Treatment of Hand and Wrist Fracture:
This is also called as Poutteau’s fracture in many parts of the world. Abraham Colles first described in the year 1814.
Definition
It is not just fracture lower end of radius but a fracture dislocation of the inferior radioulnar joint. The fracture occurs about 11/2″ (about 2.5 cm) above the carpal extremity of the radius.
Following this fracture, some deformity will remain throughout the life but pain decreases and movements increase gradually.
Mechanism of Injury
The common mode of injury is fall on an outstretched hand with dorsiflexion ranging from 40-900 .The force required to cause this fracture is 192 kg in women and 282 kg in men.
Fracture pattern: It is usually sharp on the palmar aspect and comminution on the dorsal surface of the lower end of radius.
Clinical Features
Usually, the patient is an elderly female in her 60s and the history given is a trivial fall on an outstretched hand. The patient complains of pain, swelling, deformity and other usual features of fracture at the lower end of radius. Though dinner fork deformity is a classical deformity in a Colles’ fracture, however, it is not found in all cases but seen only if there is a dorsal tilt or rotation of Colles’ Fracture.
Styloid Process Test
Normally, the radial styloid process is lower by 1.3cm when compared to the ulnar styloid process. In Cones’ both radial and ulnar styloid processes are at the same level and are found in all displacements of Colles’ fracture. Hence, this is a more reliable sign than dinner fork deformity.
Radiology
Radiographs of the wrist both AP and lateral views of the affected wrist and lower end of the radius are taken. The Points noted in the AP view are metaphyseal comminution, fracture line extending into the radiocarpal or inferior radioulnar joint and fracture of the ulnar styloid process (seen in about 60% of the cases). In the lateral view, the points noted are dorsal displacement and dorsal tilt of the distal fragment, sharp palmar surface and dorsal comminution of the lower end of radius, distal radioulnar joint subluxation, etc.
Classification
Contrary to popular belief, Colles’ fracture is both intra-articular and extra-articular and not only extra-articular. Frykmann’s classification takes into consideration both and the fracture of ulna.
Treatment Methods
Aim: The aim of treatment is to restore fully functional hand with no residual deformity. The treatment methods include Conservative methods, Operative methods and External fixators.
Conservative Methods
Here fracture reduction is carried out by closed methods under general anesthesia (GA) or local anesthesia (LA). The examiner holds the hand of the patient as if to shake hand. With an assistant giving counteraction by holding the forearm or arm of the patient, the examiner gives traction in the line of the forearm. This disimpacts the fracture and the examiner corrects the other displacements of the fracture. At the end of the procedure, styloid process test is carried out to check the accuracy of reduction. If the level of the styloid processes is restored back to normal, it indicates that the reduction has been achieved satisfactorily. Then the limb is immobilized by any one of the methods in the table above (mainly Cones’ cast) and a check radiograph is taken. The plaster cast is removed after 6-’8 weeks and physiotherapy is begun.
The common causes for failure of reduction are incomplete reduction of the palmar fracture line and dorsal comminution of the lower end of radius.
Operative methods
Operative treatment is rarely required for Colles’ fracture and may be required in the following situations:
Indications: Extensive comminution, impaction, median nerve entrapment and associated injuries in adults.
Modalities of operative treatment: Depending upon the degree of comminution and the intra-articular extensions, one of the following surgical methods is chosen:
Closed reduction and percutaneous pinning with K-wires: Here, after closed reduction by the usual methods the fracture fragments are held together by percutaneous pinning by one or two K-wires.
Arm control: This method is known to prevent collapse and gives good results in a few select cases.
Open reduction: in certain fractures involving of the distal articular surfaces (Bartons variety open reduction and plate fixation (Ellis’ plate) is advocated.
Indications: Same as for external fixation and for marginal volar or dorsal Barton’s fractures.
Advantages
- Provides buttress
- Resists compression
- Load sharing
- Early mobilization
External fixators
These are found to be extremely useful in highly comminuted fractures, unstable fractures , compound fractures and bilateral Colles’ fracture. Through a lightweight UMEX frames, two pins are placed in the forearm bones and two pins in the metacarpal bones of the hand. These pins are then fixed to an external frame and the fracture fragments are held in position by ligamentotaxis. The frame should be applied after obtaining closed reduction by the usual method.
Complications
The important complications of Colles’ fracture are listed in. Few significant complications are discussed here.
- Malunion: This is the most common complication of Colles’ fracture. Six important causes are responsible for it.
- Improper reduction: If the fracture is not reduced properly, in the initial stages it may result in mal-union later.
- Improper and inadequate immobilization: This fracture needs to be immobilized at least for a period of six weeks failing which malunion results.
- Comminuted dorsal surface: Due to extensive comminution, the fracture collapses and recurs after reduction and casting.
- Osteoporosis may lead to collapse and recurrence.
- Recurrence: This is due to extensive comminution and osteoporosis.
- Rupture of the distal radioulnar ligament: This usually goes undetected in the initial stages of treatment and is responsible for the later recurrence.
Treatment
There are six options of treatment in a malunited Colles’ fracture:
- No treatment is required if the patient has no functional abnormality.
- Remanipulation is attempted if fracture is less than 2 weeks old.
- Darrach’s operation is more often indicated if the patient complains of functional disability.
- Corrective osteotomy and grafting if the patient wants cosmetic correction and if the patient is young (Fernandez and Campbell). Fernandez is a dorsal wedge osteotomy and Campbell is a lateral wedge osteotomy.
- Arthrodesis (for intra-articular fracture): The patient complains of pain in the wrist joint due to traumatic osteoarthritis following an intra-articular fracture. In these patients, arthrodesis of the wrist in functional position is the surgery of choice.
- Combination of these like Darrach’s operation with osteotomy, etc. is also tried in some situations.
Rupture of extensor pollicis tendon: This occurs due to the attrition of the tendon as it glides over the sharp fracture surfaces. This usually occurs after 4-6 weeks and may be repaired or left alone with no residual disability.
Sudeck’s osteodystrophy: This is due to abnormal sympathetic response, which causes vasodilatation and osteoporosis at the fracture site. The patient complains of pain, swelling, painful wrist movements and red-stretched shiny skin. Treatment consists of immobilization of the affected part with plaster splints, injection of local anesthetics near the sympathetic ganglion in the axilla or cervical sympathectomy in extreme cases.
Frozen hand shoulder syndrome: This is a troublesome complication, which develops due to unnecessary voluntary shoulder immobilization by the patient on the affected side for fear of fracture displacements. It is said that the patient has performed a mental amputation and kept the limb still.
Carpal tunnel syndrome: Malunion of Colles’ fracture crowds the carpal tunnel and compresses the median nerve.
Nonunion: This is extremely rare in Colles’ fracture because of the cancellous nature of the bone, which enables the fracture to unite well. However, soft tissue interposition may cause this problem. The treatment consists of open reduction, rigid internal fixation and bone grafting.