXED

AJAY GUPTA

F rom L N JP H o sp ita l, N ew D eT h i

In a p rospec tive study , 204 consecu tiv e p a tien ts w ith d isp laced Colles frac tu res had closed reductionth en pla s ter imm obilisa tio n . T hree d iffe ren t po sitio ns ofth e w rist in p la s ter w ere random ly a lloca ted : p alm arflex ion , n eu tra l and dorsif lex ion . The resu lts in th e th ree groups w ere com pared . F rac tu re s im m obilised withth e w ris t in dors iflex ion sh owed the low est inc idence of red isp lacem ent, e specially of do rsa l tilt, and had theb est early fun ction al re su lts .

Imm ob ilisa tio n of the w ris t in p alm ar f lex ion has a d etrim enta l effec t on hand fun ctio n ; it is suggestedtha t i t is a lso one o f the m ain cau ses fo r red isp lacem en t of th e fractu re. T his is d iscu ssed in rela tio n to thef unc t iona l an a tomy of the w ris t and the m echan ics o f p las te r fixa tio n .

C olle s frac tu re is a ve ry comm on in ju ry , bu t the re is noag reem en t on th e best w ay o f trea tm ent. A w ide varie tyo fm e thods hav e been describ ed , in clud ing reduc tio n andim m obilisa tio n of the w ris t and fo rea rm in va riou spos itions, pe rcu tan eo us p inn in g , ex terna l fix atio n andopen redu ctio n w ith in te rn al f ixa tion .

A lthough a C o lle s frac tu re can usua lly be reducedqu ite eas ily , it is d ifficu lt to m a in tain the reduc tion ,espec ially w here the re is comm inu tion or in tra -ar ticu la rex tension . G artland and W erley (1951)repo rted th at 60%o fthe ir pa tien ts healed in an unreduced po sition .

W hen th e w ris t is im m obilised in p alm ar flex ion ,th ere is a risk o fs tiffness o fthe fin ge rs , and esp ec ia lly them etacarpo pha langea l jo in ts . T h is is a com m on com p li-ca tion (G artland and W erley 1951 ; B aco rn and Ku rtzke1953). D ors iflex ion is the b est fu nc tio na l positio n for theh and , so it w as d ec id ed to eva lua te and com pare theresu lts o f imm obilisa tion o f C o lle s frac tu res in th reed ifferen t positio ns o f th e w ris t jo in t : p alm ar flex ion ,neu tra l and d orsiflex io n .

PAT IEN TS AND M ETHODSA p rospec tive s tu dy w as m ade of204 con secu tive pa tien tsw ith d isp laced C olle s frac tu re s at LN JP H osp ital , N ewD elh i from June to N ovem ber 1986 . O f th ese , 6 0 w ere

A . G upta , M S O rth , A ss is tan t P rofessor in O rthop aed icsMaulana A zad M ed ical Co llege and LN JPN H osp ita l, N ew D elh i 1 10002, Ind ia .

im m ob ilised w ith the w ris t in pa lm ar f lex ion , 75 inneutra l p osit ion and 69 in dors iflex ion . Se lection w asm ade on a random basis. T here w ere 122 w om en and 82m en, w ith 106 left s ided and 98 righ t s ided fractu res . T hem ean age o f the pa tien ts w as 46 years (range 18 to 74 ),ev iden ce of the younger popu la tio n a t risk in Ind ia.M anagem en t. A nte roposte rio r and late ra l rad iograph sw ere tak en of bo th the in ju red and the unin jured w rists.T he frac tu re s w ere m anipu la ted unde r in trav enou sd iazep am and pen tazo cine sed ation , u s ing m anua ltrac tio n w ith the fo rea rm in prona tion . A below -elbowplas te r cas t w as applied , and m ou ld ed ve ry ca refu llyaround the fractu re. T he d is ta l rad ial fragm en t w aspressed in a vo lar d irection w ith coun ter p ressure aga in s tthe p rox im a l fragm en t in a dorsa l d irec tio n (F ig . la).T h is lo ca l m ould ing hold s the frac tu re in flex ion ,m ain ta in ing the no rm a l an te rio r tilt o f the d is ta l rad ia larticu la r surface.

W h ile the surg eon w as m ou ld ing th e p la s te r, anassis tan t, ho ld ing th e f inge rs , m oved th e w ris t to th ese lected po sitio n of pa lm ar flex ion , neu tra l po sitio n o rdors iflex ion (F ig . lb ). It is essen tia lth at the vo lar pressu reis app lied to the low er end of th e rad ius an d no t to th eca rpa l bo nes. Th is is b es t en su red if th e w ris t is m ovedin to dors iflex ion : v o la r pre ssu re can th en on ly be app liedto the d is ta l rad iu s.

T he fin al m ovem ent, as th e p la s ter ha rdened w as tob ring the w ris t in to s lig h t u lna rdev iation . A t the ex trem esof flex ion or ex ten sion of the w ris t, th e jo in t is locked(W eber 1984) and ulna r d ev ia tion can take p lace only a tthe frac tu re s ite . T h is he lps to m a in tain the no rm a lalignm ento fth e d is ta l rad ia lsurface . A check rad iographw as tak en th e n ex t day , and aga in a fte r 10 day s. P la s te r

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Fig. Ia Fig. lb

THE TREATM ENT O F COLLES FRACTURE 31 3

VOL. 73-B , N o. 2, MAR CH 1991

Figure 1 a - The cast is m ou lded around the fractu re by p ressin g the distal fragm ent in a vo lar d irec tio n , w ith coun ter p res sure on the proxim alfragm ent. F ig ure 1 b - A w ell m ould ed cast , w ith th e w rist in dorsiflex io n m ak ing a tube w ith a doub le curve in an S sh ape .

w as k ep t o n fo r six w eeks, excep t w h ere the fractu re w asin tra -a rticu la r, in wh ich case the p la ste r w as rem oveda fter five w eeks.R ev iew . F ractu res w ere class ified rad iograph ica lly in tof ive ty pes : type I w ere u nd isp laced and ex tra-a rticu la r;ty pe II , und isp laced w ith in tra -a r ticu lar inv o lvem en t;typ e III d isp laced , ex tra -ar ticu la r bu t w ith no com m inu -t ion ; ty pe IV , d isp laced , ex tra -a rticu la r w ith com m inu -t ion ; and typ e V d isp laced w ith a r ticu lar inv o lvem en t.T ypes I and II w ere ex clu ded from the stu dy . The re w ere94 typ e III frac tu re s (46% ), 53 typ e IV (26% ), and 57 typ e

Tab le 1 . P osition o f imm ob ilisation o fthe w rist an d the typ e ofd isp laced C ollesf racture

Type o f f ra c tu r eIII IV V

Pa lm ar flexion (n = 60) 28 17 15N eu tral (n = 75) 34 19 22Dorsif lex ion(n = 69 ) 32 17 20Total 94 53 57* III , ex tra-a rticu la r no com minutionIV , extra-a rticu la r w ith com minutionv, in tra-ar t icu lar

V (28% ). T he dis trib u tion of these typ es acco rd ing toposition o f imm obilisa tion is g iven in T ab le I .

T he ave rag e fo llow -up w as 1 5 m onth s (f ive m on thsto tw o yea rs ). M easu rem en ts o fvo lar tilt, rad ia l d ev iatio nand rad ia l len g th b efo re reduc tion w ere m ade onan te ropo ste rio r and la te ra l rad io g rap hs, o f th e in ju redand the u n in ju red w rist. M easu rem en ts w ere rep ea ted onth e po stope rativ e, 10 -d ay , and la st ava ilab le rev iew film s.

RESULTSAnatom ica l resu lts . T he de fo rm itie s w ere sev e re . B efo rereduc tion th e m ean dorsa l ang u la tion w as 30 #{176}14#{176}o41#{176} ) ,ean rad ial angu la tion w as 16#{176}6#{176}o 2 0# {1 76 })nd m eansho rten ing of the rad ius w as 13 mm (5 to 20 ). N orm alvo la r tilt is 1 0#{176 }nd norm a l rad ia l an gu la tion is 22 #{176}va nde r L inden an d E ric son 1981) .T ab le II show s th e lo ss o f po sition w hich occu rredb etw een th e po stop era tive and the 1 0-day rad iog raph s.L ittle d ifference w as fo und be tw een the 10-day and thelate st fo llow -u p film s.

In ty pe IV and V in jurie s the loss o f vo lar tilt w aslea st in frac tu re s imm obilis ed in do rsif lex ion (F ig . 2 ).Vo la r tilt w as usu ally m ain ta ined in th is g roup even ifthe re w as sign if ican t co llap se . L oss o f rad ia l an gu la tionw as a lm ost the sam e in a ll th ree positio ns o f imm obilisa -tion . L oss o f rad ial leng th w as g rea tes t af te r imm obilisa -

T ab le H . Loss of pos itio n in th ree typ es o f disp la ced Co lle s fra ctu re afte r im m obilisa tio n of thew rist in d iffe ren t pos itions (m ean and range)

Posit ion ofimmobilisat ion

V olar lii t ( d eg r ee s ) Radia l t il t ( de gr ee s) S hO rt e nin g ofr ad i u s(m m)III IV V III IV V HI IV V

Pa lm ar f lex ion 2Oto l l

80to28

100to32

2Oto5

5Oto l6

62tol4

1Oto6

4Otol4

3Otoll

Neutra l 1O to 8

8Oto3 l

6Oto3O

1Oto3

8Oto l7

82to18

2Oto8

6Oto l8

8Otol8

D ors iflex io n IO to 9

2OtolO

3Otoll

2Oto6

5l to l3

4Oto l2

1Oto3

2O to 8

2OtolO

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Fig . 2 a F ig . 2 b

Fig . 2c Fig . 2d

F ig .2 e F ig . 2f

R ad iog raphs of a ty pe IV fra cture. F igures 2a and b - B ef or e r ed uc ti on .F igu res 2c and d - The w ris t in do rsif lex ion in a b elow -e lbow cast.Correc tion of vo lar t ilt ha s been po ssib le on ly to 0#{176}.igu res 2 e and f -F ina l rad iog raph show s healin g w ith no furth er deterio ration in th evola r til t.

Table III . Fun ct ion al r esu lts in d isp la ced C olles fra ctu res a fte rimm ob ilisation w ith the w rist in d iffe ren t p ositions , show ingnum ber and percen tage of each trea tm ent gro up

Type off racture E

Pa lma rG

flexion*F P E

Neut ra lG

posit ionF P E

Dorsif lex ionG F P

III 9 1 1 7 1 13 1 3 7 1 20 8 4 0

Iv 5 5 3 4 4 4 8 3 9 6 20

V 5 4 2 4 6 7 5 41 1 5 31

19 20 12 9 23 24 2 0 8 40 19 9 1

P erc en ta ge 3 4 33 2 0 1 3 30 32 2 7 1 1 58 2 8 1 3 1E , excellent; G , g ood ; F , fair, P , p oo r

31 4 A . G UPT A

THE JOURNAL OF BONE AND JO IN T SURGERY

tion in the neu tra l po sitio n and leas t in tho se im m obilisedin d o rs iflex io n (T ab le II). In the typ e III frac tu re s (ex tra -a r ticu lar , no com m inu tion )the p ositio n o f im m ob ilisa tiono f the w ris t m ade no sign ifican t d ifference .Func tiona l resu lts . T hese w ere asse ssed by the c rite ria o fS a rm ien to et al (19 75) . F rac tu re s imm obilised w ith thew ris t in dors iflex ion had th e b est re su lts (T ab le III).C om parison o f v a riou s jo in t m ovem ents w ith tho se onth e un in ju red sid e show ed th at frac tu re s im m obilised inp alm ar flex ion had m o re jo in t s tiffn ess , pa rticu la rly o fth e m etaca rpopha lang ea l and in te rph a langeal jo in ts .E ven in Type III fractu re s, w here th e posit ion o fim m ob ilisatio n o f th e w ris t d id no t s ign if ican tly a ffec tth e ana tom ical resu lt, im m obilisa tio n in dors iflex ionp rov ided the b est recovery o f fun ction (T able III).

D I SCUSS IONCo lle s frac tu re can be difficu lt to trea t : the m ajo rp rob lem is m ain tenance of redu ction . T his is p artly du eto its an a tom ical s ite , ad jacen t to th e m u ltil ink ed systemo f the ca rpu s, and pa rtly to ou r poor unders tand ing o fth e m echan ics of the fractu re itse lf.

T he ca rpa l bones tran sm it fo rces from th e h and toth e fo rea rm , bu t a re under no d irec t m otor con tro l. T h em ain force-b ea ring co lum n o fthe w rist inc lud es th e d is ta lrad ia l a rticu la r su rface , the lun ate and the p ro x im a l tw o-th ird s of th e scaphoid , th e cap itate , the trapezo id and th ejo in ts o f the secon d and th ird m e tacarpa ls (W eb e r 1 984 ).Co lle s frac tu re b reaks the contin u ity o f th is co lum np rox im ally , so the m ain m uscle fo rces in fluenc ingd isp lacem ent a re th ose ac ting on the w hole co lum n.T hese a re the w ris t flexors and ex tensors in serted at th eb ases o f the seco nd and th ird m etaca rpa ls .A fte r a Co lle s frac tu re , w hatev er the position o f th ew ris t, th e ex ten sors of the ca rpu s tend to in crease th eposte rio r d isp lacem ent of the fractu re w hile the w ris tflexo rs ac t in the d irec tio n of ov er reduc tio n . T he rad ia lex ten so rs of the w ris t are m ore pow erfu l th an the rad ia lflexo rs (V on Lanz and W achsm uth 1959). T his im p lie stha t the best position for im m obilisation w ith ba lancedfo rces is do rsif lex ion , w he re th e w ris t ex tenso rs a re p laceda t a re la tiv e m echan ica l d isadvan tage .

T he pe rio stea l h inge on th e concave , dorsa l s id e o f aC o lle s fractu re can be an im portan t s tab ilis in g facto r.W hen it is in tact, it p reven ts ove r reduc tio n ; it sh ou ld beexplo ited by be ing kep t under tensio n by sligh t vo la rangu lation at th e fractu re. T en sion can be m ain tain ed inthe pe rio stea l h inge by m ould ing th e p la ste r in thed irection of ov er co rrec tion . F lex ion at the fractu re s iteis im po rtan t s in ce it m akes th e b est u se o f the do rsa lperios teal h ing e, bu t th e flex ed positio n n eed not b em ain tain ed a t th e w ris t jo in t.

W hen the w ris t is pa lm ar flexed the dorsa l ca rpa ll igam en t, a ttached m ain ly to the dorsa l a sp ec t of th etriqu etrum , lim its flex ion of the prox im al carp al row , sotha t m o st p alm ar flex ion takes p lace at the m id -carp al

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Rad iu s

Vo la rrad io t r ique t ra ll igamen t

Rad iocap i ta tel igamen t I

P A LM A R FLE X IO NF ig . 3a

D O R S I FL E X I O NF ig . 3 b

In pa lm ar flex ion th e dorsal carpal lig am ent is taut, b ut canno t s tab ilis e th e fra ctu re becau se of its lack of anatta chm en t to d ista l ca rpa l row . The de form ing fo rce s and the po tential d isp lacem en t of the frac ture are paralle l, inthe sam e dire ction . In dors( f lex ion , th e vola r lig am ents are taut and tend to pull the fra ctu re fragm ent an ter ior ly .The de form ing forces act a t an ang le w hich tend s to redu ce the disp la cem en t of the fra cture.

P alm ar fle xio n

Neu tra l

Dors i f lex ionFig . 4

TH E TREATM ENTO F COLLES FRACTURE 31 5

VOL. 73-B , No . 2 , MARCH 1991

Raduu 1 D o rsa l\ carpa l l igamen t

Dis ta l ca rp a l rowro x ima la rp a l rowDe fo rm in gfo rces

The fracture w ill co llapse m o st eas ily in sid ea stra igh t tu be . W hen the w ris t is dorsi-flexed, th e pla ster form s a tub e w ith adouble curve in an S sh ap e.

articu la tion , w h ere the re is n o dorsa l lig am en t (F ig . 3a ).T h is lack o f con tro l a t m id -ca rp al leve l allow s the s tro ngrad ia l ex tenso rs o fth e w ris t to ro ta te the p ro x im a l row o fth e ca rp us, tog e th e r w ith the d ista l rad ia l fragm en t, in toex ten sion , w ith conseq uen t lo ss o f red uc tion .

By contra s t, w hen the w rist is d ors iflexed the vo la rrad io tr iqu etra l an d rad iocap ita te ligam en ts becom e tau t:the se stab ilise b o th row s of th e ca rp us w ith re sp ec t to the

rad ius, an d re sis t any de fo rm in g fo rces by pro v id in g avo lar pu ll o n the d ista l fractu re fragm en t (F ig . 3 b ) .M o reov er , fo rces ap p lied in th e line o f th e dorsif lex edca r pus ac t a t an an g le w h ich tends to reduce th e frac tu re.In pa lm ar f lex ion these fo rce s act in a d irec tion tend ingto inc rea se d isp lacem en t (F igs 3 a and 3b ).

In a g ro ssly comm inu ted frac tu re som e co llapse isp robab ly in ev itab le , bu t th is is like ly to be m in im isedw hen the w ris t is im m ob ilised in dorsif lex ion . F igu re 4sh ow s tha t co llap se o r im p ac tion , especia lly o f th e do rsalco rtex , is m ore like ly in side a stra igh t o r sm oo th ly cu rvedtub e than in a tub e w ith a do ub le cu rve in an 5 sh ap e.Conc lu sion . A fte r m anipu la tio n o f a C olles frac tu re,im m ob ilisa tion o f th e w ris t in do rsif lex ion w ou ld app ea rto p rov id e be tte r m a in tenance o fred uc tion . F u rth er tr ia lsan d eva lua tion a re req u ired .N o benefits in any fo rm have b een rece iv ed o r w ill be rece ived from acomm erc ial p arty re lated directly or ind irec tly to th e sub jec t of th isarticle .

REFERENCESB acorn RW , Ku rtzk e JF . Co lles fracture : a stu dy of tw o thou sand cases

from the N ew Y ork S tate W orkm ans C om pen sation Board . JB one Jo in t S urg [A m ] 1953 ; 35-A :643-58 .

Gartland JJ Jr , W erley CW . Evalu ation of hea led Co lles fracture s. JB one Jo in t S urg [A m J 1951 ; 3 3-A : 89 5-9 07 .

Sarm iento A , Pratt GW , B erry NC , S in cla ir W F. C olles frac tu res:fu nction al bracing in sup ina tio n . J B one Jo in t Surg [A m ] 1975 ; 57 -A:31l-7 .

va n der L ind en W , E rlcson R . C olle s fra cture : how shou ld itsd isp lacem ent b e m easured and how should it b e imm obilized? JB one Jo in t S urg [A m ] 1981 ; 63-A:l285-8 .

V on L anz T , W achsm u th W . P rak tisc he A n a to m ic . 2nd ed. B er lin :S prin ge r-V erlag , 1 959 .

W eber ER . C oncep ts gov ern in g the ro tat ion al sh ift of th e in te rca latedsegm ent of th e ca rpu s. O rthop C /in N o rth A m 1 98 4; 1 5: 2: 19 3- 20 7.