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Fractures of the distal radius have been referred to as Colles fractures since they were first described by Irish surgeon Abraham Colles in 1814. Wrist fractures are the single most common fracture in the under-65 population, occurring at a rate of approximately 270,000 per year in the United States, and most often involving the radius.

“Over the last decade, hand experts have learned that patients who heal with the radius in a poor position often develop functional problems and osteoarthritis,” observes Edward Hayes, MD, an orthopedic hand surgeon at Marshfield Clinic (Eau Claire Center) and Sacred Heart Hospital in Eau Claire, Wis. “This has prompted an evolution toward more aggressive surgical treatment, but new plating systems allow for excellent early stability and facilitate early rehabilitation of Colles fractures.” Colles fractures most often occur as “FOOSH” injuries, in which the radius is broken in a forward fall on the outstretched hand. The incidence of these fractures is higher in people older than 60 or with osteoporosis, and increases during winter months from slip-and-fall incidents on icy surfaces.

Diagnosis

“These types of fractures are seldom clean breaks,” observes Michael Hausman, MD, chief of hand and elbow surgery at Mount Sinai Medical Center in New York. “Since they’re caused by falling on the hand, there is a crushing component, so that the radius is impacted and shortened, leaving the ulna disproportionately longer.”

Hayes points out that when a distal radius fracture heals in poor alignment, the wrist joint mechanics are altered and can predispose the patient to osteoarthritis. “The load across the wrist is shared between the radius and the ulna, with the radius absorbing about 80% of the load and the ulna 20%,” Hausman explains. “If the radius is shortened by even two millimeters, the ulna has to bear as much as 50%, causing pain, premature wear and tear and, eventually, osteoarthritis.”

Ulna-shortening osteotomy is not indicated for all radius fractures, but it may be the best solution to salvage a severely shortened radius malunion that is causing ulnocarpal abutment, particularly for those who are young, active, and have good bone quality. “Simply performing a USO is like taking two wrongs to make a right,” Hayes cautions. “Assuming the radial injury has healed in a significantly shortened position relative to the ulna but with minimal dorsal tilting, then shortening the ulna surgically is a viable solution for realigning the joint.”

Making the Cut

“The surgical decision depends on the patient, the symptoms, and the anticipated level of function,” Hausman says. “Many are inclined to accept more displacement in an older person who does not use his or her hand vigorously, but particularly in a younger person, I wouldn’t accept more than a few millimeters of displacement.”

The operation is done on an outpatient basis and through an 8 cm to 10 cm incision on the forearm. Based on the measured preoperative prominence of the distal ulna, a thin slice of the ulna shaft is removed and the remaining pieces are brought together with a plate and screws. Although plating is standard procedure for an ulna shortening osteotomy, the “wafer” or Feldon procedure, which involves trimming a sliver from the distal end of the ulna does not require plates and may be an option in cases where the length discrepancy is only slight.

“Advocates of this procedure assert that healing is more rapid since it is not necessary to create a cut in the bone, which is a new fracture. However, the Feldon procedure involves removing healthy bone and cartilage, which some consider destructive,” Hausman says. “Data only suggests that the outcomes are equivalent or better, but they’re not so definitive that I would recommend this procedure.”

Return to Function

By all accounts, postsurgical care is critical to the optimal healing and function of the wrist. “Patients should be followed closely after surgery to ensure that they move their fingers well,” Hausman says. “If the fingers are allowed to stiffen for even a few weeks, they may never move again.”

For this reason, early occupational therapy is invaluable. At Seattle Hand Clinic, patients are fitted with a custom splint and immediately engaged in moving their fingers from the first day. “We initiate AROM for the digits, wrist, forearm, and, if necessary, elbow and shoulder; provide a home exercise program that includes scar mobilization and edema management; and, depending on the type of surgical stabilization, may start gentle PROM,” says Debbie Howard, MOT, OTR/L, CHT, an occupational therapist at the Seattle Hand Rehabilitation Clinic.

The advantage of the plating systems is that they provide significant stability of the bone so that gentle wrist movement is possible early on, notes Hayes, who advises against strengthening and aggressive ROM until the bone is healed, usually by about three months. “Once the bone begins to heal, we can remove the cast and perform therapy on the wrist and thumb to regain wrist motion and forearm rotation,” Hausman says. “In my cases, when to remove the cast depends on the compliance of the patient.”

When it comes to therapy, it is important that all exercises be completed at a comfortable level and within a pain-free zone, and built up gradually in order to aid healing and evade reinjury. “As OTs we have a very functional base, so we initiate instructions for completing light ADLs and one-handed living skills: for example, recommending slip-on shoes or shoes with Velcro closures rather than laces,” Howard says.

Most patients enjoy good function by the 12-week mark. However, recovery is very individualized, and it can take a year or more to reach maximum improvement. “Strengthening in the clinic usually begins around week six after surgery, but some patients can take several more months to regain functional hand strength,” Howard says. “A patient whose job requires heavy lifting may have to work on strengthening exercises for an additional four to six weeks, not returning to work until 12 weeks after
surgery, while a computer engineer may take off a few days after surgery and return to work even before the stitches are removed.”

In Howard’s experience, the majority of patients do very well following therapeutic programs at home. “Most patients will have a significant decrease in their pain and successfully regain motion after surgery simply by taking precautions, wearing their splints, and following their home exercise program,” she says.

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Ceri Usmar is a medical writer for the Gannett Healthcare Group.To comment, e-mail oteditor@gannetthg.com.

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