TRAUMA

Review Article

Evidence-based review of Colles’ fracture

Trauma 2015, Vol. 17(3) 191–200 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460408614561174 tra.sagepub.com

Awais Habeebullah, Aleks Vasiljevic and Mohamad Abdulla

Abstract Background: A Colles’ fracture occurs as a transverse fracture of the metaphyseal region of the distal radius, approximately 25–40 mm proximal to the radio-carpal joint, and is associated with dorsal displacement and angulation of the distal fragment. Other features include radial shortening and palmar tilt. Key radiological measurements usually noted are that of radial length (normally 11 mm), dorsal angulation of the distal radius (normally 10 volar angulation) and radial inclination (normally 22 ). A Colles’ fracture is one of the most common types of osteoporotic fractures seen, especially in females above the age of 50. Incidence of men vs. women over the age of 35 was 9/10,000 vs. 37/10,000, respectively. Management: Conservative management is commonly an option in stable or minimally displaced fractures which are described as 2 mm loss of radial height, 5 change in radial inclination and 10 of dorsal angulation. This can be managed in a plaster cast for five to six weeks. Furthermore, age of >60 years was found to be the most important factor in predicting whether a reduced unstable fracture would redisplace. Kirschner-wire fixation is a useful and simple operative method to help stabilise fragments that are not severely comminuted. This option was found to be better than plaster cast management alone, but was associated with surgical complications such as infection and nerve injuries. A more common management option utilised for unstable fractures today is open reduction and internal fixation using either dorsal or volar plates. Dorsal plates are less commonly used due to increased risk of volar collapse and tendon rupture with up to a 22% removal of implant rate due to tendon irritation. Volar plates are more popular as they allow a more stable fixation and thus early mobilisation with a better radiological outcome when compared against K-wire fixation. They are also associated with a lower incidence of tendon complications. External fixation management options may either be bridging or nonbridging in regards to the radio-carpal joint. Immobilising the wrist with a bridging external fixation device can be an option when managing a severely comminuted fracture without a large enough distal fragment to secure a distal pin. However, dorsal malunion was six times more likely when compared against a nonbridging option. Though studies showed external fixation devices provided better radiological outcomes when compared to conservative management, there is insufficient evidence to conclude that long-term functional outcomes are also improved. Prevention: Often a fracture of this nature is considered as one of the first signs of osteoporosis in a middle-aged adult. Hormone replacement therapies and use of bisphosphonate therapy have been proven to reduce the risk of osteoporotic fractures with alendronate being found to significantly reduce the risk of spine, hip and wrist fractures in postmenopausal women with a mean age of 70 years. Incorporation of other health care professionals such as physiotherapists and occupational therapists is also of vital importance to ensure osteoporotic patients are at a lower risk of sustaining falls.

Keywords Colles’ fracture review, distal radius fracture epidemiology and management

Introduction Abraham Colles, born in 1773 in Dublin, Ireland, was an accomplished professor of surgery and anatomy in the early 19th century at the Royal College of Surgeons, Ireland. He received his license to practice surgery in

Anatomy Department, School of Infection and Immunity, University of Birmingham, Birmingham, UK Corresponding author: Awais Habeebullah, Anatomy Department, University of Birmingham, School of Infection and Immunity, Birmingham B15 2TT, UK. Email: [email protected]

192 1795 and went on to further his education in Edinburgh and then in London in the late 18th century.1 He was described by many as a modest and humble skilled man who was also an excellent and inspirational teacher.2 Through his work in anatomy, Colles discovered the Colles Fascia and Colles Ligament whilst clinically leading the way in treatment of syphillis. However, what he is famously renowned for is describing what we know today as the Colles’ fracture. The definitive description of this injury was first accurately described in literature almost 200 years ago, in an article ‘On the fracture of the carpal extremity of the radius’ by Abraham Colles.3 To date, it has been described as a ‘Colles’ fracture. Colles describes this injury as a ‘fracture proximal to the carpal ends of the radius’. He noted that the posterior aspect of the extremity was characterised as deformed, with a depression of the forearm approximately 1.5 in (38 mm) above the distal end of the radius, where the carpus and the base of metacarpus appear to be thrown backward.1,3 A Colles’ fracture occurs as a transverse fracture of the metaphyseal region of the distal radius, approximately 25–40 mm proximal to the radiocarpal joint, and is associated with dorsal displacement and angulation of the distal fragment. Other features include radial shortening and palmar tilt.3,4 These features result in a characteristic ‘dinner-fork’ or ‘bayonet’ deformity. Extension of the fracture line through the radiocarpal joint, distal radio-ulnar joint and involvement of the ulnar styloid process can also be seen.5

Epidemiology Amongst young adults, Colles’ fractures are sustained following high-impact trauma, however in older adults fractures often result from low-to-moderate impact trauma, such as a fall from a standing height, particularly in females. Due to the mechanism of injury, a Colles’ fracture is one of the most common sites for osteoporotic fractures.6 The estimated the life-time risk amongst Caucasian females aged 45–50 years of age is believed to be between 15% and 20%, in comparison to a life-time risk of merely 2–3% in males amongst an average western population.7–9 The incidence of general fractures amongst females rises significantly above 50 years of age, almost twice as likely as compared to male. However, the incidence amongst males prior to menopausal age is almost three times as likely as compared to females.10 A multicentre study of patients aged 35 years and above reported an annual incidence of 9/10,000 in men and 37/10,000 in women based in the United Kingdom.11 It is hypothesised that 20% of patients suffering from Colles’ fracture will also require hospital admission as part of their initial management.11 These studies highlight the

Trauma 17(3) significant role of osteoporosis in the rising incidence of Colles’ fractures.

Clinical presentation The classical mechanism of injury for a Colles’ fractures involves a ‘fall on outstretched hand’, as described frequently throughout the literature.12,13 In practice, two distinct mechanisms exist to produce a Colles’ fracture. As mentioned above, one involves the elderly osteoporotic female patient and a low-energy impact. An example of such an event is when the patient has fallen forward from a standing height with their arm extended out and down and the wrist hyperextended in an attempt to break their fall.12,14 The fracture is common due to several factors including poor ambulation, a high risk of falling and having a low bone density.14 An increasingly common mechanism is that seen in the younger cohort of patients, which relates to an increasing frequency of high-energy injuries to the upper limb that force dorsiflexion at the wrist with or without the presence of falling.14–16

Assessment Colles’ fractures, as with any pathology, need to be approached systematically. Having mentioned the classical presentation in the section above, one should be suspicious of a fracture of this type from a basic history, either from the patient, relatives, or paramedics attending the patient. As a priority, the patient needs to be made comfortable with adequate analgesia. Analgesic requirements for a fracture are high, and patients will most likely benefit from intramuscular or intravenous morphine for rapid pain relief, as well as being in line with guidance from World Health Organisation on appropriate analgesia. A brief examination of the forearm, wrist and hand needs to be carried out, with special attention paid to the neurovascular status.12,14 Any obvious neurovascular defects must be documented clearly and should highlight the need for senior or specialist input as a matter of urgency.14 The next step involves comprehensive examination of the injury which must be systematic and thorough, comparing the injured side with the uninjured side.13 Inspect the wrist for any obvious deformity, swelling, or bruising. Colles’ fractures present with a dorsal deformity which should be actively looked for.14 Palpation of the distal radius, ulna and carpal bones should be performed next, identifying any bony tenderness, crepitus, bogginess, or swelling. The neurovascular status of the hand including all digits must be examined.12,14 The median nerve is of most importance in Colles’ fractures, however, the radial and ulnar nerve

Habeebullah et al. should also be examined. Movements of the wrist, hand and digits should be tested as part of the neurovascular status examination.13 Special note should be made to test all movements of the injured wrist, hand and digits and to compare these with the uninjured limb. Diagnosis should be apparent from the history and examination. If there is any suspicion of a fracture then x-ray films should be carried out.13 As a minimum two views should be ordered, including anterior–posterior and lateral views. X-ray films not only confirm the presence of a fracture but they also provide important information surrounding the injury, including direction of displacement, degree of shortening, comminution and involvement of the articular surface.14 Key radiological measurements usually noted are that of radial length (normally 11 mm), dorsal angulation of the distal radius (normally 10 volar angulation) and radial inclination (normally 22 ).17

Initial management Initial treatment of the fracture is aimed at restoring anatomical alignment and maintaining this alignment until the fracture has healed.14,18 Management of most Colles’ fractures is commonly carried out in the form of closed reduction and plaster cast immobilisation.19 Reduction of a fracture is a painful procedure which requires anaesthesia, of which many methods have been used in the past. In modern practice, it is commonplace to use a haematoma block or Bier’s block with the trend having moved away from general anaesthesia.20 However, 20% of reductions are carried out using intravenous benzodiazepenes, which have the benefit of an amnesic and sedative effect.20 Haematoma block has become the more commonly used anaesthetic technique for reduction, recent literature showing up to 50% of cases implementing this technique.20 This involves infiltrating the fracture haematoma with a needle and syringe and inserting a local anaesthetic agent.21 Advantages of this method include that it is quick and technically simple,22 it is a safe method of block with few documented adverse events, it is effective for up to 12 h postinfiltration and it is low cost.13 One must take into account the disadvantages of this method which include the theoretical risk of introducing infection into the fracture site.22 Bier’s block is an alternative to haematoma block that can be implemented for fracture reduction. Local anaesthetic agents are inserted intravenously in the upper limb, whilst a tourniquet is applied proximally, providing effective regional anaesthesia.23 Research has shown Bier’s block to be superior in analgesic efficacy during reduction, radiological result of reduction and early remanipulation rate when compared to haematoma block.22 Bier’s remains a relatively unpopular

193 choice however, with recent figures showing that only 17% of distal radial fractures were manipulated with this anaesthetic management.20 Factors involved with this low popularity may revolve around preconceptions surrounding time taken to perform block, the risks of intravenously injected local anaesthetic agent and the need to have two clinicians present in the department when administering the block.22 Although the literature does show an advantage for Bier’s over haematoma block,22 clinicians should use a technique that they are familiar with and comfortable administering. However, if a clinician is familiar with both techniques, and as long as there are no contraindications to Bier’s block, the literature shows it is beneficial to the patient to receive this over haematoma block.22 Once the patient has been appropriately anaesthetised, time should be allowed for the analgesic effects to set in before reduction is attempted.13 A good way to gauge analgesic efficacy after haematoma or Bier’s block is to attempt a gentle manipulation approximately 10 min after application. If pain is elicited allow a further 5 min for the anaesthetic to take effect.13 Pain-free reduction is ideal, ensuring the maximal relaxation of the patient and the muscles surrounding the fracture, allowing for a more anatomically congruent reduction.22 Reduction of the fracture segments requires a period of effective traction, followed by manipulation. Initially traction must be placed across the fracture, allowing the fracture segments to disimpact. For distal radius fractures, the elbow is placed in flexion and an assistant applies countertraction on the upper arm, provided there are no contraindications.13 The clinician performing the manipulation takes the patients hand almost as if shaking it, and provides traction. Longitudinal traction should be applied for 5 min, allowing the distal fragments to fully disimpact.12,13 Manipulation of the segments can then be performed. Traditionally the wrist is flexed with ulnarisation.18 Wrist flexion locks the articulation at the wrist joint, ensuring that ulnar deviation occurs at the fracture site, maintaining alignment of the distal radial articular surface.18 Several techniques for reduction have been attempted, ranging from the finger-trap method to manual manipulation. No one technique has been shown to be superior in terms of functional outcome at the end of treatment.23 A recently documented technique is called the handshake technique. It involves similar manoeuvres to traditional manual manipulation, however it ensures that the wrist is not hyperflexed, which could endanger the median nerve as well as increasing the rate of redisplacement.18 Once reduced, the fracture must be immobilised in this position. Traditionally, circumferential casting and

194 splinting are the immobilisation of choice. There has been no proven benefit in maintenance of anatomical reduction between the two modes of immobilisation, and therefore the modality that is familiar and readily available to the clinician performing the reduction should be the one carried out.24 One study has shown the use of a lightweight splint to be preferable to patients due to comfort, and has been shown to allow earlier mobilisation of the elbow, hand and fingers reducing stiffness and swelling.25 Post-immobilisation x-ray films should be taken to ensure the reduction has been maintained.12 When satisfactory reduction and immobilisation has been performed, the patient should have a follow up in fracture clinic,14,26 with advice to maintain a vertical position of the hand and active movement of the fingers to reduce swelling and stiffness.18

Management The management of distal radius fractures is dependent on many factors which include the severity and stability of the fracture, bone quality, patient age, comorbidities and functional status.27,28 The management can thus be broken down into operative and non-operative approaches.

Non-operative management This approach is utilised most commonly in stable or minimally displaced fractures. This is defined as 2 mm loss of radial height, 5 change in radial inclination and 10 of dorsal angulation.27,29,30 Fractures fulfilling the above criteria may then be managed by immobilising in a plaster cast for five to six weeks.29 However, in a study carried out by Leonne et al., 7 out of 21 undisplaced fractures that were managed conservatively did go on to fail. These were predominantly in women over the age of 65 thus implying that close follow-up may be warranted in elderly patients despite having an initially stable fracture.31 There is ongoing debate in regards to management of fractures that are initially present as unstable. Lafontaine et al. managed to set criteria in regards to predicting instability of a fracture based on initial presentation which included dorsal angulation of >20 , dorsal or intra-articular comminution, associated ulna fracture, age >60 years and radial shortening.32 Nesbitt et al. utilised this criteria and found that age was one of the main predictive factors for whether an unstable fracture managed conservatively would displace. The study showed that patients around 58 years of age had a 50% chance of re-displacement despite acceptable closed reduction, whilst patients 80 years of age had a 77% risk of re-displacement and may thus require an operative fixation if suitable.33

Trauma 17(3) Another factor guiding a decision towards conservative management is patients with low functional status. Two Cochrane reviews have shown that there was insufficient evidence to conclude that different types of conservative management or even surgical management provided a better functional outcome.16,34 There is also literature to support that the functional status of patients who underwent conservative management was better than expected at one year and malunion did not necessarily provide poor functional results.33,35

Operative management There are many options available when managing a Colles’ fracture operatively. These range from minimally invasive Kirschner Wire fixation to an open reduction and internal fixation using plates.

Kirschner wire fixation Percutaneous K-wire fixation has been quite a popular choice of management of unstable uncomminuted extra-articular distal radius fractures over many years. It is a minimally invasive procedure that can help reduce the risk of secondary displacement of the fracture along with improving the anatomical and functional results.36 However, this option may be deemed unsuitable for patients with severe comminution or osteoporosis as the trabecular bone of the metaphysis may not provide enough stability.27 Although there are many techniques that exist,37 a common approach is to insert K-wires through the radial styloid, reducing distal fragments and going transversely across the radio-ulna joint to secure the reduction. Another method of percutanrous fixation is the Kapandji procedure first described in 1988. This involves drilling the K-wire through the fracture site itself and restoring the radial inclination by manipulating/buttressing the distal fragment using the wire. Another wire is then introduced perpendicular to the initial wire in a dorsal to palmar direction so as to maintain a volar tilt.38 A Cochrane review compared different types of percutaneous pinning techniques along with the Kapandji procedure and found that cross fracture pinning was indeed superior to just plaster cast immobilisation in terms of avoiding deformity and malunion. The Kapandji procedure did not show any significant difference in comparison to other pinning techniques which provided similar functional results.39 Complications noted with this procedure is diverse and may be associated with the injury itself such as vessel or tendon ruptures along with median nerve dysfunction.40 Care must be taken when introducing

Habeebullah et al. the K-wires so as to ensure nerve and tendon impalement is avoided. A recent study showed that the rate of infection without administering prophylactic antibiotics in 100 patients who underwent K-wire fixation was 2%.41 Another study compared the infection rates of buried vs. exposed K-wires and found that there was only a slight increase in superficial pin site infection in the exposed group, however the buried group had a higher risk of superficial radial nerve damage as they require another surgical procedure to have the buried pins removed.42 The reduction in pin-tract infections by burying the pins was also demonstrated by Hargreaves et al. where the infection rates were reduced from 20% to 4%.43

Plating Recently, there has been a trend towards managing patients with unstable Colles’ fractures with open reduction and internal fixation.44 A study in 2008 showed that open fixation of distal radius fractures had increased from 42% in 1999 to 81% in 2007 despite no clear evidence of open fixation being the superior option.45 Common plating options that are available are via the dorsal or volar approach. Each has its own merit based upon the characteristic of the fracture. As most unstable Colles’ fractures tend to displace dorsally, an open reduction internal fixation with a dorsal plate provides direct visualisation of the displaced fragments allowing an accurate reduction.46 There are however some drawbacks to this approach whereby the natural 10 volar tilt of the radius may not allow adequate purchase when using a fixed angle plate. Ruch et al. showed that 5 out of 20 patients resulted in volar collapse post-dorsal plating which was found to be statistically significant.47 Osada et al. also found that dorsal plating was associated with higher risk of volar collapse as the distal fragment can pull away in osteopenic bone during forearm pronation.48 Another disadvantage to this management option is the risk of extensor tendon irritation and rupture which has been well documented.47,49,50–53 Ruch found that the commonly irritated tendon was the extensor carpi radialis brevis over Lister’s tubercle once extensor pollicus longus had been transpositioned. The most commonly ruptured tendon was found to be the index extensor tendon.47 Another study found that even with low profile plates, the rate for implant removal was approximately 22% due to irritation. This alongside other literature thus suggests that dorsal plates have a higher risk of extensor tendon rupture associated with them regardless of the design.50,52

195 Volar plating has recently become a popular option in regards to managing unstable Colles’ fractures. Furthermore, with the introduction of locked volar plates, trends have shown that elderly patients with unstable distal radius fractures who may have previously been managed nonoperatively are now treated surgically with promising results.28,54,55 The volar plate helps transfer forces from the dorsal metaphysis towards the volar cortex and restores anterior continuity thus providing more stability.47,56 Cadaveric studies have also shown that volar locking plates can withstand significantly more force by having superior biomechanical properties thus allowing the possibility of early mobilisation.57,58 Another study comparing volar plates against Kirschner wire fixation found volar plate fixation to be superior both radiologically and in functional outcome.59 This finding was supported by Ruch et al. where no patients who underwent volar plate fixation had either a dorsal or volar collapse.47 Furthermore, a study carried out by Rhee et al. looked at 120 patients with distal radius fractures who were managed with a volar locking plate. The study showed that the mean radial shortening at six months postoperatively was 0.0 mm and no patient had radial shortening beyond 5 mm nor did any patient have any dorsal angulation postoperatively.60 Rozental and Blazar however retrospectively found that despite good to excellent functional outcomes, 4 out of 41 patients experienced loss of reduction and fracture collapse after volar plate fixation.61 In comparison to dorsal plates, the incidence of tendon complications is lower when using volar plates as the pronator quadratus muscles separates the implant from the flexor tendons.47,62–64 However, there is still a risk of extensor tendon rupture in a volar approach if screw lengths are too long thus breaching the dorsal cortex.63 Volar plate fixation can also be associated with carpal tunnel syndrome that may then require release of the median nerve. This is likely to be due to retraction of the median during the volar approach which could then lead to neuropathy.65 Despite their documented differences between dorsal and volar plates, a meta-analysis showed no statistically significant differences in the overall risk of complications.66

External fixation This method has been utilised for many decades and overcomes the displacing forces of the forearm muscles that may cause the radial fracture to displace or collapse.27,67 Unstable extra-articular fractures of the distal radius can be managed with a non-bridging external fixation device where pins are inserted in the distal

196 fragment of the radius and externally fixed to pins proximal to the fracture site. Bridging involves wrist immobilisation by inserting distal pins into the second metacarpal.55,56 This approach may be preferred when there is a severely comminuted distal radial fracture without a large enough distal fragment to secure a distal radial pin. Atroshi et al. in a randomised trial found that patients who underwent non-bridging fixation had better radiological outcomes in terms of radial length.68 This finding was supported in a large retrospective study looking at 588 patients that compared the two options for external fixation. The study found that patients treated with external bridging fixation were six times more likely to get dorsal malunion and 2.5 times more likely to have radial shortening.69 Although this study did not look at functional outcomes, other studies have shown patients to have better functionality with non-bridging fixation.70–72 Atroshi et al. however noted that there was no significant difference in functional status in the long term.68 A Cochrane review found that external fixation devices provided better radiological outcomes when compared to conservative management along with a slightly reduced need for secondary surgery. There was however insufficient evidence to conclude that functional outcomes are also improved with this type of fixation.16 Although individual studies have shown some differences, another systemic review looking at different methods of external fixation could not show any statically significant differences between them.73 A prospective trial looking at internal fixation using plates versus external fixation found that although functional outcomes in the long term were quite similar between the two groups, there was less pain and disability associated with the internal fixation group in the early postoperative period. Radiological outcomes were also found to be slightly superior to external fixation group.74 A retrospective study looking at only 55 patients also found favourable results for plating as opposed to external fixation based again on radiological outcomes, but also showed improved functional scores.75 Cadaveric studies have shown percutaneous pinning can also be used as an adjunct to any type of external fixation to help prevent fracture displacement further.76 This however involves further drilling of pins which then introduces further risks of complications. Studies have also found that excessive flexion and distraction which were once the norm should be avoided so as to reduce the risk of complications such as developing postoperative pain, stiffness, median nerve compression, or reflex sympathetic dystrophy.67,77–79 Furthermore, pin tract infections are not an uncommon complication which can be managed

Trauma 17(3) with antibiotics.68 Radial neuritis and reflex sympathetic dystrophy are also associated complications in external fixation.68,73,79,80

Functional outcome Abraham Colles mentioned that most patients with such a fracture would predominantly heal in an unreduced position. This was supported by Gartland and Werley.81 Colles also went on to state that ‘the limb will at some remote period again enjoy perfect freedom in all its motions and be completely exempt from pain’.3 Majority of recent studies however, have shown that although a distal radius fracture may eventually heal in an unreduced position, the functional status of the wrist hand may be less than adequate and may result in painful, stiff and functionally weak wrist.70,82 Today there are many tools to assess the subjective patient related outcome after a Colles’ fracture. A common assessment used is the Disabilities of the Arm Shoulder and Hand questionnaire (DASH). This is a 30-item questionnaire introduced by the American Academy of Orthopaedic surgeons that takes into account different physical activities, patient’s symptoms and social activities. The score ranges from 0 (least disabling) to 100 (severely disabling).83,84 This is a widely used assessment tool that many studies have utilised to measure subjective patient outcomes. Another valuable tool is the Patient-Rated Wrist Evaluation (PRWE). This was developed by Macdermid and involves 15 questions focusing on patient’s pain rating and disability after distal radius fractures.85 The shorter format of this questionnaire was found to be more efficient and user friendly.86 Many studies tend to utilise either one of these popular tools. Further outcome measures described are the Brigham and Women’s carpal tunnel questionnaire and the Gartland and Werley score. The latter is a more objective assessment which has yet to be validated. It looks at the range of motion along with complications post-distal radius fractures however does have a small subjective aspect to it.81 The Brigham and Women’s carpal tunnel questionnaire is a more disease specific assessment for carpal tunnel syndrome. A study comparing the mentioned assessment tools showed that the PRWE score is most useful for assessing outcomes in patients with distal radius fractures, whilst the DASH score is more useful when evaluating patients with multiple upper limb issues.87 These assessment tools help provide a subjective outcome of treatment provided for Colles’ fractures. Radiological outcomes, grip strength and range of movement all provide an objective outcome after management that may be compared against other treatment

Habeebullah et al. modalities. Many prospective studies showed that in patients usually above 55, radiological parameters were not necessarily associated with functional outcomes.88–90

197 orthogeriatricians, physiotherapists, occupational therapists and pharmacists. Conflict of interests None declared.

Prevention Commonly the pathophysiology of Colles’ fractures is associated with a fall on an outstretched hand with a dorsiflexed wrist, in an individual with a reduced bone mineral density (BMD).6 Often a fracture of this nature is considered as one of the first signs of osteoporosis in a middle-aged adult.4 Nguyen et al. reported a 50% increase in fracture risk per standard deviation reduction in BMD amongst both genders.91 It is believed that osteoporotic females in the lowest quintile of BMD are four times more likely to suffer from a fracture compared to those in the highest quintile.92 BMD decreases markedly after menopause because of oestrogen deficiency. The trabecular and cortical bone changes along with the reduced BMD predispose patients to osteoporotic fractures.93 Evidence has also shown that an active lifestyle can also increase the likelihood of such fractures.94 Thus, the risk of sustaining a Colles’ fracture can be seen as twofold; a combination of increased physical activity which predisposes elderly patients to falls and reduced BMD. Other lifestyle factors such as smoking, body mass and comorbidities have not shown a significant role in the predisposition of such injuries.95 Thus, the challenge lies with clinicians in the diagnosis and treatment of osteoporosis before the development of fractures. The use of hormone replacement therapies (HRT) has been utilised. Evidence over the past decade has proven that HRT have shown a significant fracture reducing potential, amongst which a prospective study highlighted a risk reduction rate of 39% (Risk Ratio [RR] ¼ 0.61).96 However, increasing risk of breast cancer and cardiovascular complications has limited their use.97 The use of bisphosphonate therapy has also been proven to reduce the risk of osteoporotic fractures of the wrist. Black et al. showed that alendronate significantly reduced the risk of spine, hip and wrist fractures in postmenopausal women with a mean age of 70 years. The cumulative proportion of women with wrist fractures was higher in the placebo group compared with the alendronate group (p ¼ 0.013).98 Preventative measures should also be sought for managing the falls risk, especially for elderly patients. Factors such as postural instability, visual, hearing and walking aids should be addressed to reduce the risk of future falls. Thus attempts at the prevention of Colles’ fractures occurrence, requires a multidisciplinary approach involving the general practioners,

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References 1. Shayota BJ, Oelhafen K, Shoja M, et al. Abraham Colles and his contributions to anatomy. Clin Anat 2014; 27: 670–674. 2. Doolin W. Abraham Colles: a tribute. J Bone Joint Surg 1954; 36: 132–134. 3. Colles A. On the fracture of the carpal extremity of the radius. N Engl J Med Surg 1814; 3: 368–372, (reprinted Clin Ortho, 1972; 83: 3–5). 4. Wagner DW, Lindsey DP and Beaupre GS. Replicating a Colles’ fracture in an excised radius: revisiting testing protocols. J Biomech 2012; 45: 997–1002. 5. Goldfarb CA, Yin Y, Gilula LA, et al. Wrist fractures: what the clinician wants to know. Radiology 2001; 219: 11–28. 6. Silman AJ. Risk factors for Colles’ fracture in men and women: results from the European prospective osteoporosis study. Osteoporosis Int 2004; 15: 927. 7. Van Staa Tp, Dennison EM, Leufkens HG, et al. Epidemiology of fractures in England and Wales. Bone 2001; 29: 517–522. 8. Cummings SR, Black DM and Rubin SM. Lifetime risks of hip, Colles or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med 1989; 149: 2445–2448. 9. Kanis JA, Johnell O, Oden A, et al. Long-term risk of osteoporotic fracture in Malmo. Osteoporosis Int 2000; 11: 669–674. 10. Singer BR, McLauchlan GJ, Robinson CM, et al. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg 1998; 80: 243–248. 11. O’Neill TW, Cooper C, Finn JD, et al. Incidence of distal forearm fracture in British men and women. Osteoporosis Int 2001; 12: 555–558. 12. Brown FM. Management of Colles’ fractures. Orthop Nurs 1998; 17: 37–40. 13. Summers A. Recognising and treating Colles’ type fractures in emergency care settings. Emerg Nurs 2005; 13: 26–33. 14. Altizer LL. Colles’ fracture. Orthop Nurs 2008; 27: 140–145. 15. Chen NC and Jupiter JB. Management of distal radial fractures. J Bone Joint Surg 2007; 89: 2051–2062. 16. Handoll HHG, Huntley JS and Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev 2007; 3: CD006194. 17. van Eerten PV, Lindeboom R, Oosterkamp AE, et al. An X-ray template assessment for distal radial fractures. Arch Orthop Trauma Surg 2008; 128: 217–221.

198 18. Salvi AE. The handshake technique: proposal of a closed manual reduction technique for Colles’ wrist fracture. Am J Emerg Med 2011; 29: 115–117. 19. Kelly AJ, Warwick D, Crichlow TPK, et al. Is manipulation of moderately displaced Colles’ fracture worthwhile? A prospective randomised trial. Injury 1997; 28: 283–287. 20. Sprot H, Metcalfe A, Odulta A, et al. Management of distal radius fractures in emergency departments in England and Wales. Emerg Med J 2012; 30: 211–213. 21. Johnson P and Noffsinger M. Haematoma block of distal forearm fractures. Is it safe? Orthop Rev 1991; 11: 977–979. 22. Kendall JM, Allen P, Younge P, et al. Haematoma block or Bier’s block for Colles’ fracture reduction in the accident and emergency department – which is best? J Accid Emerg Med 1997; 14: 352–356. 23. Earnshaw SA, Aladin A, Surendran S, et al. Closed reduction of Colles’ fractures: comparison of manual manipulation and finger-trap traction: a prospective, randomized study. J Bone Joint Surg 2002; 84: 354–358. 24. Grafstein E, Stenstrom R, Christenson J, et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles’ fractures. Can J Emer Med 2010; 12: 192–200. 25. O’Connor D, Mullet H, Doyle M, et al. Minimally displaced Colles’ fractures: a prospective randomised trial of treatment with a wrist splint or a plaster cast. J Hand Surg 2003; 28: 50–53. 26. Blakeney W and Webber L. Emergency department management of Colles-type fractures: a prospective cohort study. Emerg Med Australas 2009; 21: 298–303. 27. Simic PM and Weiland J. Fractures of the distal aspect of the radius: changes in the treatment over the past two decades. J Bone Joint Surg 2003; 85: 552–564. 28. Arora R, Lutz M, Deml C, et al. A prospective randomised trial comparing non-operative treatment with volar locking plate fixation for displacement and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg 2011; 93: 2146–2153. 29. Abramo A, Kopylov P and Tagil M. Evaluation of a treatment protocol in distal radius fractures. Acta Orthopaed 2008; 79: 376–385. 30. Mackenney PJ, McQueen MM and Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg 2006; 88: 1944–1951. 31. Leone J, Bhandari M and Adili A. Predictors of early and late instability following conservative treatment of extraarticular distal radius fractures. Arch Orthop Traum Surg 2004; 124: 38–41. 32. Lafontaine M, Hardy D and Delince P. Stability assessment of distal radius fractures. Injury 1989; 20: 208–210. 33. Nesbitt KS, Failla JM and Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg 2004; 29: 1128–1138. 34. Handoll HHG and Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003; 2: CD000314. 35. Egol KA, Walsh M, Romo-Cardoso S, et al. Distal radial fractures in the elderly: operative compared with non-

Trauma 17(3)

36.

37.

38.

39.

40. 41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

operative treatment. J Bone Joint Surg 2010; 92: 1851–1857. Clancey GJ. Percutaneous Kirschner wire fixation of Colles’ fractures. A prospective study of thirty cases. J Bone Joint Surg 1984; 66: 1008–1014. Rayhack JM. The history and evolution of percutaneous pinning of displaced distal radial fractures. Orthop Clin North Am 1993; 24: 287–300. Trumble TE, Wagner W, Hanel DP, et al. Intrafocal (Kapandji) pinning of the distal radius fractures with and without external fixation. J Hand Surg 1998; 23: 381–394. Handoll HHG, Vaghela MV and Madhok R. Percutaneous pinning for distal radial fractures in adults. Cochrane Database Syst Rev 2007; 3: CD006080. Belsole RJ and Hess AV. Concomitant skeletal and soft tissue injuries. Orthop Clin North Am 1993; 24: 327–331. Subramanian P, Kantharuban S, Shilston S, et al. Complications of Kirschner wire fixation in distal radius fractures. Tech Hand Up Extrem Surg 2012; 16: 120–123. Murphy M, Flannery O, McHugh G, et al. Outcome following buried vs exposed Kirschner wiring of distal radius fractures: a randomised controlled trial. J Bone Joint Surg 2010; 92: 50–51. Hargreaves DG, Drew SJ and Eckersley R. Kirschner wire pin tract infection rates: a randomised controlled trial between percutaneous and buried wires. J Hand Surg 2004; 29: 374–376. Trumble TE, Schmitt SR and Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994; 19: 325–340. Koval KJ, Harrast JJ, Anglen JO, et al. Fracture of the distal part of the radius, the evolution of practice over time. Where’s the evidence? J Bone Joint Surg 2008; 90: 1855–1861. Martineau PA, Berry GK and Harvey EJ. Plating for distal radius fractures. Orthop Clin North Am 2007; 38: 193–201. Ruch DS and Papadonikolakis A. Volar vs dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg 2006; 31: 9–16. Osada D, Viegas SF, Shah MA, et al. Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study. J Hand Surg 2003; 28: 94–104. Lowry KJ, Gainor BJ and Hoskins JS. Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without plate failure: a case report. Am J Orthop 2000; 29: 789–791. Herron M, Faraj A and Craigen MA. Dorsal plating for displaced intra-articular fractures of the distal radius. Injury 2003; 34: 497–502. Mckay SD, MacDermid JC, Roth JH, et al. Assessment of complications of distal radius fractures and development of complication checklist. J Hand Surg 2001; 26: 916–922. Ring D, Jupiter JB, Brenwald J, et al. Prospective multicentre trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997; 22: 777–784.

Habeebullah et al. 53. Hove LM. Delayed rupture of the thumb extensor tendon. A 5 year study of 18 consecutive cases. Acta Orthop Scand 1994; 65: 199–203. 54. Chung KC, Shauver MJ and Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg 2009; 91: 1868–1873. 55. Blakeney WG. Stabilisation and treatment of Colles’ fractures in elderly patients. Clin Interv Aging 2010; 5: 337–344. 56. Schneppendahl J, Windolf J and Kaufmann RA. Distal radius fractures: current concepts. J Hand Surg 2012; 37: 1718–1725. 57. Leung F, Zhu L, Ho H, et al. Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate: a biomechanical study in a cadaveric model. J Hand Surg 2003; 28: 263–266. 58. Levin SM, Nelson CO, Botts JD, et al. Biomechanical evaluation of volar locking plates for distal radius fractures. Hand 2008; 3: 55–60. 59. McFayden I, Field J, McCann P, et al. Should unstable extra-articular distal radial fractures be treated with fixed angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised trial. Injury Int J Care Injured 2011; 42: 162–166. 60. Rhee SH, Kim J, Lee YH, et al. Factors affecting late displacement following volar locking plate fixation for distal radial fractures in elderly female patients. Bone Joint J 2013; 95: 396–400. 61. Rosental TD and Blazar PE. Functional outcome and complications after volar plating for dorsally displaced unstable fractures of the distal radius. J Hand Surg 2006; 31: 359–365. 62. Lee Y, Wei T, Cheng Y, et al. A comparative study of Colles’ fractures in patients between fifty and seventy years of age: percutaneous K-wiring versus volar locking plate. Int Orthop 2012; 36: 789–794. 63. Shin EK and Jupiter JB. Current concepts in the management of distal radius fractures. Acta Orthop Trauma Cechosl 2007; 74: 233–246. 64. Jupiter JB, Ring D and Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg 2002; 27: 714–723. 65. Rein S, Schikore H, Schneiders W, et al. Results of dorsal or volar plate fixation of AO type C3 distal radius fractures: a retrospective study. J Hand Surg 2007; 32: 954–961. 66. Wei J, Yang T, Luo W, et al. Complications following dorsal versus volar plate fixation of distal radius fracture: a meta-analysis. J Int Med Res 2013; 41: 265–275. 67. Anderson R and O’Neil G. Comminuted fractures of the distal end of the radius. Surg Gyn Obstet 1944; 78: 434–440. 68. Atroshi I, Brogren E, Larsson G, et al. Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures, a randomised assessor blind clinical trial of 38 patients followed for 1 year. Acta Orthop 2006; 77: 445–453. 69. Hayes AJ, Duffy PJ and McQueen MM. Bridging and non-bridging external fixation in the treatment of

199

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81. 82.

83.

84.

85.

unstable fractures of the distal radius, a retrospective study of 588 patients. Acta Orthop 2008; 79: 540–547. McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised prospective study of bridging versus non bridging external fixation. J Bone Joint Surg 1998; 80: 665–669. Bednar DA and Al-Harran H. Non-bridging external fixation for fractures of the distal radius. Can J Surg 2004; 47: 426–430. Uchikura C, Hirano J, Kudo F, et al. Comparative study of non-bridging and bridging external fixators for unstable distal radius fractures. J Orthop Sci 2004; 9: 560–565. Handoll HHG, Huntley JS and Madhok R. Different methods of external fixation for treating distal radial fractures in adults. Cochrane Database Syst Rev 2008; 1: CD006522. Grewal R, Macdermid JC, King GJ, et al. Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: a prospective randomised clinical trial. J Hand Surg 2011; 36: 1899–1906. Rizzo M, Katt BA and Carothers JT. Comparison of locked volar plating versus pinning and external fixation in the treatment of unstable intra-articular distal radius fractures. Hand 2008; 3: 111–117. Wolfe SW, Austin G, Lorenze M, et al. A biomechanical comparison of different wrist external fixators with and without K-wire augmentation. J Hand Surg 1999; 24: 516–524. Comballa A. Over-distraction of the radio-carpal and mid-carpal joints with external fixation of comminuted distal radius fractures. J Hand Surg 1995; 20: 566–567. Agee JM. External fixation, technical advances based upon multiplanar ligamentotaxis. Orthop Clin North Am 1993; 24: 265–274. Duncan S and Weiland AJ. Minimally invasive reduction and osteosynthesis of articular fractures of the distal radius. Injury 2001; 32: 12–24. Hutchinson DT, Strenz GO and Cautilli RA. Pins and plaster vs external fixation in the treatment of unstable distal radial fractures. A randomised prospective study. J Hand Surg 1995; 20: 365–372. Gartland JJ and Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg 1951; 33: 895–907. Smilovic J and Bilic R. Conservative treatment of extraarticular Colles’ type fractures of the distal radius: prospective study. Croa Med J 2003; 44: 740–745. Gummesson C, Atroshi I and Ekdahl C. The disabilities of the arm shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. Musc Disord 2003; 4: 11. Hudak PL, Amadio PC and Bombardier C. Upper Extremity Collaborative Group: development of an upper extremity outcome measure: the DASH. Am J Ind Med 1996; 29: 602–608. MacDermid JC, Turgeon T, Richards RS, et al. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998; 12: 577–586.

200 86. MacDermid JC and Tottenham V. Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. J Hand Ther 2004; 17: 18–23. 87. Changulani M, Okonkwo U, Keswani T, et al. Outcome evaluation measures for wrist and hand – which one to choose? Int Orthop 2008; 32: 1–6. 88. Anzurat A, Johnson JA, Rowe BH, et al. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg 2004; 29: 1121–1127. 89. Roumen RM, Hesp WL and Bruggink ED. Unstable Colles’ fractures in elderly patients. A randomised trial of external fixation for redisplacement. J Bone Joint Surg 1991; 73: 307–311. 90. Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg 2005; 87: 837–840. 91. Nguyen TV, Center JR, Sambrook PN, et al. Risk factors for proximal humerus, forearm, and wrist fractures in elderly men and women: the Dubbo Osteoporosis Epidemiology Study. Am J Epidemiol 2001; 153: 587–595. 92. Kelsey JL, Browner WS, Seeley DG, et al. Risk factors for fractures of the distal forearm and proximal humerus,

Trauma 17(3)

93.

94.

95.

96.

97.

98.

The Study of osteoporotic fractures research group. Am J Epidemiol 1992; 135: 477–489. Gorai I, Nonaka K, Kishimoto H, et al. Cut-off values determined for vertebral fracture by peripheral quantitative computed tomography in Japanese women. Osteoporos Int 2001; 12: 741–748. Ivers RQ, Cumming RG, Mitchell P, et al. Risk factors for fractures of the wrist, shoulder and ankle: the Blue Mountains Eye Study. Osteoporosis Int 2002; 13: 513–518. Hemenway D, Azrael DR, Rimm EB, et al. Risk factors for wrist fracture: effect of age, ciga- rettes, alcohol, body height, relative weight, and handedness on the risk for distal forearm fractures in men. Am J Epidemiol 1994; 140: 361–367. Mosekilde L, Beck-Nielsen H, Sørensen OH, et al. Hormonal replacement therapy reduces forearm fracture incidence in recent postmenopausal women – results of the Danish Osteoporosis prevention Study. Maturitas 2000; 36: 181–193. Beral V. Million women study collaborations, breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 2003; 362: 419–427. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348: 1535–1541.