Colles' Fracture
Upper LimbOverview
Colles' fracture is a distal radius fracture with dorsal angulation and displacement, typically occurring within 2-3 cm of the wrist joint. It is the most common type of wrist fracture, accounting for approximately 90% of distal radius fractures. The injury typically results from a fall onto an outstretched hand (FOOSH) with the wrist in extension.
Pathophysiology
A fall onto an extended wrist creates a compressive and shear force through the distal radius, causing a transverse fracture line typically 2-3 cm proximal to the articular surface. The dorsal angulation occurs because the distal fragment is displaced and angulated dorsally. Associated injuries may include ulnar styloid fractures (50-60% of cases), anterior interosseous nerve injury, or compartment syndrome in severe cases. Healing typically occurs over 6-12 weeks depending on fracture complexity and patient factors.
Patient Education
Most Colles' fractures heal well with appropriate immobilization and rehabilitation; early mobilization of non-immobilized joints and progressive wrist exercises after cast removal are essential to restore function and prevent stiffness.
Typical Presentation
Site
Distal forearm, dorsal wrist, and radial-sided wrist; swelling extends from hand to mid-forearm
Quality
Sharp, throbbing pain with immediate onset; associated with 'dinner fork' deformity if severely displaced
Intensity
Severe (8-10/10) immediately post-injury; moderate (4-6/10) during healing phase
Aggravating
Any wrist movement, gripping, weight-bearing through the arm, direct pressure over fracture site
Relieving
Immobilization in cast or splint, elevation of arm, ice application, analgesic medication
Associated
Swelling and bruising, visible deformity ('dinner fork'), loss of wrist extension range, finger swelling, potential sensory changes in radial nerve distribution
Orthopaedic Tests
Clinical Inspection and Palpation
Procedure
Visually inspect the wrist for swelling, deformity (dorsal prominence or 'dinner fork' deformity), and bruising. Palpate the distal radius and ulna for tenderness and step-off deformity. Assess for median nerve paresthesia (carpal tunnel signs).
Positive Finding
Visible dorsal angulation ('dinner fork' deformity), loss of radial height, loss of radial inclination, or reversal of volar tilt; marked swelling and ecchymosis; tenderness over distal radius; paresthesia in median nerve distribution
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Clinical inspection is essential for initial recognition of Colles' fracture and associated soft-tissue injury or neurovascular compromise. Identifies need for urgent imaging and assessment of median nerve entrapment risk.
Axial Loading Test (Compression Test)
Procedure
Apply gentle longitudinal compression along the axis of the forearm from the elbow toward the wrist while supporting the proximal forearm. Assess for sharp pain or reproduction of injury mechanism symptoms.
Positive Finding
Sharp pain along the distal radius, reproduction of acute injury pain, or audible/palpable crepitus
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Reproduces pain from the fracture site and may elicit crepitus, supporting fracture diagnosis. Used primarily to confirm clinical suspicion when imaging is pending.
Pronation–Supination Range of Motion Assessment
Procedure
With the elbow flexed to 90°, gently guide the forearm through pronation and supination. Quantify active and passive range of motion using visual estimation or goniometry.
Positive Finding
Loss of pronation and/or supination (typically supination more limited acutely), pain at extremes of motion, guarding or muscle splinting
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Limited and painful pronation–supination is consistent with acute distal radius fracture and intra-articular involvement (radiocarpal joint). Helps assess severity and intra-articular extension.
Scaphoid Compression Test
Procedure
Palpate the scaphoid fossa (anatomical snuffbox) with thumb while applying gentle medial-to-lateral compression. Assess for focal tenderness. If scaphoid tenderness is present, apply axial loading along the thumb (metacarpal compression).
Positive Finding
Focal tenderness in the scaphoid fossa or reproduction of pain with axial thumb loading; swelling localized to scaphoid area
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Associated scaphoid fracture or scaphoid contusion may occur with Colles' fracture. Tenderness warrants imaging (CT or MRI) to rule out occult carpal fracture, which affects prognosis and treatment.
Two-Point Discrimination and Median Nerve Sensory Testing
Procedure
Assess light touch and two-point discrimination over the thumb, index, middle, and radial half of ring finger (median nerve territory). Compare bilaterally.
Positive Finding
Loss of sensation, reduced two-point discrimination (normal <6 mm), paresthesia, or diminished response in median nerve distribution
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Detects acute median nerve compression (carpal tunnel syndrome) or direct nerve injury, which may occur with Colles' fracture displacement or severe swelling. Early identification is critical for urgent decompression consideration.
Distal Radioulnar Joint (DRUJ) Stability Test
Procedure
With the patient's elbow flexed 90° and forearm in neutral, grasp the distal radius with one hand and the distal ulna with the other. Apply gentle anteroposterior and rotational translation to assess DRUJ translation and reproduction of pain.
Positive Finding
Excessive translation (>3 mm), clunking or catching sensation, pain with anteroposterior displacement, or instability in pronation–supination
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Assesses for DRUJ involvement or associated ulnar-sided injury (ulnar styloid fracture, triangular fibrocartilage complex tear). DRUJ instability may complicate recovery and require specific rehabilitation or surgical intervention.
⚠ Red Flags
- •Immediate post-injury with severe deformity requiring emergency reduction
- •Signs of neurovascular compromise: absent radial pulse, cold fingers, sensory loss in radial nerve distribution, severe pain out of proportion
- •Signs of compartment syndrome: severe pain, paresthesias, pallor, paralysis, pulselessness
- •Open fracture with skin breach or wound contamination
- •Multiple trauma or polytrauma
- •Severely comminuted fractures with intra-articular involvement requiring surgical intervention
⚡ Yellow Flags
- •Anxiety about loss of hand function affecting compliance with rehabilitation
- •Fear-avoidance behavior limiting active participation in recovery
- •Depression or mood disturbance affecting motivation for rehabilitation
- •Poor understanding of fracture healing timeline leading to unrealistic expectations
- •Social or occupational factors that may compromise immobilization compliance
- •History of osteoporosis or metabolic bone disease affecting healing capacity
Osteopathic Techniques
Region
Cervical and thoracic spine
Technique
Soft Tissue
Rationale
Addresses compensatory muscle tension in the neck and shoulder girdle that develops from immobilization and protective posturing; improves postural alignment to optimize healing environment
Region
Shoulder girdle and glenohumeral joint
Technique
Articulation
Rationale
Maintains shoulder range of motion during forearm immobilization period; prevents shoulder stiffness and promotes circulation to support distal healing
Region
Elbow joint
Technique
Articulation
Rationale
Maintains elbow mobility and proprioception; prevents compensatory elbow stiffness that commonly occurs when wrist is immobilized
Region
Distal forearm and wrist (post-immobilization phase)
Technique
Soft Tissue
Rationale
Gentle soft tissue mobilization after cast removal reduces scar tissue formation, decreases pain, and improves tissue extensibility for restoration of wrist mobility
Region
Distal radius fracture site (post-immobilization phase)
Technique
MET
Rationale
Gentle muscle energy techniques address restrictive wrist movement patterns without stressing healing bone; improves proprioception and restores functional range of motion
Region
Thoracic outlet and upper limb lymphatics
Technique
Lymphatic
Rationale
Supports lymphatic drainage of upper limb to reduce post-immobilization edema and improve circulation for optimal tissue healing and function
Add-On Approaches
Chinese Medicine
Acupuncture and moxibustion targeting LI4 (Hegu), LI10 (Shousanli), and local points around the wrist to promote qi and blood circulation; herbal formulas containing bone-healing herbs such as Du Zhong and Xu Duan support fracture consolidation
Chiropractic
Mobilization of the shoulder complex and cervical spine to maintain upper kinetic chain mobility; gentle traction techniques in the post-immobilization phase to support joint space recovery
Physiotherapy
Progressive range of motion exercises beginning immediately post-reduction; graded strengthening program; proprioceptive training; functional task practice for return to activities of daily living
Remedial Massage
Gentle soft tissue techniques to the forearm, hand, and shoulder post-cast removal; myofascial release to address scar tissue formation; preventive massage to shoulder and neck to manage compensatory tension
Rehabilitation Exercises
Finger and Thumb Flexion-Extension (in cast)
Elbow Flexion-Extension (pendulum swings)
Shoulder Circumduction (active-assisted)
Wrist Flexion-Extension (post-cast removal)
Wrist Radial-Ulnar Deviation (post-cast removal)
Forearm Pronation-Supination (active-assisted)
Wrist Flexor Stretch (doorway lean)
Wrist Extensor Stretch (over-table hang)
Grip Strength Training (squeezing therapy putty)
Wrist Flexion Against Resistance (light dumbbells)
Wrist Extension Against Resistance (light dumbbells)
Shoulder Blade Stability (prone Y-T-W positions)
Referral Criteria
- •Immediately post-injury: refer to emergency department or orthopaedic urgent care for imaging, reduction, and immobilization
- •Any neurovascular compromise requiring emergency vascular or surgical assessment
- •Signs of compartment syndrome requiring emergency fasciotomy
- •Open fractures requiring wound management and surgical intervention
- •Fractures with significant intra-articular involvement or severe comminution requiring surgical consultation
- •Failed conservative management or loss of reduction during healing phase
- •Post-immobilization: refer to physiotherapy for structured rehabilitation program if significant functional loss
- •Persistent pain, stiffness, or swelling beyond expected healing timeline suggesting complex regional pain syndrome
- •Associated injuries requiring specialist assessment (nerve injury, vascular injury, other fractures)