Keywords
Colle's fracture - conservative treatment/methods - aged
Introduction
Anatomically upper limb and that to hand and wrist is meant for precision. The singular
anatomy of volar tilt, radial inclination, and radial height of the distal end of
the radius gives the wrist the amazing freedom of movement necessary for precision
work that sets the humans apart from the rest of the world. The disadvantage of the
upright posture and of the high degree of movements is that the upper extremity is
more prone to injury than the lower limbs.[1] Fractures involving the distal end of the radius are the most common and account
for ∼ 17.5% of all fractures.[1]
[2] It has bimodal age distribution with one peak at 6 to 10 years and another peak
at 60 to 70 years.[2] Elderly women are seven times more prone to this type of injury, which may be due
to postmenopausal osteoporosis.[3] The mode of injury is mostly due to simple fall with outstretched hands.[4] The fracture pattern is typically distal metaphyseal, involving one inch from the
distal end of radius with its classical dorsal comminution, dorsal angulation, dorsal
displacement, radial displacement; this type of lesion is named Colles fracture, after
Sir Abraham Colles, who first described it in 1814.[4] Until today, conservative management with a cast below the elbow with wrist in a
neutral to mild flexion position and ulnar deviation is accepted as standard treatment
for elderly patients with low physical demands.[5] The healing process is usually accompanied by deformity, which may be skillfully
treated in up to 60% of cases.[6]
[7]
There is a discussion of whether this deformity impairs the functional outcome in
aged patients or not. There are numerous publications regarding this but giving confusing
messages. Most of them state Colles fracture does require special attention as the
resulting deformity rarely damages the wrist function.[5]
[8] Some say even small changes in the anatomical parameters of the distal end of the
radius can lead to poor functional outcome in up to 17% of cases.[9] Others say the functional outcome following Colles fracture is multifactorial and
not necessarily anatomical reductions as deciding entity.[10]
Hence, this study was conducted to assess the anatomical and functional results of
Colles fracture treated conservatively in elderly people and to evaluate the correlation
between individual anatomical parameters and functional results to determine borderline
values of each of them corresponding with a better functional outcome.
Material and Methods
After obtaining ethical committee approval and patients consent, the data were collected
and analyzed prospectively for 70 patients with Colles fractures, who attended the
Out Patient Department (OPD) and emergency care unit between May 2016 and May 2020.
Patients between 60 and 80 years of age, with unilateral, extraarticular distal radius
closed fractures were included in the present study; individuals with bilateral distal
radius fracture, intraarticular fracture, and open fracture were excluded.
Posteroanterior (PA) and lateral views X-rays of both wrist (as case and control)
were taken. The fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification (AO/OTA-2R3A2.2). A hematoma
block (with 1 ml of 2% lignocaine) was given, followed by close manipulation, and
cast under image intensifier.[11] After achieving acceptable anatomical reduction, the forearm was immobilized with
a below-the-elbow cast for 4 weeks. Following cast removal, the patient underwent
supervised physiotherapy to prevent stiffness and was then followed-up at 3 and 6
months and yearly for anatomical and functional evaluation. The anatomical parameters
were measured radiologically by determining the radial inclination, dorsal angulation
or palmar tilt and radial bone length.[12] ([Fig. 1]) The MicroDicom software was used to calculate angles and lengths from the X-rays
([Fig. 2]).
Fig. 1 Diagrammatic way of measurement of different anatomical parameters (A) Radial inclination measurement; (B) Palmar tilt measurement; (C) Radial length measurement.
Fig. 2 Measurements taken using the MicroDicom software. (A) Radial inclination; (B) Dorsal angulation; (C) Radial height.
The anatomical results were assessed as per criteria established by Stewart et al.[13] According to Stewart et al.,[13] acceptable dorsal angulation was 10 degrees, acceptable loss of radial inclination
was 9 degrees, and acceptable loss of radial bone length was 6 mm ([Table 1]). The functional outcome was assessed with the Mayo wrist score measured at 6 months
at the latest follow-up[14] ([Table 1]). A goniometer was used to measure the flexibility of the wrist joint of the healthy
and the injured hand. A dynamometer was used to measure the grip strength.
Table 1
|
Scoring system
|
Dorsal angle (degree)
|
Loss of radial length (mm)
|
Loss of radial angle (degree)
|
Score
|
Rating
|
|
1.1
Anatomical assessment of treatment results of radial bone fracture in a typical zone
(Stewart et al.)
|
Neutral
|
0–3
|
0–4
|
0
|
[Rating: combined score dorsal angle, radial length, and radial angle; Excellent = 0;
Good = 1–3; Fair = 4–6; Poor = 7–12)
|
|
1–10
|
4–6
|
5–9
|
1
|
|
11–14
|
7–11
|
10–14
|
2
|
|
> 15
|
> 12
|
> 15
|
4
|
|
1.2
Functional score by the Mayo wrist score
|
Category
|
Score
|
Finding
|
Points
|
|
Pain (25 points)
|
25
20
20
15
10
5
0
|
No pain
Mild pain with vigorous activities
Pain only with weather changes
Moderate pain with vigorous activity
Mild pain with activities of daily living
Moderate pain with activities of daily living
Pain at rest
|
[*Total points 90–100 = Excellent; 80–89 = Good; 65–79 = Fair; < 65 = poor]
|
|
Satisfaction (25 points)
|
25
20
10
0
|
Very satisfied
Moderately satisfied
Not satisfied, but working
Not satisfied, unable to work
|
|
Range of motion (25 points)
|
25
20
10
5
0
|
100% of normal
75–99%of normal
50–74% of normal
25–49% of normal
0–24% of normal
|
|
Grip strength
(25 points)
|
25
15
10
5
0
|
100% of normal
75–99% of normal
50–74% of normal
25–49% of normal
0–24% of normal
|
The demographic data were measured with mean, range, and proportions. For com- paring
anatomical and functional outcomes, we used the chi-squared test of association using
2 × 2 tables in which the fields with excellent and good results and the fields with
fair and poor results were combined. A p-value < 0.001 was considered statistically significant. To examine strengths of associations,
we computed odds ratios (ORs) with 95% confidence intervals (CIs) for the functional
result in relation to the anatomic result.
Results
Of the 70 patients, 42 were female and 28 were male. The mean age was 66.3 ± 3.2 years
(range, 60–80 years). In 42 patients, the fracture occurred in the dominant hand,
and in 28 patients in the non-dominant hand. The anatomical parameters of the normal
(control) hand are mentioned below ([Table 2]).
Table 2
|
Patients (n)
|
70
|
|
Mean age (years)
|
66.3 ± 3.2 (60–80 years.)
|
|
Female patients
|
42 (60%)
|
|
Male patients
|
28 (40%)
|
|
Female: Male
|
3:2
|
|
Affected side:
• Unilateral, dominant hand
• Unilateral, non-dominant hand
|
42
28
|
|
Radiological parameter of control hand:
• Radial inclination
• Palmar angulation
• Radial length
|
20–30° (25.6 ± 2.8 degree)
0–15° (7.9 ± 4.2 degree)
8–18 mm (13.4 ± 1.7 mm)
|
The functional result was excellent in 43, good in 12, fair in 8, and poor in 7 patients.
The anatomical result was excellent in 41, good in 7, fair in 10, and poor in 12 patients
at 6 months, which was depicted in a 2 × 2 table that showed a statistically significant
association (p < 0.001 [0.0009]) between the anatomical and functional results. ([Table 3] and [Figure 3])
Table 3
|
Sl.no
|
Parameters for comparison
|
2 × 2 tables
|
Results
|
Statistical significance
|
|
3.1
|
Anatomical outcome with functional outcome
|
Anatomical result
|
Functional result (no. of patients)
|
Chi-square = 10.99, DF = 1, p < 0.001 (0.0009). Odds ratio = 7.17(95% CI 2.01–25.01)
|
Significant
|
|
Excellent/Good
|
Fair/Poor
|
|
Excellent/Good
|
43
|
5
|
|
Fair/Poor
|
12
|
10
|
|
3.2
|
(< 10°) loss of dorsal angulation with functional outcome
|
Dorsal angulation
|
Functional result (no. of patients)
|
Chi-squared = 11.75, DF = 1, p < 0.001(0.0006) Odds ratio = 7.67(95% CI: 2.18–26.92)
|
Significant
|
|
Excellent/Good
|
Fair/Poor
|
|
< 10°
|
46
|
6
|
|
> 10°
|
9
|
9
|
|
3.3
|
(< 9°) loss of radial inclination with functional outcome
|
Loss of radial angle
|
Functional results (nr. of patients)
|
Chi-squared = 11.77, DF = 1, p < 0.001(0.0006). Odds ratio = 7.67 (95% CI, 2.18–26.92)
|
Significant
|
|
Excellent/Good
|
Fair/Poor
|
|
< 9 °
|
41
|
4
|
|
> 9 °
|
14
|
11
|
|
3.4
|
(< 6 mm.) loss of radial height with functional outcome
|
Loss of radial height
|
Functional result (nr. of patients)
|
Chi-squared = 6.62, DF = 1, P > 0.001(0.01). Odds ratio = 4.57 (95% CI, 1.33–15.33)
|
Not significant
|
|
Excellent/Good
|
Fair/Poor
|
|
< 6 mm
|
44
|
7
|
|
> 6 mm
|
11
|
8
|
|
3.5
|
(< 4 mm.) loss of radial height with functional outcome
|
Loss of radial height
|
Functional result(no of patients)
|
Chi-squared = 11.70, DF = 1, p < 0.001 (0.00062) odds ratio = 8.94 (95%CI: 2.23–35.84)
|
Significant
|
|
Excellent/Good
|
Fair/Poor
|
|
< 4mm
|
38
|
3
|
|
> 4mm
|
17
|
12
|
Fig. 3 Follow-up of Colles fracture of right wrist. (A) Clinical picture; (B) Radial inclination; (C) Dorsal tilt; (D) Radial height.
Comparing the individual anatomical parameters with functional results, there was
a statistically significant association (p < 0.001) between the dorsal angulation and the functional results (chi-squared = 11.75,
degree of freedom [DF] =1, p = 0.0006, odds ratio [OR] =7.67, 95% CI, 2.18–26.92) with 10° or less of dorsal angulation
as a borderline value ([Table 3]).
A statistically significant association (p < 0.001) was found between the loss of radial inclination and functional results
(chi-squared = 11.77, DF = 1, p = 0.0006, OR = 7.67, 95% CI, 2.18–26.92), with 9° or less of loss of radial inclination
as a borderline value ([Table 3]).
A non-statistically significant association (p > 0.001[0.01]) was found between the loss of radial height and functional results
(chi-squared = 6.62, DF = 1, p = 0.01, OR = 4.57, 95% CI, 1.33–15.33), with 6 mm or less loss of radial height as
a borderline value ([Table 3]).
For estimating the borderline value for loss of radial height, a statistically significant
association was found with the functional result (chi squared = 11.70, DF = 1, p = 0.00062, OR = 8.94, 95% CI, 2.23–35.84), with 4 mm or less of loss of radial height
from the mean as a borderline value ([Table 3]).
Discussion
The incidence of the Colles fracture was highest among the elderly in the 60 to 69
years age group (range 60–80). It was 3 times more common in women (42 [60%]) than
men (28 [40%]). These findings were similar to those of Chung et al.,[15] in which 86.7% were women with a mean age of 70.9 ± 8.9 years.
The normal morphometry of the distal radius measured from the normal wrist were: radial
inclination mean of 25.6 ± 2.8° (20–30°), palmar tilt of 7.9 ± 4.2° (0–15°), and radial
bone length of 13.4 ± 1.7 mm (8–18 mm). The morphometric data may vary as per geographical
locations and races ([Table 4]).[11]
[16]
[17]
[18]
Table 4
|
Source
|
Radial inclination
|
Palmar inclination
|
Radial bone length
|
Ulnar variance
|
|
Campbell 13 th ed. 2017 (p.2993)[16]
|
20°
|
11°
|
12 mm
|
± 2 mm
|
|
Green operative hand surgery 7th ed. (2017)[11]
|
23°
|
11°
|
|
–1 mm
|
|
Mishra et al. (2016)[17]
|
23.27 ± 7.42° (11.3–42.1°)
|
10.7 ± 5.28° (1–16.9°)
|
11.31 ± 4.9 mm (7.1–30.4 mm)
|
0.66 ± 2.46 mm (-2.4 + 4.1 mm)
|
|
Dario et al. (2014)[18]
|
21–25°
|
7–15°
|
10–13 mm
|
0.7- 4.1 mm
|
|
Present study
|
25.6 ± 2.8°(20–30°)
|
7.9 ± 4.2°(0–15°)
|
13.4 ± 1.7 mm (8–18 mm)
|
|
Comparing functional and anatomical results, the functional result was excellent or
good in 55 (78.5%) and satisfactory or poor in 15 (21.5%) cases, whereas the anatomical
results were excellent or good in 48 (68.5%) and satisfactory or poor in 22 (31.5%)
elderly patients with Colles fracture treated non-operatively ([Table 5]). The statistical analysis showed a significant correlation between them, with p = 0.0009, chi-squared = 10.99, OR =7.17. This differs from the results obtained by
Gartland and Werley, who obtained surprisingly good functional results despite poor
repositioning and inadequate immobilization.[6] Our results also differ from those reported by Finsen et al.[10] and Chung et al.,[15] who reported that precise restoration of the wrist anatomy is not associated with
better functional outcome.[10]
[15] Arrora et al.[19] found that anatomic reconstruction did not convey any improvement in the range of
motion or better ability in the daily activities of the elderly. Anzarut et al.[20] and Young & Rayan[21] also agreed that radiographic reduction was not associated with better functional
outcome and obtained good function in cases in which the anatomical results were poor.
However, few other authors reported a significant correlation between the anatomical
and functional results, which agrees with this study, such as Kong et al.,[22] who determined that satisfactory reduction is the first choice, as malalignment
leads to decreased grip strengths, unsatisfactory appearance, and certain limitation
of wrist movements. Slogaard et al.[23] found that the function was influenced by radiographic results; thus, it would make
sense to improve the function by better reduction technique of the fracture and prevention
of secondary displacements. Jenkins et al.[24] found that final recovery of the grip strength was related to the inclination of
the articulate surface of the healed radius both coronal and sagittal planes, and
loss of radial length appears to become an important determinant of long-term pain.
Table 5
|
Author
|
Study
|
Results
|
Conclusion
|
|
Chung et al. (2020)[15]
|
Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults:
A Secondary Analysis of a Randomized Clinical Trial
|
Data of 166 patients analyzed with 2-phase multivariable regression models only 2
of the 84 correlation coefficients calculated were statistically significant; grip
strength with radial inclination and MHQ ADL score with ulnar variance.
|
They conclude that precise restoration of the wrist anatomy is not associated with
better functional outcome.
|
|
Kong et al. (2019)[22]
|
The Necessity of Restoration of Radiologic Parameters by Closed Reduction in Elderly
Patients with Distal Radius Fractures
|
0ut of 96 patients 75 (78.1%) got acceptable reduction and 21 (21.9%) got poor reduction.
A significant correlation was found between ulnar positive variance with grip strength
(r = 0.35, p = 0.03) and dorsal angulation with wrist flexion (r = 0.31, p = 0.02)
|
They concluded that satisfactory reduction is the first choice as malalignment leads
to decreased grip strengths, unsatisfactory appearance and certain limitation of wrist
movements.
|
|
Finsen et al. (2013)[10]
|
The relationship between displacement and clinical outcome after distal radius (Colles)
fracture
|
Reviewed 260 patients. Though there exist a statistically significant association
between functional and anatomical results by Bivariate analysis however multiple regression
showed dorsal angulation, ulnar variance and radial inclination accounts only 11%
of variability.
|
They concluded that final radiological alignment of distal radius fracture has minor
influence on clinical outcome of Colles fracture.
|
|
Arrora et al. (2011)[19]
|
A prospective randomized trial comparing nonoperative treatment with volar locking
plate fixation for displaced and unstable distal radial fractures in patients sixty-five
years of age and older
|
Prospectively analyzed 73 patients the range of motion, the level of pain, and the
Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder and Hand
(DASH) scores were not different between the operative and nonoperative treatment
groups
|
Thus achieving anatomic reconstruction did not convey any improvement in range of
motion or better ability of daily leaving activities in elderly.
|
|
Anzarut et al. (2004)[20]
|
Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively
treated distal radius fractures
|
Out of 74 patients 47 (69%) had acceptable radiographic outcome and 44 (59%) had satisfied
functional result at 6 months.
|
Concluded that acceptable radiographic reduction was not associated with better functional
outcome.
|
|
Young and Rayan et al. (2000)[21]
|
Outcome following nonoperative treatment of displaced distal radius fractures in low-demand
patients older than 60 years
|
Got 88% excellent or good functional results and 68% excellent or good anatomical
results
|
Radiographic outcome did not correlate with the functional outcome.
|
|
Slogaard et al. (1988)[23]
|
Function after distal radius fracture
|
Functional results were excellent or good with dorsal angulation below 10° and loss
of radial height < 7 mm.
|
Function was influenced by radiographic results. It is rational to improve the function
results by better reduction technique of the fracture and prevention of secondary
displacements.
|
|
Jenkins et al. (1988)[24]
|
Mal-union and dysfunction-in Colles fracture
|
Results of 61patients. The anatomical parameters at union were: mean dorsal angulation
of 9° (SD 12.1), mean loss of radial inclination 7.8° (SD 7.2°) and mean radial shortening
of 4 mm (SD 3.9 mm). Loss of grip strength and loss of flexion were taken as the functional
parameter. A multilinear regression analysis showed statistically significant correlation
between grip strength and loss of radial inclination and dorsal angulation and same
with loss of flexion but did not reach level of significance.
|
Final recovery of the grip strength was related to the inclination of the articulate
surface of healed radius both coronal and sagittal plane. Loss of radial length appears
to become important determinant of long-term pain.
|
|
Garland and Werely (1951)[6]
|
Evaluation of healed Colles fractures
|
Good functional results (68.3%) achieved despite of poor radiological appearances.
|
The residual dorsal tilt more strongly associated with poor outcome than the loss
of radial inclination or radial height or ulnar variance. However Cases showing more
accurate reduction have best outcome.
|
|
Present study
|
Determining the borderline values of anatomical parameters for better functional outcome
of Colles fracture. A prospective study
|
Of 70 patients excellent to good functional results was seen in 55 (78.55) and anatomically
in 48 (68.5%) with a statistically significant correlation between them p < 0.001(0.0009)
|
Concludes anatomical reduction and maintaining the reduction is priority for better
functional outcome.
|
By studying the association of individual anatomical parameters with the functional
results, the present study showed a significant association of dorsal angulation < 10°
and loss of radial inclination of < 9° with functional results, (p = 0.0006, chi-squared = 11.75, OR = 7.67) but not with loss of radial height < 6 mm,
(p = 0.01). Instead, when loss of radial length was kept to < 4 mm, statistical significance
was achieved (p = 0.00062, chi- squared = 11.70, OR = 8.94). ([Table 6]) Stewart et al.,[13] in his work on functional cast bracing for Colles fracture, found that fractures
with dorsal angulation < 10 degrees, loss of radial inclination of < 9 degrees and
loss of radial height < 6 mm had better functional outcome, irrespective of the methods
of immobilization of casting or bracing. Altimissi et al.[25] reported unsatisfactory results with dorsal angulation > 15 degrees, loss of radial
inclination of < 5 degrees and ulnar variance > 5 mm. Slogaard et al.[23] found that functional results were excellent or good with dorsal angulation < 10°
and loss of radial height < 7 mm. Salmon and Patrick et al.[26] defined malunion in distal radius fracture with dorsal angulation > 10 degrees,
loss of radial inclination of < 17 degrees and loss of radial height > 3 mm and ulnar
variance > 1 mm. Fuji et al.[27] reported radial shortening of more than 6 mm may result in poor functional outcome.
Smilovic et al.[28] defined borderline values as dorsal angulation ≤ 9 degrees, loss of radial inclination
of ≤ 3 degrees, and loss of radial height ≤ 2 mm for achieving good function.
Table 6
|
Author
|
Study
|
Dorsal angulation
|
Loss of radial inclination
|
Loss of radial height
|
Ulnar variance
|
Remarks
|
|
Stewart et al. (1984)[13]
|
Functional cast-bracing for Colles fractures: a comparison between cast-bracing and
conventional plaster casts
|
< 10°
|
< 9°
|
< 6 mm
|
|
The anatomic results were not influenced by methods of immobilization but was related
to efficacy of reduction.
|
|
Altimissi et al. (1986)[25]
|
Long term results of conservative treatment of fractures of the distal radius
|
> 15°
|
< 5°
|
|
> 5 mm (radio ulnar index)
|
No statistically significant relation between the final results and type of fracture.
However unsatisfactory results reported with extreme values three radiographic parameters
as mentioned.
|
|
Slogaraad et al. (1988)[23]
|
Function after distal radius fracture
|
< 10°
|
|
< 7 mm
|
|
Functional results were excellent or good with dorsal angulation below 10° and loss
of radial height < 7 mm.
|
|
Salmon & Patrick et al. (1999)[26]
|
Prevention of malunion of distal radius fracture
|
> 10°
|
≤ 17°
|
> 3 mm
|
> 1 mm
|
They have taken these radiographic measurements to define malunion in distal radius
fracture.
|
|
Fuji k et al. (2002)[27]
|
Fractures of the distal end of radius in elderly patients: a comparative study of
anatomical and functional results
|
3°
|
|
4 mm
|
|
Minor deformities as mentioned did not affect functional outcome. However radial shortening
of more than 6 mm may result in poor functional outcome.
|
|
Smilovic et al. (2003)[28]
|
Conservative treatment of extra-articular Colles type fractures of the distal radius:
prospective study
|
≤ 9°
|
≤ 3°
|
≤ 2 mm
|
|
There was significant association between anatomical and functional results. And borderline
values for better functions were as mentioned.
|
|
Campbell 13th ed. 2017 (p.2993)[16]
|
Acceptable reduction of distal radius fracture
|
Neutral (0°)
|
No less than 10°
|
|
No more than 2mm of shortening relative to ulnar head
|
|
|
Present study
|
Determining the borderline anatomical parameters for better functional outcome of
Colles' fracture. A prospective study
|
< 10°
|
< 9°
|
< 4 mm
|
|
Recommends anatomic reduction of the fracture with in the borderline limits of the
individual parameters as mentioned for achieving excellent to good functional results.
|
The limitation of this study is its small sample size (n = 70). It followed a bivariate analysis using the chi-Square test and OR for data
analysis, as distal radius fracture is influenced by multiple variables apart from
fracture reduction, so a multivariable regression model of analysis would have been
a better choice for statistical analysis. Anatomic reduction may not always be the
only parameter for better function, as indicated by Cooney et al.,[29] who pointed out that soft-tissue injury was equally responsible for the resulting
stiffness. This was not considered in the present study, which may have been a limitation.
The strength of the present study is that only a few other studies, such as the one
by Smilovic et al.,[28] have been conducted for measuring the borderline values of anatomical parameters
needed for good function. Therefore, we believe that further research with larger
sample sizes and higher statistical analytic models would confirm the values found
in this study.
Conclusion
Until today, the non-operative management of Colles fracture, especially in elderly
patients, has remained as an acceptable modality of treatment; however, good function
can be achieved with better anatomical reduction. The present study recommends acceptable
borderline values of anatomical parameters as dorsal angulation < 10°, loss of radial
inclination < 9°, and loss of radial height < 4 mm to achieve excellent or good functional
results.
