Colle’s Fracture

Introduction It is named after Abraham Colles  an Irish surgeon who first described it in 1814 just by looking at the classical deformity before the advent of X-rays.  Colles fracture is a fracture of the distal radius in the forearm with dorsal (posterior) displacement of the wrist and hand. The fracture is sometimes referred to as a "dinner fork" or "bayonet" deformity due to the shape of the resultant forearm.

Characteristics Of Colle’s Fracture Transverse fracture of the radius 1 inch (2.54 cm) proximal to the radio-carpal joint Dorsal displacement and angulation

Dorsal Displacement Of Fragment

Aetiolgy It usually occurs about an inch or two proximal to the radio-carpal joint with posterior and lateral displacement of the distal fragment resulting in the characteristic "dinner fork“ deformity. Colles' fracture is a common fracture in people with osteoporosis,

Incidence Colles fractures occur in all age groups, although certain patterns follow an age distribution. In the elderly, because of the weaker cortex, the fracture is more often extra-articular. Younger individuals tend to require a higher energy force to cause the fracture and tend to have more complex intra-articular fractures. In children with open epiphyses, an equivalent fracture is the "epiphyseal slip", as can be seen in other joints, such as a slipped capital femoral epiphysis in the hip. More common in women because of post-menopausal osteoporosis.

Clinical Features Swelling Echymosis: a small hemorrhagic spot in the skin or a mucous membrane forming a nonelevated, rounded, or irregular blue or purplish patch. Tenderness at Fracture Site Loss of Function

(Dinner Fork #)

X-RAY – COLLES FRACTURE

Conservative Management Management depends on the severity of the fracture. (An undisplaced fracture may be treated with a cast alone). The cast is applied with the distal fragment in palmar flexion and ulnar deviation. A fracture with mild angulation and displacement may require closed reduction. There is some evidence that immobilization with the wrist in dorsiflexion as opposed to palmarflexion results in less redisplacement and better functional status

Reduction Pop Cast

Surgical Management Significant angulation and deformity may require an open reduction and internal fixation (ORIF) or external fixation. The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures, including Colles' fracture A higher amount of instability criteria increases the likelihood of operative treatment.

Complications Carpal Tunnel Syndrome Compartment Syndrome Reflex Sympathetic Dystrophy Stiffness of Fingers and Wrist Joint Osteoarthritis

Malunited Colle’s Fracture

Smith's fracture It is called a reverse Colles' fracture is a fracture of the distal radius but less common than Colles' fractures It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension. The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.

Physical Therapy Short term goals to Long term goals to Control pain Reduce contractures Reduce inflammation Long term goals to Gain normal ROM Gain normal strength Gain normal function of hand

Phase: I (Week 1-6) Start with the fingers PROM  AAROM  AROM DIP, PIP, MCP flexion/extension Radiocarpal Flexion, extension, supination, pronation, radial deviation, and ulnar deviation

Phase: II (Week 7- 12) Continue with ROM activities Wrist stretching Joint mobilizations Start with grade I and II Grade III and IV Concave/Convex rules Start isometric strengthening of the fingers, wrist, elbow, and shoulder Theraputty Against table/wall Pain free

Theraputty

Theratubing/Therabar strengthening Theratubing- Light to heavy resistance Flexion, extension, ulnar deviation, and radial deviation Not just for the wrist Therabar Supination and pronation

Phase III (week 13- return to play) Continue to perform wrist stretches Begin more complex strengthening Free weight Wrist flexion/extension, radial/ulnar deviation, and supination/pronation Elbow flexion/extension exercises Shoulder strengthening exercises

Scaphoid Fractures

Anatomy The scaphoid lies at the radial border of the proximal carpal row, but its elongated shape and position allow bridging between the 2 carpal rows because it acts as a stabilizing rod. The scaphoid (boat-shaped) bone has an outer convex part that articulates with the lunate and distal articular surface of the radius. Other bones that are closely related to the scaphoid are the capitate, trapezium and trapezoid. The scaphoid has 5 articulating surfaces: with the radius, lunate, capitate, trapezoid, and trapezium. Has economic as well as physical significance due to the importance of scaphoid in wrist mechanics and because of the frequency of the fracture in young adult male. Uncommon in children because the physis of distal radius fails first.

These carpal bones articulate with each other and are held together by strong ligaments. An injury resulting in disruption of these ligaments (or bones) can cause carpal instability Nearly, the entire surface is covered by hyaline cartilage. Scaphoid fractures constitute 60-70 % of all carpal bone fractures.

Blood supply The proximal half of the scaphoid receives its blood supply from a branch of the radial artery that is given off at the level of ‘dorsal ridge’, which lies distal to the waist of scaphoid. Fractures across scaphoid may destroy blood supply to its proximal part. Failure of revascularization following a fracture may lead to ‘avascular necrosis’ of the proximal half of scaphoid.

Mechanism of injury Two different mechanisms Compression injury: usually results in non displaced # Hyperextension bending injury (a fall on the outstretched hands): Usually results in displaced # Compression injury results from a more longitudinal load or impaction of the wrist leads to intraction of the scaphoid without displacement Hyperextension bending injury :tensile stresses generated palmarly when excessive hyperextension is applied to the wrist and when the excessive tensile forces exceed bone strength produce a fx thru the scaphoid that commonly results in fx displacement

Mechanism of injury Hyperextension of the wrist during the fall causes a tensile stress on the volar ligaments and a compressive force on the dorsal structures. The scaphoid usually fails when the wrist is in radial deviation while it hyperextends. With continued motion of the wrist ulnarwards, the intercarpal ligaments may fail giving rise to significant instability in the wrist.

Diagnosis A strong index of suspicion is the key to early diagnosis The diagnosis should be based on : - History (Occurs after a fall on an outstretched hand, athletic injury, or MVA . Usually happens in young adult men. Pain at the radial side of the wrist, Associated injuries) - Clinical examination - Radiographic evaluation

Clinical Examination The patient usually presents with pain in the wrist. Tenderness in the anatomical snuff box (scaphoid). Movements of the wrist and thumb are often painful, especially in the presence of an associated injury to the intercarpal ligaments. ‘Watson’s Test’ is often used to detect scapholunate instability. As the wrist is moved towards the radial side from its starting position of ulnar deviation, the patient often experiences significant pain due to an abnormal dorsal displacement of the scaphoid. limitation of wrist motion – but not dramatically

Clinical Examination Scaphoid flexes with wrist flexion & extends with wrist extension It also flexes during radial deviation & extends during ulnar deviation These factors make immobilization of scaphoid fractures difficult especially when there is displacement. limitation of wrist motion – but not dramatically

Radiographic Evaluation The 4 essential views (AP, lateral and oblique projections in ulnar and radial deviation) are necessary to identify majority of fractures. Special radiographs called ‘scaphoid views’ are necessary (AP radiograph with the wrist extended 30° and deviated ulnarly 20°. This view helps to stretch out the scaphoid and is also used for assessing the degree of scaphoid fracture angulation). A clenched-fist radiograph has also been useful for visualization of the scaphoid waist.

Radiographic Evaluation If the initial X-rays fail to reveal a fracture, they should be repeated within two weeks If symptoms persist and there are no radiological findings, a bone scan may be considered.

An undispalced # of the waist of the scaphoid

Classifications of scaphoid # A- Classification according anatomical level (Weissman & Sledge) Type I: neck Type II: waist (65% fractures) Type III: body Type IV: proximal pole

Type I: Horizontal oblique fracture line Distal third Middle third B- Classification according to Direction of the fracture (Russe Classification) Russe classified scaphoid fractures into 3 type according to the relationship of the fracture line to the long axis of the scaphoid Horizontal Type I: Horizontal oblique fracture line Distal third Middle third Proximal third Type II: Transverse fracture line Type III: Vertical oblique fracture line (unstable)

C- Classification according to Time since injury Acute fracture - less than 3 weeks old Delayed union - 4 to 6 months old Nonunion - more than 6 months old Undisplaced ---- stable Displaced ---- unstable D- Classification according Amount of fracture displacement (stability ) Time since injury : these are - of course – arbitrary definitions and no one can say with certainty when a delayed union begins or ends Nonunion - more than 6 months old ---- however many clinicians diagnose these fractures as nonunions regardless of the time period if bone resorption ,cyst formation , or sclerosis is present.

Treatment It must be remembered that failure to identify and treat scaphoid fractures early may result in permanent impairment of wrist function. Cast immobilization is recommended in patients with clinical suspicion of a scaphoid fracture, even if the radiological signs of a fracture are absent. “Treat the symptoms and signs not the X-ray!”

Treatment Undisplaced fractures are generally treated in a ‘scaphoid cast’ (slight dorsiflexion of the wrist with immobilization of the thumb interphalangeal joint).

Treatment Displaced fractures are generally best treated by internal fixation with a single screw (Herbert’s, Acutrek, etc.). Percutaneous fixation is usually successful. However, significant fracture displacement or angulation may warrant an open reduction and internal fixation (k-wire, screw).

Complications Delayed union is incomplete union after 4 months of cast immobilization Non-union and avascular necrosis The fracture may fail to unite even after appropriate treatment. This usually occurs due to disruption of the intraosseous blood vessels. Fractures close to the proximal pole are particularly at risk. The proximal pole may show signs of ischaemia (increased radiopacity) on X-rays. ORIF should be supplemented with bone grafting (Russe, vascularized bone graft, etc.), if non-union occurs.

Complications Recurrent carpal instability and scapholunate advanced collapse (SLAC) Disruption of the radioscapholunate and intercarpal ligaments, if left untreated, may result in chronic ‘scapholunate dissociation’. Degenerative osteoarthritis gradually develops affecting the radial styloid process initially, followed by the involvement of the articulating surfaces of capitate and lunate. The wrist function is significantly impaired due to severe mechanical derangement of the carpal bones.