The Colles Fracture, named after Sir Abraham Colles, who first described the injury in 1814, is a fracture of the distal radius (the long bone of the forearm on the thumb side) and is the most common fracture treated by orthopaedic surgeons in North America. Typically, this fracture occurs when someone lands on their outstretched arm during a fall. The force is directed to the distal radius and the bone fractures, resulting in a “dinner fork” deformity of the wrist, with the bend being the distal radius and the prongs being the fingers. Keep that image in mind as I discuss treatment. You’d think something so common would have a consistently recommended treatment, but the fact is, depending on where you live and the physician you see, treatments vary widely and there is no single best treatment identified.
Prior to the mid-1970s, treatment of this fracture was pretty uniform. The treating physician would do something to numb the fracture, manipulate the bone back into place, and cast it. To hold the bone in place the cast was typically flexed at the wrist and went above the elbow. Weekly x-rays were required because the fracture tended to displace back to its original deformity, and multiple manipulations over the course of treatment were usually necessary. This process was time consuming and often unpleasant for the patient.
In the late 1970’s fluoroscopy (real time x-ray) as well as studies showing cast treatment to be sub-optimal led to the development of surgical treatments for these fractures. As well as providing better-looking x-rays and cosmetic improvements in the contour of the wrist, radiographic studies demonstrated that the frequency of wrist arthritis was directly correlated to improved alignment of the fracture fragments, which was possible with surgical treatment.
By the 90’s there was an explosion of different operative techniques and equipment to fix these fractures. It was driven by two factors: the drive to fix the fracture as perfectly as possible and the technology in the form of new hardware to accomplish this. Of course, the companies that manufacture the hardware were more than happy to drive this trend. It got to the point where surgeons were putting up to three plates, one on the front, one on the back and one on the side of the bone to fix the fracture as perfectly as possible. Not only was this approach technology-driven, but certain surgeons were only too happy to present their expertise in this ever-complex surgery, and promote themselves in the process. Not surprisingly, these surgeons also had a financial stake in the companies providing the equipment. Suddenly, a seemingly common and simple fracture to treat was becoming more complex than splitting an atom, not to mention extremely expensive.
This is a common thread in medicine. Over the past 20 years studies have shown that whether it’s cardiac bypass surgery or treatment of wrist fractures, simpler treatments are often equally or more effective, as well as cheaper, than more complex interventions. The treatment of Colles fractures with multiple plates, while often producing superb x-rays, results in more complications and more cost. Those plates and screws are not cheap, and there is little or no evidence that a perfect x-ray leads to better function.
Though The American Academy of Orthopaedic Surgeons has begun a process of reviewing the most common injuries and writing treatment consensus guidelines, there is still very little consensus on the treatment of Colles fractures. You might think that for a fracture that has been treated for over 200 years this would have been done earlier, but that demonstrates how much historical dogma, technique, profit, and technology often advance treatments faster than results-driven studies do. In fact, there is not a lot of evidence that a little bit of a crooked wrist or a little bit of arthritis noted on x-ray leads to a bad result in the long term. The question really is: how bad it can be before treatment is necessary, and if the benefits of aggressive treatment outweigh the risks. In this way, the most common fracture on the planet mirrors much more complex and serious issues in medicine.
Currently, surgical treatment is still recommended for Colles fractures when they are displaced and obviously unstable. It is actually easier for the patient to have a single surgery than multiple cast changes, and the above-elbow cast is uncomfortable, heavy, and inconvenient. The results of surgery probably improve outcomes over non-surgical treatment enough to justify possible complications but not definitively so.
So, without clear guidelines, what happens? If you look nationally, treatment varies widely. The rate of non-operative treatment is 96% in Covington, KY but only 60% in San Luis Obispo, CA. Colles fractures are treated with percutaneous (through the skin) fixation only 2%of the time in Boulder, CO as compared to almost 40% in San Luis Obispo. Open treatment with a plate varies from just 0.4% in Wilkes Barre, PA to 25% in Great Falls MT. These are huge discrepancies and reflect the lack of clear evidence that favors one treatment over the other. Again, this is 2016 and this is the most common fracture treated.
So what do I think? With a lack of consensus, I do what most every surgeon does; I go by my experience and arrive at a plan with which the patient and I are both most comfortable. I know that most patients hate the long arm cast (with all due respect to those in Covington, KY). I also know it’s very difficult to convince a patient with a crooked wrist that they will be OK. I will generally recommend operative treatment, but arriving at that recommendation comes only after I’ve had a discussion with my patient about all of the various options and have addressed any questions or concerns they may have about the recovery process and their long term outcomes.
The wide range of opinions about the appropriate treatment of Colles fractures illustrates the importance of having an open dialogue with your medical providers about any procedure you may be faced with. Medicine is an ever-evolving discipline, and a physician’s views on certain procedures will often evolve as well, based on new science and first-hand experience. As a patient, you should be encouraged to ask your doctor’s opinion about the full range of treatment options in order to make an informed decision about what is in your own best interest.
William Vranos, MD, is a board-certified orthopaedic surgeon with BMH Orthopaedics & Sports Medicine, a member of BMH Medical Group. BMH Orthopaedics & Sports Medicine is located at 17 Belmont Avenue, Brattleboro, VT. Dr. Vranos can be reached at 802-251-8611.