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Colles’ Fractures: Functional Treatment in

Supination

Collesova zlomenina: funkční léčení v supinaci

A. Sarmiento, L. L. Latta
Department of Orthopedic and Rehabilitation University of Miami, Florida, USA

ABSTRACT
Purpouse of the study
Abraham Colles classified and described fractures of the distal epiphyseal radius. He recommended the arm should be
immobilized in a cast that extends from the base of the fingers to above the elbow, while holding this joint at ninety degrees
of flexion the forearm in pronation and the wrist in slight flexion and ulnar deviation. We identified the brachioradialis mus-
cle as the main culprit in the frequently observed loss of reduction of the fracture. Since the brachioradialis is attached to
the distal region of the radius and functions as a flexor of the elbow when the forearm is in pronation, its stimulation easily
displaces a reduced fracture, particularly if its geometry suggests axial instability. We concluded that post-reduction stabili-
zation in supination was more desirable than in pronation.

Material and Methods

Prospective study of one hundred and fifty-six patients suffering from Colles’ fractures who were treated with the func-
tional method. Approximately one-half of the fractures were immobilized in pronation and the other half in supination. The
median age of the patients was 49 years. After approximately eleven days of immobilization in an above-the-elbow cast that
held the forearm in a relaxed attitude of supination and the wrist in slight flexion and ulnar deviation, a new cast or brace was
applied. The appliance permitted flexion of the elbow and slightly limited extension. We utilized modified Lindstom criteria to
assess radiological results, according to types of fractures and by groups treated in supination and pronation.

Results
In the type I and III (non-displaced) fracture series there appeared to be no significant difference in the functional results
between the pronation and supination treated groups. In the type II category, in the supinated fractures, there were 9 excel-
lent, 4 good and no fair or poor results. In the pronated group 9 excellent, 8 good and one fair result. The functional results
in type IV fractures treated in supination were excellent in 11 instances, good in 7 and fair in 2. In fractures treated in prona-
tion there were 5 excellent, 10 good and 5 fair results. There were no poor results in either group. 85% of type II fractures
and 85% of type IV fractures treated in supination had excellent or good results. In the pronation group, 67% had excellent
or good results in type II and 40% in type IV classification. In combining the results for all types of braced Colles’ fractures,
(I–IV) 93% of the supination group and 87% of the pronation group achieved excellent or good functional results. In analyzing
overall results regardless of type of fracture or position of immobilization, 90% of the patients had excellent or good results.

Conclusion
We treated Colles’ fractures in supination and compared the results with those obtained when treated in pronation. The
results indicated a lower incidence of re-displacement in the supination group. We developed a forearm brace that permits
flexion of the elbow, but prevented pronation of the forearm, and limited extension of the elbow in approximately the last
fifteen degrees. It permits minimally limited flexion of the wrist but prevents wrist dorsiflexion. It makes impossible any radial
deviation. The place of surgery in the management of Colles’ fractures should be limited to those fractures that when treated
by non-surgical means are not likely to render satisfactory functional and cosmetic results. There is not at this time a con-
sensus as to when to use the surgical approach. The complication rate from the surgery have not clearly identify superiority
of one over the other. Nonetheless, the surgical treatment has a definite place in the armamentarium of the orthopaedic
surgeon. In a number of situations, it is the treatment of choice.

Key words: Colles’ fractures, conservative treatment, supination, surgical treatment.

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Introduction a

Ever since Abraham Colles classified and described

fractures of the distal epiphyseal radius, his ideas have
guided the thinking about these fractures and their ma-
nagement. He recommended that following manual re-
duction of the fracture, the arm should be immobilized
in a cast that extends from the base of the fingers to
above the elbow, while holding this joint at ninety de-
grees of flexion, the forearm in pronation and the wrist
in slight flexion and ulnar deviation. Despite the inevi-
table development of complications that accompanies
all treatment modalities, the overall results have been b
gratifying. Millions of people over the years have en-
joyed a residual painless joint and in most instances
a functional wrist.
As surgical techniques in the management of other
fractures improved, recent attempts to obtain anatomi-
cal reduction and elimination of articular incongruity
by surgical means have been popularized. It is perhaps
too early to cast final judgment on the place and role of
surgery, versus conservative treatment of these fractu-
res. Nonetheless, there is sufficient data to support the
concept that certain Colles’ fractures are best treated
surgically with the use of immobilizing metallic plates Fig. 1. Electromyographic study demonstrating that: a – if the
(11). forearm is a pronation and the elbow is actively flexed, the
After carefully observing the radiological findings function of the biceps is minimal, but that of the brachiora-
of a large number of Colles’ fractures, as well as ana- dialis is maximal, b – if the elbow is actively flexed while the
elbow is in supination the biceps shows maximal contraction
tomical dissections and electromyographic studies, we and the brachioradialis remains quiet.
concluded that post-reduction stabilization in supina-
tion was more desirable than in pronation. We identi-
fied the brachioradialis muscle as the main culprit in a reduced fracture, particularly if its geometry suggests
the frequently observed loss of reduction of the fracture axial instability (7, 9, 10).
(Figs 1 and 2). Since the brachioradialis is attached to These observations led us to develop first a cast that
the distal region of the radius and functions as a flexor allows the elbow to flex to more than one-hundred de-
of the elbow when the forearm is in pronation, we do- grees, but its extension is limited in the last 25 to thirty
cumented the fact that its stimulation easily displaces degrees.

Material and Method

We conducted a prospective study of one

hundred and fifty-six patients suffering from
Colles’ fractures who were treated with the
functional method (10). The subsequent re-
sults have been published in the orthopaedic
literature (2, 3, 8–10). Approximately one-
-half of the fractures were immobilized in
pronation and the other half in supination.
The median age of the patients was 49 years.
The cast applied following the initial re-
duction is a circular one that holds the elbow
at ninety degrees of flexion, the forearm in
supination and the wrist in moderate flexion
and ulnar deviation (Fig. 3).
At approximately one week after the ini-
Fig. 2. Schematic drawing of a co- Fig. 3. The cast applied after the initial tial treatment the cast is replaced with either
mminuted fracture illustrating the reduction holds the elbow at 90 degrees a functional cast or a functional brace. They
pull of the brachioradialis muscle of flexion, the forearm in supination and permit limited motion of the elbow to minus
and the resulting collapse of the the wrist in a few degrees of flexion and 15–20 degrees of flexion to minus twenty de-
radial fracture. ulnar deviation.
grees of extension. This limitation of motion
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a b

c d
Fig. 4. a – the forearm is flattened, b – the cast is extended over the distal arm while holding the elbow at 90 degrees and the
forearm in supination, the supracondylar area is firmly compressed, c – the anterior wall of the cast is removed to make possible
flexion of the elbow, while preventing full extension of the elbow, d – notice the firm compression of the supracondylar area.

a b
Fig. 5. a – schematic drawing of the functional brace and the manner in which pronosupination is prevented, b – plastic func-
tional brace illustrating the metallic joint that allows for flexion of the wrist while preventing dorsiflexion and lateral motions.
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is made possible by the careful molding of the cast over the

Representative examples
humeral condyles (Fig. 4).
When plastic material or prefabricated braces are
used, the same basic principles are sustained. Mechani-
cal joints are attached to the body of the brace.
After approximately eleven days of immobilization in
an above-the-elbow cast that held the forearm in a rela-
xed attitude of supination and the wrist in slight flexion
and ulnar deviation, a new cast or brace was applied.
The appliance permitted flexion of the elbow and slight-
ly limited extension.
We utilized modified Lindstom criteria to assess ra-
diological results, according to types of fractures (I to
IV) and by groups treated in supination and pronation.

Results

Twenty-three (15%) fractures fell within category I; Fig. 6. Photo of patient being treated with plastic functional
44 (28%) in category II; 40 (26%) in category III; and 49 braces with metallic wrist joints.
(31%) in category IV. Ninety-three fractures were dis-
placed and 63 were non-displaced. 85% of type II fractures and 85% of type IV fractures
For types I and III (non-displaced fractures), there treated in supination had excellent or good results. In the
was no significant change in position of the fracture pronation group, 67% had excellent or good results in
from the time of injury to the last follow-up, regardle- type II and 40% in type IV classification.
ss of whether braced in pronation or supination. In combining the results for all types of braced Colles’
In the displaced fractures (Types II and IV) we ob- fractures, (I–IV) 93% of the supination group and 87%
served the following. From bracing to first follow-up of the pronation group achieved excellent or good func-
in type II fractures (displaced, extra-articular) treated tional results.
in supination, only one patient lost radial length repre- In analyzing our overall results regardless of type of
senting 8% of the group, while 7 of those treated in fracture or position of immobilization, 90% of the pati-
pronation showed at least two millimeters (39%). None ents had excellent or good results.
of the supination patients experienced any further loss
of volar tilt once braced. However, 3 (17%) patients in Discussion and recommendations
the pronation category had further dorsal angulation of
at least 2 degrees. There was no appreciable difference Solid data have indicated that the brachioradialis
between the groups with regard to radial deviation. muscle plays a major role in the recurrence of deformity
In patients with Type IV fractures (intra-articular, dis- when the forearm is stabilized in pronation and that the
placed) there was no significant difference in respect to ra- incidence of recurrence of deformity decreases when the
dial displacement. However, in analyzing radial length and forearm is stabilized in supination, indicating that patients
volar tilt, we found that the overall results in the pronation treated in supination have a superior anatomical result.
group were inferior to those in the supination group. We treated Colles’ fractures in supination and compared
After bracing in supination, one (5%) of the total the results with those obtained when treated in pronation.
group of patients lost 2 degrees of volar tilt, whereas 10 The results indicated a lower incidence of re-displacement
(50%) patients in the pronated group angulated 2 degre- in the supination group. We developed a forearm brace that
es or more while in the brace. permits flexion of the elbow, but prevented pronation of
In the type I and III (non-displaced) fracture series the- the forearm, and limited extension of the elbow in appro-
re appeared to be no significant difference in the functio- ximately the last fifteen degrees. It permits minimally limi-
nal results between the pronation and supination treated ted flexion of the wrist but prevents wrist dorsiflexion. It
groups. In the type II category, in the supinated fractures, makes impossible any radial deviation (2, 9, 10).
there were 9 excellent, 4 good and no fair or poor results. The place of surgery in the management of Colles’
In the pronated group 9 excellent, 8 good and one fair fractures should be limited to those fractures that when
result. All fractures in the type II category with excellent treated by non-surgical means are not likely to render
anatomical results had excellent functional results. satisfactory functional and cosmetic results.
The functional results in type IV fractures treated in Any concerns about secondary osteoarthritis due to
supination were excellent in 11 instances, good in 7 and residual incongruity must be objectively assessed. Sym-
fair in 2. In fractures treated in pronation there were 5 ptomatic osteoarthritis is rare following Colles’ fractures
excellent, 10 good and 5 fair results. As with type II whether intraarticular or extraarticular even though some
fractures, all type IV fractures which had excellent ana- limitation of motion may be present. This is true regar-
tomical results had excellent functional results. There dless of their surgical or non-surgical management. If in-
were no poor results in either group. congruity were to readily lead to arthritis, its ­incidence
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Representative examples Původní práce

Fig. 7. a – initial radiograph illustrating the severe dorso-

-lateral displacement of the distal radial fragment, b – long
term radiograph showing the restoration of length and align-
ment and the persistent painless subluxation of the radio-ulnar
joint, e-f – patient illustrating the rotation of the forearm and
the dorsal and volar motion of the wrist, notice the mild, in-
consequential loss of the last few degrees of volar and palmar
motion.

ac
bd
e
f
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Representative examples

Fig. 8. Illustration of severely displaced Colles’ fracture

showing the reduction following manipulation and radiologi-
cal appearance in the plastic brace.

ab
c

would extremely common, which definitely is not the articular congruity in instances when the comminution
case. The power of cartilage remodeling has been unde- and displacement of the fragments is major. It must be
restimated having lead to the performance of unnecessa- kept in mind that ultimate restoration of anatomy fo-
ry surgery in many instances. Our laboratory work has llowing surgery does not necessarily mean normal range
shown evidence that without perfect anatomical reappro- of motion. Anecdotally, we have observed that in many
ximation of fractured articular cartilage a reparative pro- instances, regardless of the treatment used – surgical or
cess begins. The fact that osteoarthritic changes develop nonsurgical – a residual limitation of motion, usually of
in some instances, in the wrist, as well as in fractures in an inconsequential nature is present.
other joints, may be due to other factors, such as initial Opinions vary regarding the incidence of osteoarthri-
irreparable damage of the cartilage (1, 4, 5). tic changes resulting from damage to the articular carti-
lage at the time of the injury (11).
Conclusion There is not at this time a consensus as to when to use
the surgical approach. The complication rate from the
During the last few decades enthusiasm has grown in two main surgeries have not clearly identify superiority
support of open reduction and internal fixation of Colles’ of one over the other (6). Nonetheless, the surgical tre-
fracture. The techniques most commonly recommended atment has a definite place in the armamentarium of the
are cross-pinning and plate fixation, which made possi- orthopaedic surgeon. In a number of situations, it is the
ble the attainment of better reduction and restoration of treatment of choice.

References
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to, A., Lovasz, G.: Repair of steps and gaps in articular carti- Colles‘ fractures. Clin. Orthop. Relat. Res., 38: 86–92, 1965.
lage. Clin. Orthop. Relat. Res, 430: 208–212, 2005. 8. Sarmiento, A.: Closed treatment of distal radius fractures.
2. Colles, A.: On the fracture of the carpal extremity of the radi- Tech. Orthop., 15: 294–304, 2001.
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4. Llinas, A., McKellop, H., Marshall, J., Sharpe, F., tional bracing of Colles‘ fractures: A prospective study of im-
Lu, B. Kirchen, M., Sarmiento, A.: Healing and remode- mobilization in supination versus pronation. Clin. Orthop. Relat.
ling of articular incongruities in a rabbit fracture model. J. Bone Res., 146: 175–187, 1980.
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Luck, J.: Cartilage changes caused by a coronal surface step Bone Jt Surg., 73-A: 990–1001, 1991.
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Facca, S., Livermeaux, P.: Prospective continuous study
Prof. Augusto Sarmiento, M.D.
comparing intrafocal cross-pinning HK2 with a locking plate Department of Orthopedic and Rehabilitation
in distal radius fracture fixation. Chir. Main., 32: 17–24, 2013. University of Miami, Florida, USA