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SOME COMPLICATIONS of COLLES' FRACTURE and THEIR TREATMENT by W

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SOME COMPLICATIONS of COLLES' FRACTURE and THEIR TREATMENT by W Postgrad Med J: first published as 10.1136/pgmj.27.314.627 on 1 December 1951. Downloaded from 627 SOME COMPLICATIONS OF COLLES' FRACTURE AND THEIR TREATMENT By W. H. STEPHENSON, F.R.C.S. From the Department of Surgery, Postgraduate Medical School of London, Hammersmith Hospital Though Colles' fracture is a common injury its other positions has been tried, such as the Cotton complications and their treatment are seldom Loder (full palmar-flexion of the wrist and ulnar dealt with in surgical papers. In this paper it is deviation with extreme pronation of the forearm), proposed to discuss the following complications: but no position is completely successful in pre- I. Redisplacement. venting redisplacement. Protected by copyright. 2. Mal-union. Gross comminution may be seen in all age 3. Laxity of the inferior radio-ulnar joint. groups but is more commonly observed in the 4. Joint stiffness and adhesions. elderly. Comminution means instability, and even 5. Traumatic arthritis of the wrist joint. with the best support redisplacement is therefore 6. Pain over the ulnar aspect of the wrist. always a possibility. 7. Late rupture of the extensor pollicis longus Compression of bone on the dorsal aspect of the tendon. fracture is the direct result of the causative force. 8. Sudeck's atrophy (post-traumatic osteo- In some instances it is so well marked that after dystrophy). good reduction has been obtained a distinct gap 9. Injuries of the median nerve. may be seen dorsally between the fracture surfaces io. Prolonged absence from work. in the lateral radiograph. I. Redisplacement Treatment This is the commonest complication of im- Minor degrees of malalignment may be accepted portance. Between I 5 and 20 per cent. of all as they are compatible with good function. In http://pmj.bmj.com/ Colles' fractures for which reduction has been elderly subjects even gross redisplacement may be required show some degree of redisplacement. accepted and it may be justifiable to allow the The three main causes for this are (a) faulty im- primary displacement to remain unreduced. mobilization, (b) gross comminution and (c) com- Success from simple manipulation can be expected pression of bone on the dorsal aspect of the up to 14 days from the initial injury, after which fracture. time the use of the Thomas' wrench offers more Immobilization of the joints immediately above chance of success. Beyond the third week it is on October 3, 2021 by guest. and below the site of a fracture is a cardinal better to accept the position and treat the case as principle in treatment, but the standard fixation of one of mal-union, because forcible attempts at re- a colles' fracture, whether by plaster cast or other duction are usually unsuccessful and may do harm. forms of splintage, makes no attempt to fix the elbow joint and so control rotation of the forearm. 2. Mal-Union It is imperative, therefore, that whatever splintage Mal-union is also a common complication. The is used it should be applied with considerable care severity and type of deformity vary considerably. and should be observed at frequent intervals, The normal forward inclination of the plane of the especially during the first two weeks. It has been articular surface of the radius is 20°, but this is stated by Lambrinudi, and repeated by Charnley lost in nearly 20 per cent. of patients. The (I950), that fixation with the forearm in pronation articular surface may be at right angles to the shaft and wrist in ulnar deviation is the most reliable or even grossly tilted backwards. This is the position for holding reduction. Immobilization in commonest form of mal-union occurring alone. Postgrad Med J: first published as 10.1136/pgmj.27.314.627 on 1 December 1951. Downloaded from 628 POSTGRADUATE MEDICAL JOURNAL Decemtiber 1951 ...Q Protected by copyright. ...... FIG. i .-Mal-united Colles' fracture with inferior radio-ulnar dislocation and traumatic arthritis. The patient, a man aged 68, had sustained the fracture many years previously. The wrist was painless, the grip good and the range of mnovement almost full. http://pmj.bmj.com/ It may be accompanied by shortening of the advised for mal-union when function is adequate. radius, or by radial and dorsal displacement of the However, in the younger age groups and especially lower fragment giving prominence to the head of in women with gross dorsal tilting of the lower the ulna and broadening of the wrist. In these radial fragment, an osteotomy through the fractuie circumstances some distortion of the anatomy of site may be performed to restore normal alignment the inferior radio-ulnar joint is inevitable and even though wrist movements have not been subluxation or even dislocation of this joint may seriously restricted. on October 3, 2021 by guest. be found. In these patients the object of the operation is to delay late traumatic arthritis and to improve the Treatment appearance of the wrist. The osteotomy is per- In many patients with mal-union the functional formed through a dorsal approach at the level of result is satisfactory even when the deformity is the old fracture. It is important to fill with a bone gross (Fig. i). Conservative treatment is in- graft the dorsal defect created when alignment has dicated when the deformity is slight, the disability been restored lest displacement should recur. The only moderate and the patient elderly. At the wrist is then immobilized in plaster until union outset a course of active exercises and hot wax has taken place. baths may regain adequate movement and power. When in addition to dorsal tilting there is con- Operation is seldom indicated. As a general siderable shortening of the radius and some radial rule its aim should be directed solely to the im- displacement, surgical interference may be re- provement of function, and it is therefore rarely quired on account of pain, stiffness and an un- Postgrad Med J: first published as 10.1136/pgmj.27.314.627 on 1 December 1951. Downloaded from December 1951 S'1'EPHENSON: Some Comlplications of Col/es' Fractture 629 sightly deformity. Here much of the disability is the best operative procedure and gives good due to the derangement of the inferior radio- results (Boyd and Stone, I944) (Figs. 3a and 3b). ulnar joint, and excision of the lower IA in. of the It is performed through a dorsi-medial incision; ulna gives a satisfactory result. Following this the bone is resected extra-periosteally to avoid operation (vide infra), the prominence of the new bone formation, and it is not necessary to ulnar head is abolished, pronation and supination remove the triangular fibro-cartilage. Active are considerably improved or fully restored and exercises should be commenced a day or two after discomfort is relieved. The results following more the procedure. As a result of the operation, little complicated operations are uncertain and often or no residual weakness of the wrist ensues. disappointing. Very occasionally in cominuted fractures a 4. Joint Stiffness and Adhesions projecting fragment of bone on the anterior or The majority of patiepts legain full movements posterior aspect of the radius interferes with of the wrist a few weeks after immobilization has tendon action and causes local pain from a trau- been disconitinued. Residual stiffness may be due matic teno-synovitis (Fig. 2). Excision of the either to intra-articular adhesions following a offending fragment is seldom required as the fracture involving the radio-carpal joint, or symptoms do not as a rule persist. to extra-articular adhesions following traumatic oedema with organization of the serofibrinous 3. Laxity of the Inferior Radio-Ulnar Joint exudate into adhesions. Stiffness due to the latter It has been demonstrated by Lippman (I937) cause is seen in particular when more than one by experiments on the cadaver, that severance of attempt at reduction has been required. It should the triangular fibro-cartilage produces a very also be remembered that persistent stiffness is small degree of abnormal laxity, but when in sometimes an early symptom of traumatic arthritis. Protected by copyright. addition the dorsal radio-ulnar ligament is divided, a dislocating radio-ulnar joint results. These findings have been confirmed by the writer in the dissecting room. Lippman has come to the con- .::: ..:: .;..:. .::..:...:...... ..:..:.. ...: :. clusion that when a Colles' fracture with displace- ment is sustained, the dorsal ligament is damaged and its subsequent failure to heal is the main ~~~~~~~~~~~... cause of the residual laxity, the associated lesion ..... being either a rupture of the triangular fibro- .... ::. .:..,:.e ........... ... ... cartilage or a fracture of the styloid process of the .i ulna. Although the condition frequently occurs with mal-union, it is quite often present when the fracture has united in excellent position. Minor degrees of laxity are sometimes followed eventually ~ *~ ~.. ~ .!:...-r http://pmj.bmj.com/ by arthritis of the joint while major degrees constitute a dislocation. *.:.t .:S.::!.:.r< Clinical Features ... ::. ::..... .?, 'S'.:8}: There may be no symptoms. Pain over the ulnar side of the wrist, local tenderness, limitation ~~~~~~~~~~~.....:::; of supination and pronation, prominence of the on October 3, 2021 by guest. head of the ulna and abnormal laxity form the full clinical picture. The radiographs reveal a dis- location when present and occasionally arthritic changes. Treatment When disability exists, a moulded leather wrist strap is the best form of conservative treatment. Manipulation in an attempt to increase pronation and supination does not meet with success and is, Fie.. 2.-Mal-united Colles' fracture showingY a smIll indeed, dangerous, several instances of fracture of spur of bone on the anterior aspect of the fracture site. This projection caused persistent local dis- the shaft of the ulna having been reported (Patrick, comfort especially at work.
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