A Colles’ fracture, also known as a broken wrist, is an injury most commonly caused due to a hard fall onto the wrist. This particular type of fracture is typically simple to treat, though treatment is heavily dependent on if the bones remained in their correct alignment or not. Depending on how displaced the wrist bones are, surgery may be necessary to realign the bones.
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| Colles' Wrist Fracture |
ANATOMY
The radius is the larger of the two bones of the forearm with the end toward the wrist called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks.A Colles’ fracture, also known as a broken wrist, is when the distal radius breaks, causing it to tilt upward. This fracture was first described in 1814 by an Irish surgeon and anatomist, Abraham Colles — hence the name Colles’ fracture.
The most common cause of a Colles’ fracture is a fall onto an outstretched arm. Another reason for this particular type of fracture is osteoporosis, a disorder that causes bones to weaken over time.
The best way to prevent Colles’ fractures is by maintaining good bone health and wearing wrist guards during activities that can result in a fall, such as skateboarding.
SYMPTOMS
A broken wrist usually causes immediate pain, tenderness, bruising, and swelling. Often, the wrist hangs in an odd or bent way (deformity).DIAGNOSIS
- X-ray
- Physical examination
Differential Diagnosis/ Associated Injuries
- Scapholunate ligament tear
- Median nerve injury
- TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
- Carpal ligament injury: Scapholunate Instability(most common), lunotriquetral ligament
- Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
- Compartment syndrome
- Ulnar styloid fracture
- DRUJ (Distal Radial Ulnar Joint) Instability
- Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures
TREATMENT OVERVIEW
The most important part of the treatment process for a Colles’ fracture is to make sure the broken bone pieces are in the correct alignment before they heal, and that they stay in place. Beyond that, there are both surgical and nonsurgical treatment options available to treat this type of fracture. |
| Colles' Wrist Fracture |
NONSURGICAL TREATMENTS
When the broken bone is positioned correctly, a plaster cast is applied until the bone heals. If the bone is not too severely displaced, a closed reduction may be necessary before casting. During a closed reduction, the bone is realigned without having to cut into the arm. For the best results, a closed reduction must be done as soon after the injury as possible.Depending on the type of fracture you have, your physician will closely check the healing by taking regular x-rays. The quantity and frequency of x-rays you would need also depend on the severity and type of your fracture.
After about six weeks, the cast can be removed. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.
SURGICAL TREATMENTS
If the bone is so displaced that it cannot heal correctly, even if put in a cast, surgery will be necessary. The procedure most commonly used is called reduction. During the procedure, an incision is made to allow access to your broken bones. Your surgeon will then realign your bones and close the incision.Depending on the fracture, there are several options for holding the bone in the correct position while it heals:
- Cast
- Metal pins (usually made of stainless steel or titanium).
- Plate and screws.
- External fixator (a stabilizing frame outside the body that holds the bones in the proper position so they can heal).
- Any combination of these techniques.
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| Colles' Wrist Fracture |
Physical Therapy Management
Many patients will present to a physiotherapist with pain, oedema, decreased range of motion, decreased strength, and decreased functional abilities.Once a Colles’ fracture has healed rehabilitation is recommended in an attempt to restore function and strength to the fractured wrist. The primary focus in early rehabilitation is to mobilise the wrist, which is indicated approximately 7-8 weeks post-fracture.
If the fracture has been managed using an internal fixation device, early mobilisation can begin as early as 1-week post-surgery.
Caution should be paid to fractures that have been treated with external fixation as the wrist is often held in a pronated position. This can predispose the patient to a contracture at the distal radioulnar joint.
Other soft tissue injuries that may affect rehabilitation progress include; oedema, cast impingement, infection, osteomyelitis, adherent scar, intrinsic or extrinsic muscle tightness, joint capsular tightness, neurovascular injury, ligament injury, and post-traumatic arthritis.
Initial Rehabilitation
One of the primary goals in early rehab is to restore normal range of motion (ROM) at the wrist with both passive ROM and progression to active ROM. Wrist flexion and extension are often the first motions emphasised working within the patient's pain-free available range.The addition of ROM exercises helps to limit scar tissue and adhesion formation that commonly occur after surgery.
It is also important to emphasise motion at the joints above and below (shoulder, elbow, and fingers) during all phases of rehab. One of the primary focuses in early rehab is to limit the pain and the amount of oedema present in the wrist and hand region.
Sub-Acute Phase
The next phase of rehab in the treatment of Colles’ fracture continues to focus on increasing wrist ROM and the commencement of strengthening exercises. For fractures that were surgically treated, ROM should be regained between 6 to 8 weeks post-op.Examples of ROM exercises that can be performed include:
- Wrist flexion/extension
- Radial/ulnar deviation
- Pronation/supination
- Making a fist and opening.
During strengthening, it is important to address all forearm muscles but also the extrinsic and intrinsic hand muscles progressively building resistance as the individual gets stronger.
During this phase, progressive stretching can begin to increase available ROM. Each stretch should be held for 30-60 seconds for 3 repetitions. If the patient is unable to tolerate a slow, prolonged stretch, shorter stretches of 10 seconds can be performed for 10 repetitions.
Modalities
Heat/Paraffin Wax
Heat whether in the form of a heat pack or paraffin wax can be very beneficial in the early stages to increase ROM and decrease pain. It is often used with cold therapy to improve venous return.Massage
Massage to reduce scar tissue and retrograde massage to reduce swelling are two effective modalities used in rehabilitation post Colles fracture. The benefit is that can also be taught to the patient to continue independently when in their own homes.Cryotherapy
Cryotherapy is an effective modality for controlling oedema in the acute phase after trauma and during rehabilitation due to its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid.Cryotherapy can also be combined with compression and elevation in the treatment of oedema.
To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post-application.
Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.
Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobinaemia, Cold urticaria.
Electrical Stimulation
The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist.Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.
Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.
The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.
Exercise
Exercise is beneficial in the restoration of range and also vital to strengthen the hand, wrist, elbow and shoulder. Immobility at the wrist has a huge effect on the range of movement and power.Exercises to increase ROM can be as simple as walking the hand up the wall, whereas exercises such as tearing paper, writing and drawing are great for strengthening the wrist and for improving the strength and dexterity of the hand.
Being able to use opposition and pinching are vital for improving function and regaining independence in ADLs. Even simple tasks like buttoning a shirt can be difficult after a Colles fracture.
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