Article ID: WMC001472 2046-1690

Functional Outcome Following Treatment Of Colles

Fracture: A Comparative Study Of Closed Reduction
And Plaster Cast Application Versus Kirschner Wire
Fixation
Corresponding Author:
Dr. Sharad Prabhakar,
Senior Research Associate, PGIMER, Chandigarh, India - India

Submitting Author:
Dr. Kamal Bali,
Registrar, Orthopedics, PGIMER, Chandigarh, India - India

Article ID: WMC001472

Article Type: Research articles
Submitted on:14-Jan-2011, 01:46:24 PM GMT Published on: 16-Jan-2011, 03:39:24 AM GMT
Article URL: http://www.webmedcentral.com/article_view/1472
Subject Categories:TRAUMA
Keywords:Colles, fracture, distal radius, closed reduction, K-wire fixation, open reduction, conservative
How to cite the article:Mam M K, Prabhakar S , Prakash J S, Bali K . Functional Outcome Following Treatment
Of Colles Fracture: A Comparative Study Of Closed Reduction And Plaster Cast Application Versus Kirschner
Wire Fixation . WebmedCentral TRAUMA 2011;2(1):WMC001472
Source(s) of Funding:
The Authors did not receive any funding for this study.

Competing Interests:
The authors do not have any competing interests

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Functional Outcome Following Treatment Of Colles

Fracture: A Comparative Study Of Closed Reduction
And Plaster Cast Application Versus Kirschner Wire
Fixation
Author(s): Mam M K, Prabhakar S , Prakash J S, Bali K

Abstract K-wires do not provide a better clinical outcome4.

Some authors believed that no special treatment was
needed as the resulting deformity barely resulted in
loss of function5. However this concept has been
Colles’ fracture is the most common of the distal radial
challenged and the restoration of normal anatomy is
fractures. There are many classifications and varied
now considered essential for normal function2.
treatment options, with variable results. Various
Various studies6,7,8 with short-term and long-term
studies with short-term and long-term results of
results of treatment of Colles’ fracture have correlated
treatment of Colles’ fracture have correlated
deformities with loss of function.
deformities with loss of function. This prompted us to
This prompted us to undertake a comparative study to
undertake a comparative study to determine the
determine the functional outcome with
functional outcome with clinico-radiological analysis of
clinico-radiological analysis of patients with Colles’
patients with Colles’ fractures treated with closed
fractures treated with closed reduction and cast alone
reduction and cast alone versus closed reduction,
versus closed reduction, Kirschner wire fixation and
Kirschner wire fixation and cast. At the last follow up,
cast.
no significant difference in the functional outcome was
obtained with closed reduction and cast versus closed Methods
reduction, K-wire fixation and cast

Introduction The study was conducted at the Department of

Orthopaedics, Christian Medical College & Hospital,
Ludhiana, Punjab. All patients with Colles’ fracture
Fractures near the wrist joint due to fall on the out
between June 2004 and June 2005 were studied. The
stretched hand constitute one of the largest of all
patients were followed up at 3 weeks, 6 weeks, 3
groups of bone injuries and are estimated to account
months and 9 months. A complete clinicoradiological
for one-sixth of all fractures seen and treated in the
assessment was performed at each visit. Patients with
emergency room1. With the passage of time, the
fused epiphysis, sustaining distal radius fracture were
epidemiological pattern of fractures has evolved from
included in the study. Patients with open fractures,
a non-comminuted extra-articular fracture as
additional major fractures in the ipsilateral upper limb,
classically described by Colles to a comminuted
associated neuro-vascular deficit and with bilateral
articular fracture associated with high velocity trauma.
Colles’ fractures were excluded from the study. Initial
Middle aged or elderly women often sustain this
anteroposterior and lateral radiographs of both the
fracture following low velocity trauma while in the
injured and uninjured side were taken. The “Universal
young it is caused by high velocity trauma2.
Classification” modified from the classifications of
The treatment modalities for this fracture have also
Gartland (1951)9 and Sarmiento (1975)10 was used in
evolved over time as understanding of this injury has
the study. The fractures were divided into -
changed1. The concept of ligamentotaxis to reduce
Extra-articular fractures: Type - I, non-displaced and
the fracture with the help of external fixation was
stable, Type – II, displaced and unstable.
introduced by Vaughan in 19853. However, closed
Intra-articular fractures: Type – III, non-displaced;
reduction and immobilization in a plaster cast remains
Type – IV, displaced.
the accepted method of treatment for 75% to 80% of
23 cases were manipulated under general
fractures of the distal radius1. Various K-wire fixation
anaesthesia. 7 cases were manipulated under regional
techniques have been described but Azzopardi et al
anaesthesia. Fracture stability was assessed
state that biomechanically a crossed K–wire construct
intra-operatively after reduction under C-arm. Patients
provides the greatest stability and supplementary

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with stable fractures underwent closed reduction and
cast. Those with unstable fractures underwent closed
reduction, K-wire fixation and cast application.
For patients undergoing closed reduction and cast
application (Fig 1), the patient was positioned supine
on the operating table. The surgeon grasped the
injured hand and disimpacted the fragments by firm
longitudinal traction. An assistant provided
counter-traction by grasping the arm above the flexed
elbow. Steady traction corrected the dorsal
displacement. This was followed by palmar flexion and
ulnar deviation of the wrist with the forearm in
pronation. Reduction was confirmed using an image
intensifier. Three point fixation was obtained in a well
moulded plaster cast which was applied to maintain
the wrist in the desired position. For comminuted
fractures an above elbow cast was given. Stable
fractures were given a below elbow cast. Active finger
mobilization, shoulder exercises and elbow
mobilization (in patients with short arm casts) were
started immediately postoperatively. A long arm cast
was converted to short arm cast at 3 weeks which was
continued for another 3 weeks. Total duration of
casting was 6 weeks.
In the percutaneous pinning group (Fig 2), the limb
was prepared and draped before closed reduction.
The fracture was reduced in the manner described
above and then fixed using two smooth Kirschner
wires. The wires were inserted through small stab
incisions under fluoroscopic control. One wire was
inserted from the styloid process of the radius directed
proximally and medially through the fracture site . The
other wire was passed from the lateral border of the
radius in a proximal to distal direction to engage the
ulnar aspect of the distal fragment. Both wires
engaged the opposite cortex. In 2 cases the second
wire was passed through the dorso-ulnar border of the
distal fragment in a distal to proximal direction.
Damage to the superficial branch of the radial nerve
and the extensor tendons was minimized by blunt
dissection to the bone. The pins were left protruding
percutaneously, dressed and the fracture was then
immobilized in a well moulded long arm cast. It was
converted to a short arm cast at 3 weeks. The wires
and cast were removed after 6 weeks. Active finger
mobilization and shoulder exercises were begun
immediately postoperatively.
Patients treated were followed up at 3 weeks, 6 weeks,
3 months and 9 months in the Orthopaedics OPD.
Clinico-radiological assessment of the patients was
performed at each follow-up visit. Functional scoring
was done using the Gartland and Werley 9 scoring
scale (Table 1). The radiographs of the wrist joint of
the patients were evaluated and the anatomical
WebmedCentral > Research articles
scoring method of Stewart et al 11 (Table 2) was used
to assess the fracture reduction.
Results
A total of 41 patients with Colles’ fracture managed at
the Dept. of Orthopaedics from June 2004 to June
2005 were studied. Of these, 3 cases were excluded
from the study. (1 had bilateral Colles’ fracture, 1 had
associated ipsilateral humerus fracture and 1 was a
compound injury). Group I, which included patients
who underwent closed reduction and cast application,
had 20 patients. Group II (closed reduction, K-wire
fixation and cast) had 18 patients. The patients were
followed up immediately post-op, at 3 weeks, 6 weeks,
3 months and 9 months. 5 patients from group I and 3
patients from group II were lost to follow-up. These
patients were also excluded from the study. The final
analysis was performed on 30 patients, closed
reduction and cast (Group I) with 15 patients and
K-wire and cast (Group II), also with 15 patients.
The mean age at injury was 38.5 ± 13.75 yrs for males
and 46.70 ± 8.37 yrs for females. The age ranged
from 21 to 59 years for the whole group and 21 yrs to
58 yrs for males and 32 yrs to 59 yrs for females.
There was no statistically significant difference in age
between the patients with different types of distal
radius fractures according to the Universal
Classification (p> 0.503). The female to male ratio was
2:1 with 20 females and 10 males. The dominant side
was involved in 17/30 (56.6%) patients whereas the
non dominant side was involved in 13/30 (43.3%)
patients. The distribution of the injuries according to
the Universal Classification System is shown in Table
3. Majority of patients in both the groups were in
Universal Classification type 4.
The post-op functional scores in both groups showed
improvement over time (Table 4). There was however
no statistically significant difference in the post-op
function scores between the two groups (p=0.267). In
Group I ( closed reduction and cast) , the anatomical
scores showed worsening in 5 out of 15 cases (Table
5). The anatomical scores improved after surgery and
remained the same post operatively in all but 2 cases
in Group II. There was worsening after 3 weeks in one
and after 3 months in the other. However, the
difference between the two groups was not statistically
significant (p= 0.412). The correlation between
pre-operative anatomical score and post-operative
functional scores at 6 weeks, 3 weeks and 9 months
was investigated. However, there was no statistically
significant correlation between pre-operative
anatomical score and post-operative functional scores
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(p=0.398).
Discussion
Fractures of the distal radius are one of the
commonest skeletal injuries treated by orthopaedic
surgeons and account for approximately one sixth of
all fractures seen and treated in emergency rooms5.
Majority of the patients in the present study had
intra-articular fractures (Table 3). A similar observation
was made by Altissimi et al6 and Sandhu et al 12.
Jupiter 1 reported that the epidemiological pattern of
fractures has evolved from a non-comminuted
extra-articular fracture as classically described by
Colles to a comminuted articular fracture . In various
studies there is still no consensus regarding the
management and assessment of outcomes of distal
radius fracture. This has made it difficult to evaluate
various methods of treatment4.
The functional scores at 6 weeks, 3 months and 9
months for treatment Groups I and II in the present
study showed that there was no statistically significant
difference in the functional outcome. Azzopardi et al4
reported similar findings. However our findings are
different from those of Sandhu et al12 who reported a
higher percentage of excellent and good results with
K-wire fixation as compared to closed reduction and
cast alone.
In the anatomical scores of Group I (closed reduction
and cast) worsening was seen in 5 out of 15 cases. In
Group II (K-wire and cast) worsening was seen in only
two cases. However, the data was not statistically
significant. Our findings are comparable with those of
Azzopardi et al4 who reported that the differences in
the radiological parameters between K-wire fixation
and cast immobilization in their study were within
errors of measurement. They concluded that
functionally K-wire fixation was marginally superior to
cast immobilization in maintaining fracture reduction
after closed manipulation.
In our study the functional scores did not correlate with
anatomical scores. Our findings are comparable with
those of Smaill13, Stewart et al11, Dias et al14 and
Gaur et al7. Gaur et al7 reported that despite a high
deformity rate with cast alone there were no patients
with poor functional results at 5 year follow up.
Smaill’s13 and Dias et al’s14 reported that good
function may be present in spite of residual bony
deformity. Stewart et al11 reported that there was no
correlation between anatomical and functional results
at 6 months follow up.
Azzopardi et al4 reported that only 1/30 patients (3.3%)
in the K-wire group required removal of the K-wires at
WebmedCentral > Research articles
2 weeks due to pin tract infection. In our study none of
the patients required removal of K-wires due to
infection. The mean age in our study was 43.3 yrs
which is less as compared to 59 yrs in the study by
Azzopardi et al4. Therefore, probably there were less
chances of pin loosening and infection in younger
individuals with normal bone quality versus elderly
patients with osteopenic bone.
In our study 1 patient out of 30 patients (3.3%)
sustained a rupture of the extensor pollicis longus
tendon. Our observations are similar to those of
Frykman15. The patient, however, recovered by 9
months with excellent functional scores. Our
observations are comparable with those of
Benjamin16. He reported that patients with extensor
pollicis longus tendon rupture left untreated for an year
had no functional disability from the tendon rupture.
In our study 3/30 (10%) patients developed reflex
sympathetic dystrophy. 2 patients had been treated
with cast alone and 1 patient with K-wire fixation. The
patients showed recovery of their functional scores by
9 months after physiotherapy. Our findings are
comparable to those of Frykman15.
Our study demonstrates that there is no significant
difference in the functional outcome obtained with
closed reduction and cast versus closed reduction,
K-wire fixation and cast. However, K-wire fixation may
play a role in maintaining post operative reduction and
anatomical score. This is evident by the fact that loss
of reduction post operatively was seen in fewer cases
with K-wire fixation as compared to cast alone, even
though the difference was not statistically significant.
Possibly a study with a larger number of cases and a
longer follow up is required to elucidate this difference.
References
1.Jupiter JB: Fractures of the distal end of the radius.
Current concepts review, J Bone Joint Surg 1991
73(3):461-9.
2.Nagi ON, Dhillon MS, Aggarwal S, Deogaonakar KJ.
External fixators for intra articular distal radius
fractures. Indian J Orthop 2004 38:19-22.
3.Vaughan PA, Lui SM, IJ Harrington IJ, Maistrelli GL.
Treatment of unstable fractures of the distal radius by
external fixation. J Bone Joint Surg Br 1985 67-B:
385-389.
4.Azzopardi T, Ehrendorfer S, Coulton T, Abela M :
Unstable extra-articular fractures of the distal radius :
A prospective, randomized study of immobilization in a
cast versus supplementary percutaneous pining. J
Bone Joint Surg 2005 87-B(6): 837-840.
5.Ark J, Jupiter JB : The rationale for precise
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management of distal radius fractures. Orthop Clin

North Am 1993 24(2): 205-210.
6.Altissimi M, Antenucci R, Fiacco C et al : Long term
results of conservative treatment of fractures of the
distal radius. Clin Orthop 1986 206:202-210.
7.Gaur SC, Swarup A, Singh HP : Long-term results of
Colles’ fracture treated by conventional methods.
Indian Journal of Orthopaedics 1992 25: 150-152.
8.Sander RA, Keppel FL, Waldrop JL. External fixation
of distal radius fracture. Results and complications. J
Hand Surg 16(A): 1991,385-389.
9.Gartland JJ, Werley CW : Evaluation of healed
colles fractures. J Bone Joint Surg 1951 33(A):
895-907.
10.Sarmiento A, Pratt GW, Berry NC, Sinclair WP :
Colles’ fracture – Functional bracing in supination. J
Bone Joint Surg 1975 57(A): 311-316.
11.Stewart HD, Innes AR, Burke FD : Functional cast
bracing for Colles’ fractures- A comparison between
cast-bracing and conventional plaster casts. J Bone
Joint Surg 1984 66(B): 749-753.
12.Sandhu HS, Singh M, Bajaj AS, Singh S : Closed
reduction and percutaneous Kirschner wire fixation in
Colles’ fracture. Indian Journal of Orthopaedics 1986
20: 198-203.
13.Smaill G : Long term follow-up of Colles’ fracture. J
Bone Joint Surg 1965 47(B): 80-85.
14.Dias JJ, Wray CC, Jones JM, Gregg PP : The
value of early mobilization in the treatment of Colles’
fractures. J Bone Joint Surg 1987 69(B): 463-467.
15.Frykman G. Fracture of the distal radius including
sequele shoulder-hand –syndrome, disturbance of the
distal radioulnar joint and impairment of nerve function.
A clinical and experimental study. Acta Orthop Scand
(Supplementum) 1967 108: 1-153.
16.Benjamin A : Injuries of the forearm. In : Wilson JN
editor, Watson Jones Fractures and Joint Injuries, 6th
ed, Churchill Livingstone 1982: 650-709.

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Illustrations
Illustration 1

Tables

Table 1 FUNCTIONAL SCORING METHOD: (Gartland and Werley, 1951)9

MOVEMENT /FUNCTION Range ( in degrees) Score

Dorsiflexion <45 5
Palmar flexion <30 1
Ulnar deviation <25 3
Radial deviation <15 1
Supination <50 2
Pronation <50 2
Circumduction loss 1
Finger flexion Not to distal crease 1-2
Grip Loss of strength 1
Radial / Median neuritis Mild- severe 1-3

FINAL GRADE Excellent 0-2

Good 3-8
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Poor >15
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Table 3 Distribution according to Universal Classification of pre-reduction radiographs

Universal Group I Group II Total Percentage

Classification
Fracture Type
n n n %
I 2 0 2 6.6
II 3 4 7 23.3
III 1 0 1 3.3
IV 9 11 20 66.6
TOTAL 15 15 30 100

Table 4 Functional score at 6 weeks, 3 months and 9 months post-operatively in Group I

( closed reduction and cast) and Group II (K wire and cast)

Group I Group II

FUNCTION 6 weeks 3 months 9 months 6 weeks 3 months 9 months

SCORE
n n n n n n

Excellent 2 12 4 13

Good 1 12 3 1 9 2

Fair 11 1 7 2

Poor 3 7
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n= number of patients
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Table 5 Showing Anatomical scores at 6 weeks, 3 months and 9 months post-operatively for
Group I ( cast alone) and Group II ( K wire and cast)

Group Group
I II

ANATOMICAL Post-o 6 3 9 Post-o 6 3 9

SCORE p weeks month month p weeks month month
s s s s
n n n n n n

Excellent 14 9 9 9 14 13 12 12

Good 1 6 6 6 1 1 2 2

Fair 1 1 1

Poor

n = number of patients

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Illustration 2

Figures

Fig 1 a,b pre-op radiographs showing stable extra articular distal radius fracture

Fig 1c,d showing reduction at 6 weeks

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Fig 1 g,h showing excellent Function score at 9 months

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Fig 2 a,b radiographs showing unstable, comminuted intra-articular distal radius fracture

Fig 2 c,d post-op radiographs at 3 weeks

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Fig 2 g,h excellent Functional score at 9 months post -op

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