Colles Fracture (Distal Radius)
Extra-articular distal radius fracture with dorsal angulation, typically from a fall on an outstretched hand.
Also known as: Colles fracture, distal radius fracture, DRF, broken wrist
Overview
Extra-articular fracture of the distal radius within 2-3 cm of the articular surface, with characteristic dorsal angulation, dorsal displacement, and radial shortening. Often accompanied by an ulnar styloid fracture. Named for Abraham Colles, who described the injury before the advent of radiography.
Epidemiology
Most common fracture of the upper extremity in adults. Bimodal distribution — high-energy injuries in young adults and low-energy fragility fractures in postmenopausal women. A distal radius fracture in a woman over 50 years is a sentinel osteoporotic fracture.
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Risk factors
- Postmenopausal women with osteoporosis or osteopenia
- Fall on outstretched hand (FOOSH) with wrist extended
- High-energy trauma in younger patients
- Prior fragility fracture, low body weight, chronic steroid use
Pathophysiology
Axial load through a dorsiflexed wrist concentrates force at the metaphyseal-diaphyseal junction of the distal radius. Cortical bone fails in tension volarly and compresses dorsally, producing the characteristic apex-volar (dorsally angulated) fracture pattern.
Clinical presentation
Symptoms
- Acute wrist pain after a fall
- Visible deformity
- Inability to use the wrist or hand
- Numbness or tingling in median nerve distribution if neurapraxia
Signs / physical exam
- Dinner-fork deformity on lateral view (dorsally displaced distal fragment)
- Swelling, ecchymosis, and tenderness over the distal radius
- Loss of normal volar tilt of the distal radius
- Assess median nerve (thumb opposition, sensation over volar thumb and index finger) and check for compartment syndrome
Classic findings
Dinner-fork deformity in an older woman after a fall on the outstretched hand.
Differential diagnosis
- Smith fracture (reverse Colles) — Volar angulation and displacement from fall on flexed wrist or direct dorsal blow; 'garden spade' deformity
- Barton fracture — Intra-articular distal radius fracture with carpal subluxation (volar or dorsal)
- Chauffeur fracture — Radial styloid fracture; often with scapholunate ligament injury
- Scaphoid fracture — Snuffbox tenderness; may coexist with distal radius fracture
- Distal radial epiphyseal injury (Salter-Harris) — Pediatric patients; growth plate involvement on radiographs
- Wrist contusion / sprain — Diagnosis of exclusion after radiographs
Diagnostic workup
Diagnostic criteria
Acceptable radiographic alignment in adults: radial shortening <3 mm, dorsal tilt <10 degrees, intra-articular step-off <2 mm, radial inclination within 5 degrees of contralateral side. Failure to meet these parameters after reduction is an indication for operative fixation.
Labs
- None required for the fracture itself
Imaging
- PA and lateral wrist radiographs are diagnostic
- Assess radial height (normal 10-13 mm), radial inclination (normal 21-25 degrees), and volar tilt (normal 10-12 degrees)
- CT for intra-articular involvement, comminution, and operative planning
- DEXA scan in patients over 50 with a fragility fracture — initial DRF often triggers osteoporosis workup
Diagnostic algorithm
| Fracture | Mechanism | Deformity | Stability |
|---|---|---|---|
| Colles | FOOSH with wrist extended | Dorsal angulation / dinner fork | Often treatable closed |
| Smith (reverse Colles) | Fall on flexed wrist or dorsal blow | Volar angulation / garden spade | Unstable — usually operative |
| Barton | Shear force across articular surface | Carpal subluxation with rim fragment | Unstable — operative |
| Chauffeur | Direct radial blow (historic crank-start injury) | Radial styloid fragment | Often operative if displaced |
Treatment
First-line
- Closed reduction under hematoma block, conscious sedation, or Bier block
- Sugar-tong splint initially, transitioning to a short-arm cast at 1-2 weeks
- Total immobilization 4-6 weeks with serial radiographs at weeks 1, 2, and 6 to monitor for loss of reduction
- Calcium, vitamin D, and osteoporosis workup in adults over 50
Second-line / adjunct
- Operative fixation indicated for: failure to achieve or maintain acceptable alignment, intra-articular displacement >2 mm, open fracture, neurovascular compromise, or bilateral injuries
- Volar locking plate fixation is the most common surgical option
- External fixation, percutaneous pinning, or intramedullary nail in select cases
- Hand therapy for stiffness after immobilization or surgery
Complications
- Malunion with persistent deformity and reduced grip strength
- Median nerve injury — acute carpal tunnel syndrome may require urgent release
- Extensor pollicis longus tendon rupture (classically 6-8 weeks post-injury from mechanical or ischemic insult at Lister tubercle)
- Post-traumatic osteoarthritis of the radiocarpal joint
- Complex regional pain syndrome
- Compartment syndrome
PANCE pearls
- A distal radius fracture in a woman over 50 is an osteoporotic fragility fracture — order DEXA and initiate treatment.
- Acute carpal tunnel syndrome after distal radius fracture requires urgent decompression.
- Delayed extensor pollicis longus rupture presents 6-8 weeks after a nondisplaced or minimally displaced fracture — patient suddenly cannot extend the thumb interphalangeal joint.
- Smith and Barton fractures are unstable and almost always require operative fixation.
References
- AAOS 2020 — American Academy of Orthopaedic Surgeons clinical practice guideline on the management of distal radius fractures
- NOF — Bone Health and Osteoporosis Foundation (formerly NOF) Clinician's Guide to Prevention and Treatment of Osteoporosis
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