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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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
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.
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
Common distal radius fracture eponyms and their distinguishing features.
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.
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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