COLLES FRACTURE

KNEE DISLOCATION
PRADHANEESH KUMARAN UTHAYAKUMARAN
ANG SHU TING
NEHSAN

COLLES FRACTURE

Transverse fracture of the radius just above the wrist,

with dorsal displacement of the distal fragment

Most common of all fractures in older people

particularly in post-menopausal osteoporosis women

An older woman who gives a history of falling on her

outstretched hand.

MECHANISM
-- FALL ON OUTSTRETCHED HAND
Force is applied in the length of the forearm with the
wrist in extension

Bone fractures at the cortico-cancellous junction

Distal fragment collapses into extension, dorsal

displacement, radial tilt and shortening

CLINICAL FEATURES
Dinner-fork deformity (prominence on the back of the
wrist and a depression in front)
Local tenderness and pain on wrist movements

DINNER FORK DEFORMITY

On X-ray:
Transverse fracture of the radius at the
corticocancellous junction
Ulnar styloid process is broken off (often)
Radial fragment is impacted into radial and backward
tilt
Sometimes
there is an intraarticular fracture;
sometimes it is severely comminuted

TREATMENT
1)

Undisplaced/slightly displaced:

) Applied

dorsal splint for a day or two until swelling

has resolved, put cast then
) Take X-ray at 10-14days to ensure the fracture is not
slipped. If slipped, surgery is required.
) Cast can usually be removed after 4 weeks to allow
mobilization

TREATMENT
2) Displaced fracture:
Reduced under anaesthesia (haematoma block, Biers
block, or axillary block)
Hand is grasped & traction is applied in the length of the
bone- to disimpact the fragments
The distal fragment is then pushed into place by pressing
on the dorsum while manipulating the wrist into flexion,
ulnar deviation and pronation
Position is checked by X-ray before dorsal plaster slab is
applied (extending from below the elbow to the metacarpal
necks) and held in position by crepe bandage - maintaining
the wrist in palmar flexion & ulnar deviation- Colles cast

COLLES
CAST

Extreme position of flexion and ulnar deviation must

be avoided; 20 degrees in each direction is adequate.
The arm is kept elevated for the next day or two,
shoulder and finger exercises are started asap.
At 7-10 days fresh x-rays are taken to check for
redisplacement (not uncommon)
For patients with high functional demands :
remanipulation and internal fixation.
For older patients with low functional demands :
modest degree of displacement is acceptable.
The fracture unites in about 6 weeks,then slab can be
safely discarded and exercises begun.

TREATMENT
3) Comminuted fractures:
Sometimes fractures can be reduced and held with
percutaneous wires
External fixator (if severe) with bone graft/substitute
placed into the gap; fixator is attached to the distal
radius and the second metacarpal shaft
Plate fixation volar locking plate applied to the front
of radius through the bed of flexor carpi radialis
Locked intramedullary nail
Crossed K-wire

Comminuted colles
fracture reduced and
held with
percutaneous wires

Outcome
Usually good.
The amount of displacement depends on the patients
factors such as age, commorbidity, functional
demands, handedness, quality of bone, and treatment
factors such as surgical skills and implants available
Shortening of > 2mm at the distal radio-ulnar joint,
dorsal tilt of >10degrees and dorsal translation of
>30% leads to poor outcome and need early
correction.
Poor outcomes can be improved by osteotomy

COMPLICATIONS
Early
1) Circulatory problems- finger circulation must be
checked, bandage is loosened
2) Nerve injury- compression of the median nerve is
common (CTS). May resolve with release of the
dressings and elevation (mild). If severe, divide the
transverse ligament

3) Reflex sympathetic dystrophy- quite common,

seldom proceed to Sudecks atrophy. There may be
swelling and tenderness of finger joint (so dont
neglect the daily exercises). 5% of cases, hand is stiff
and painful on removal of plaster. X-rays show
osteoporosis and there is increased activity on the
bone scan
4) TFCC injury as the distal radius displaces dorsally.

COMPLICATIONS
Late
1) Joint stiffness
Finger is the commonest; also shoulder and elbow
stiffness from neglect.
Joints which are out of plaster should be moved
several times/day
2) Malunion - Due to not complete reduction or
redisplacement of the fracture within the plaster so
that a dinner-fork deformity results. There is
weakness and loss of rotation. Excised the lower
1.5cm of ulna to restore rotation and osteotomy
to correct the radial deformity

3) Delayed union and Non-union : Non-union of the

radius is rare.
4) Rupture of the extensor pollicis longus tendon - very
rare, due to loss of blood supply to the tendon at the
time of fracture/friction on the tendon in a malunited
fracture

SMITHS FRACTURE

Reversal of Colles fracture

Uncommon, seen in adults and elderly

Falls on the back of the hand

Distal fragment displaces ventrally and tilts ventrally

Garden Spade deformity

Treatment: closed reduction and plaster cast

immobilisation for 6 weeks

Complications are similar to Colles fracture

SMITHS FRACTURE

In contrast to colles
fracture, the
displacement of lower
radial fragment is
forwards not
backwards.

Knee dislocation
The knee is a very stable joint generally
requiring high-energy trauma to produce
dislocation.
The cruciate ligaments and one or both
lateral ligaments are torn.

Motor vehicle collisions

Auto-pedestrian impact
Industrial injuries
Falls
Athletic injuries

Knee dislocation

Knee dislocations are described using either

positional or anatomical classification
systems.
The positional classification system was
developed by Kennedy and describes 5 major
types of positional dislocation. It describe the
position of the tibia relative to the femur.

Knee dislocation
1. Anterior dislocation :
most common typeof dislocation (30-50%)
due to hyperextension injury
usually involves tear of PCL
arterial injury is generally anintimal teardue to
traction

2. Posterior dislocation:
2nd most common type (25%)
due to axial load to flexed knee (dashboard injury)

or a high-energy fall on a flexed knee.

highest rate ofcomplete tear ofpopliteal artery

Knee dislocation
3. Lateraldislocation :
13% of knee dislocations
due to varus or valgus force
usually involves tears of both ACL and PCL
highest rate of peroneal nerve injury

4. Medial dislocation :
varus or valgus force
usually disrupted PLC and PCL

5. Rotational dislocation :
posterolateral is most common rotational dislocation
usuallyirreducible

Knee dislocation
The

anatomical classification system :

Schenck Classification
based on pattern of multiligamentous injury of knee dislocation (KD)
Schenck Classification

KD I

Multiligamentous injury with involvement of

ACL or PCL

KD II

Injury to ACL and PCL only (2 ligaments)

KD III

Injury to ACL, PCL, and medial collateral

ligament (MCL) or lateral collateral ligament
(LCL) (3 ligaments)

KD IV

Injury to ACL, PCL, PMC, and PLC (4 ligaments)

KD V

Multiligamentous injury with periarticular fracture

- C (added to above) - Arterial injury included

- N (added to above) - Nerve injury included

Knee dislocation
Clinical Features :
Severe bruising and swelling
Gross deformity of the knee
Circulation maybe impaired as the popliteal
artery maybe torn or obstructed
May have compartment syndrome
Common peroneal nerve injury (20%)
decreased sensation at the first webspace
with impaired dorsiflexion of the foot.

Knee dislocation
X- Ray: AP and Lateral

Abnormal joint space

Subluxation
Associated Fractures (proximal tibia, distal femur)

Knee dislocation
Avulsions
tibial spine
posterior part of the
plateau (PCL avulsion),
fibular styloid (LCL)
lateral tibial condyle
(Segond fracture).
Also, medial
epicondyle (MCL)
Lateral epicondyle
(LCL)

Knee dislocation
Arteriograph
Only when clinical assessment of
circulation is abnormal.
Ankle/brachial arterial pressure index(ratio of
systolic pressure at the ankle relative to systolic
pressure at the elbow) should not be less than
0.9.

Knee dislocation

CT Scan

Avulsions ( better detail)

Associated fractures
(distal femur, proximal tibia)
CT Angio

MRI

Gives detail of all non-bony structures :

Menisci
Articular cartilage
Ligaments
Tendons (biceps, Popliteus, ITB)
MR Angiogram (MRA)

Knee dislocation

Treatment:
REDUCTION under ANESTHESIA (Closed Reduction)
- Should be done IMMEDIATELY with sufficient
muscle relaxation (Dont apply aggressive force!)
- By pulling directly in the line of the leg
(hyperextension should be avoided because of
the danger to the popliteal vessels).
After reduction, resting the limb on a back-splint
and the circulation is checked repeatedly during
48 hours.
Vascular injury required immediate repair and the
limb is splinted with an anterior external fixator.

Closed Reduction
Maneuver
POSITION of DISLOCATION
(Tibia relative to Femur)
Anterior

Traction & elevation of distal femur

Posterior

Traction & extension of proximal tibia

Lateral

/ Medial

Traction & correctional translation

Rotational

Traction & correctional derotation

Open Reduction
Irreducible by Closed methods
Rare
Typically POSTEROLATERAL

Dimple sign Puckering of anteromedial skin

Buttonhole of medial femoral condyle through soft
tissues (capsule, MCL, retinaculum, vastus
medialis)
Watch for skin necrosis

Knee dislocation
Repair or reconstruction of the capsule and
collateral ligaments enable early
movement of the knee with the support of a
hinged knee brace.
Early reconstruction of the torn ligaments
followed by protected movement of the joint
reduces the severity of the joint stiffness.
Prolonged cast immobilization is no longer
recommended(less good at preseving
function of the knee)

Knee dislocation
Complications :
a) Early :
- arterial damage : popliteal artery
damage (20%)

Needs immediate repair; if delay, can leads to

ischemia and result in amputation.

- nerve injury : lateral popliteal nerve

injury

spontaneous recovery is possible if nerve is

not completely disrupted. If no sign of
recovery, a transfer of tendon of tibialis
posterior through the interosseous membrane
to the lateral cuneiform restore the ankle

Knee dislocation
b)

Late :
- joint instability
- stiffness : loss of movement due to
prolonged immobilization

THANK
YOU