LONG-TERM

G.

FOLLOW-UP
B. SMAILL,

OF

COLLESS
NEw
ZEALAND

FRACTURE

WELLINGTON,

One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions and be completely exempt from pain : the deformity, however, will remain undiminished through life. This was the prognosis given to patients with untreated Fractures of the Carpal Extremity of the Radius by Abraham Colles in 1814. He then

proceeded

to

describe

how

the

fracture limb, in this

Colless

should

be

treated time since

five to

so

as

to

recover

without

the

smallest defect How far description

ninety-seven

or deformity of the have we progressed to answer

sustained patients who

in the ordinary the 150 years question

fractures

for the cure of fractures. Colles published his classical the

six

? In an attempt

I reviewed

records
years

and

radiographs

of

previously.

Method ofstudy-All ninety-seven were circulanised and forty-one attended for re-examination. Of the remainder, eight were found to be seriously ill or deceased. The average age at the time of fracture was fifty-six years and there was a range from eighteen years to eighty-seven years with 78 per cent women. The left wrist was affected in 53 per cent of cases and the right wrist in 47 per cent. At the review the patients and
or

were wrist

asked had

about

pain, a stable

appearance, state. The

functional wrist was

limitation, examined for was which

complications
deformity

whether
and

the

reached

swelling,

measured. measurements

Antero-posterior of residual

the range of finger, wrist, elbow and lateral radiographs of both dorsal tilt and shortening of radius

and shoulder movements wrists were taken, from were made.

METHOD

OF

TREATMENT

Manipulation seventy of wrist in palmar on swelling to just removed and

stiffness

after injection of local the ninety-seven patients. flexion, ulnar deviation ceased, the plaster The Check was

anaesthetic into the fracture haematoma was done A dorsal plaster slab was then applied with the and pronation. The following day, or as soon as from just proximal to the metacarpal heads usually changed were taken after Only those physiotherapy of house ten to fourteen days later and manipulation and again at seven patients after surgeons with more than usual removal of the plaster. and registrars.

had

completed

below the elbow. at four weeks.

of

plaster was radiographs

fourteen the initial

days and on removal of the plaster. wrist or fingers were referred for was carried out

The

manipulation

by a number

OBJECTIVE

FINDINGS

Appearance-Some Three patients thickening prominence or dinner

had

cosmetic defect slight prominence

was found in twenty-five of the radial styloid

ofthe process,

forty-one patients three had slight

examined. generalised some wrist

of the wrist, and nineteen-or about a fifth of the ulnar styloid, occasionally associated fork deformity ; in eight patients this deformity

of the patients with radial was moderate

examined-had deviation of the or severe.

Prominence previous fracture

such a fracture.

of the ulnar styloid process did not appear necessarily of the process ; only ten of the nineteen patients with
There were fifty-three fractured ulnar styloids in the

to be associated with prominence had had

ninety-seven fractures.

Movement-Since the great majority of Colless fractures are sustained outstretched hand, some injury to other bones or joints might be expected. forty-one patients examined was there any other injury of the upper limbs the treatment or ultimate outcome of the Colless fracture.
80
THE JOURNAL OF BONE

by

falling on the In none of the likely to influence

AND

JOINT

SURGERY

LONG-TERM

FOLLOW-UP

OF COLLESS

FRACTURE

81 with for the it was a goniometer. purposes considered of

The This comparison

range

of movements is between not very the two

of the fingers, accurate sides, for and with

wrist absolute the

and one

elbow measurement, examiner

was

measured but, throughout,

method

adequate. Fingers and hand-Two the little finger but not years since the fracture. Two movements which had All other patients had

patients restricting arthritis

were found movement. involving

to have early It had not the

Dupuytrens progressed joints

any

contracture involving more rapidly in the of both hands, longus of the the but tendon thumb. power of

interphalangeal

were virtually full. Two patients had caused limitation of active extension patients had a full range of finger

rupture of the extensor at the interphalangeal An attempt

pollicis joint to assess

movements.
TABLE I
NORMAL

COMPARISON

OF MOVEMENTS

OF THE

AND

INJURED

WRISTS

Average

range

of movements

in degrees

Normal

Injured
58

Dorsiflexion
Palmar Radial flexion deviation

. . . .

59 50 30
40

45 30
37

Ulnar

deviation

TABLE CoMPARIsoN
OF THE
THE SMALLEST NORMAL AND

II
RANGES INJURED OF MOVEMENTS WRISTS BETWEEN

Smallest Normal Dorsiflexion . 30

range

of movements Injured wrist 30 or less

in degrees Number fractures 0 of

w rist

Palmar Ulnar
Radial

flexion deviation
deviation

30 25 20

30 or less 25 on less 20 or less

I
1

the grip examiners

was

done fingers. slight

by the somewhat crude method of asking the patient One patient had marked weakness of grip on the weakness. the components distal ulnar difference radial deviation. between of a Colless fracture If uncorrected of the of movements range are listed these various on may

to squeeze two of the injured side, and three dorsal lead injured tilt to and limitation showed uninjured styloid or III). and only only a few and radial of

others had Wrist-Among displacement palmar surprisingly

of the flexion little and

fragment. the

Measurements

wrist the

movements

sides (Tables I and Rotation-Damage by much shortening Elbow and shoulder one patient months and
VOL.

II). to the inferior of the radius, movements-No

radio-ulnar joint, shown by fracture of the ulnar might also be expected to affect rotation (Table patient had any limitation of elbow movements had been present for

had was
1.

limitation of shoulder movements, which not associated with the Colless fracture.
FEBRUARY

47B,

NO.

1965

82

G.

B.

SMAILL

Radiographic both wrists radius were sought. It was at the distal

findings-For the purposes of this study antero-posterior and lateral views of were taken (Fig. 1). Measurements of residual dorsal tilt and shortening of the made. Evidence of osteoarthritis in the wrist or inferior radio-ulnar joints was found radial that in the uninjured surface. wrists It was there found was an average of 13 degrees view ventral that, on tilt the

articular

on the

antero-posterior

FIG.

Radiographs the residual

of the normal (right) and injured (left) wrists, showing how dorsal tilt and shortening of the radius were measured.

uninjured articular fiexion

side, surface

the head of the of the radius.

ulnar was The effects

level with of residual

or very dorsal

slightly proximal tilt on dorsiflexion

to the distal and palmar

are shown in Table IV. Shortening ofthe radius was found in twenty patients which ranged from 2 to 6 millimetres. This amount had no significant effect on movements at the inferior radio-ulnar joint. Fractured ulnar styloid-This is invariably associated with subluxation of the inferior radioulnar joint as the triangular fibrocartilage is attached to the proximal part of the ulnar styloid rather than to the fossa at its base (Mayer 1940). Some writers attribute most of the poor end-results after Colless fracture to the failure to recognise the loss of integrity of the radioulnar joint as shown by fracture of the ulnar styloid (Grasby and Trick 1929, Taylor and

Parsons

1938);

motion and perhaps

is also

said

to be limited,

chiefly

in pronation and
THE

and Parsons
OF

supination, 1938).
BONE AND JOINT

and

likely

to be painful

accompanied

by a click

(Taylor

JOURNAL.

SURGERY

LONG-TERM

FOLLOW-UP

OF COLLESS

FRACTURE

83

This a fracture
injuries

review confirms that of the ulnar styloid,

rotation is limited more but that the incidence

often in those wrists in which there was of pain later is no greater than in those found in the radiographs by asymmetrical narrowing
In a few wrists there

where the ulnar styloid was left intact (Table V). Osteoarthritis-Evidence of osteoarthritis of the wrist was the forty-one patients examined. Usually this was shown joint space with some subchondral condensation
TABLE
NUMBER OF PATIENTS WITH OUT Loss OF OF

of ten of of the
was some

of the
III
THE

bone.

FORTY-ONE

REVIEWED

ROTATION

Limitation

Number ______9

of patients Pronation 1
-

Supination

Slight. Moderate
Severe
.

3
-

TABLE
THE EFFECTS OF RESIDUAL DORSAL TILT ON

IV
MOVEMENTS AFTER C0LLESS FRACTURE

N un:. ber w is

Rangeof dorsitlexion in degrees 59

Rangeofflexion palmar in degrees

Normal Fractured

side side:

41

50

0 to 13 degrees 0 to 5 degrees
5 to 10 degrees
10

ventral dorsal dorsal tilt

tilt

.
.

16

59 61
50

47 46
39

6
4

tilt dorsal tilt

degrees

or more

15

58

42

TABLE
EFFECT
OF FRACTURE OF

V
ON MOVEMENT AFTER C0LLESS FRACTURE

THE

ULNAR

STYLOID

Limitation

of rotation

Number
Number

of wrists of wrists
Total.

with without
.

fractured fractured
.

ulnar ulnar
.

styloid styloid
. .

22 19 41

10 3 11

generalised radio-ulnar Grasby

decalcification. In none was there any evidence of involvement joint; the changes in most wrists were slight. This is contrary the caused free.
SUBJECTIVE

of the inferior to the findings of precipitated by cold

and Trick (1929) but supports Three of the ten arthritic wrists weather. The others were symptom

views of Platt (1932). slight and infrequent

aching,

FINDINGS

Though It is impossible
VOL.

the subjective findings are less easy to assess, to the patient they to set a single standard of efficiency beyond which all results
1,
FEBRUARY

are all important. are declared good

47 B.
F

NO.

1965

84 and others poor. What would

G.

B. SMAILL

be considered failure patient

a good

result

in an

old

arthritic

patient

might 1929).
wrist was

be deplored as a comparative Factors of importance to the

Pain-Fourteen

in a young working are pain, functional

of some pain in the

man (Edwards limitation, and

injured wrist. In

and Clayton appearance.

only one

patients

complained

the
Nine

pain

continuous
fourteen

of the

and in no case was it ofmore than had pain only in cold weather;

moderate the site

severity-usually of the pain varied

it was slight. considerably,

ranging from the first carpo-metacarpal The type of fracture did not seem patients felt was necessary
Function-The

joint to radial to have any bearing been gardening closely before

was anything

styloid, ulnar n where the

styloid, wrist or arm. pain was felt. Three always at all.

so well with

pain only when they had to question the patients

patient was asked

or doing heavy work. Almost they would admit to any pain

that he was not able to do

it

if there

the hand in sixteen movements, small longus

No

or wrist patients such such

was

after the fracture than he could and was of three main types. as wringing clothes or opening as pins. Seven
forced
most

before. Four doors. patients was

because

Limitation of function was found patients had difficulty in twisting Five had difficulty in picking up with
of by

objects tendon.
patient

These
a change
not

included found
of
seriously

two the
occupation

rupture than
the their

of the before
injury-indeed disability.

extensor their
most

pollicis accident.
were

patients
to
were

that

wrist

weaker

housewives-and

inconvenienced

Appearance-The Some were Five ulnar looked patients satisfied Fourteen thought with

assessment complained the patients the wrist appearance

of

appearance not of a wrist

varied readily which

considerably detected was badly by

with the deformed.

the observer,

type

of while

patient. others degree. that the the wrist

of deformity thought that was generally

there was some residual thicker than the uninjured

deformity of a varying side and six noticed that

styloid was crooked.

more prominent This was a more

than on the normal side. Three complained serious complaint than the others.

COMPLICATIONS

carpal this

There are a number tunnel syndrome, series no patient

of recognised Sudecks atrophy a carpal in the atrophy

complications and ruptured tunnel syndrome time

following extensor necessitating of the

Colless pollicis fracture,

fractures such longus tendon. A few this but settled

as In had

developed

operation.

transient paraesthesiae spontaneously. Sudecks

Two patients presented

fingers about the did not occur. at review with ruptured of dexterity after their because even

extensor

pollicis

longus

tendons.

They

had become used to the lack likely that the tendon ruptured
from

which it imposed and declined operation. discharge from the fracture clinic about there if the was patient no mention did not of it in the draw attention records to it.

It seems eight weeks and it is

the

time to have

of the been

fracture, overlooked

unlikely

PROGRESS

None in the same state from

of the patients of the two injured or three

examined wrist months over after

felt that the removal

there

had three of their

been

any

change, In fact

for better most had

or for worse, remained the

previous

years. plaster.

DISCUSSION

This following and it was Trick felt

complicated

survey Colless 1929,

forms

was

made

to confirm were and not Werley not

or so bad

deny

a clinical writers

impression would lead

that one

the

overall

results (Grasby

fractures Gartland
of

as some

to believe

treatment

(DePalma

that

the

position

could

There has recently 1952, Scheck 1962) be maintained by the more

THE JOURNAL

1957).

been a trend towards more for Colless fracture because orthodox splints or plasters.
OF BONE AND JOINT SURGERY

LONG-TERM

FOLLOW-UP

OF

COLLESS

FRACTURE

85 raged Trick throughout 1929, Fairbank which the years 1932, I feel is

This
on

is a more how best unjustified

No attempt

disturbing to hold 1932,

has

development fracture 1932, light

made

of a controversy after 1932,

points

which (Grasby 1932).

has and

a Colless Howell

reduction Page study.

for

Girdlestone quite

Jones
to award

It is a development
appearance

in the
been

of the

present

movements,

or complications,

because it is felt with such widely

the patient is, on

that this is an artificial and varying ages and occupations.

the whole, perfectly satisfied

invalid The
with

method of assessing a result real criterion of a good result

the result. In this series there

in patients is whether
war no

doubt

that

the

vast

majority

were

quite

satisfied.

SUMMARY

I 2.

A five-year
The no objective reason to belief

follow-up
results depart that

of forty-one
were from not the so present the

patients
satisfactory methods would

who
as of

sustained
the managing full

Colless
but these painless

fractures
overall by injuries function

was
there

made.
seems to

subjective,

be

manipulation irrespective of

and
3.

immobilisation
CoIless

in plaster.
in time patient regain

how
I wish

the
to

fracture
thank Mr

was
J. H.

treated
North,

seems

to be vindicated.
Wellington Hospital, for permission to publish this

Superintendent-in-Chief,

paper and also in its preparation.

Sister

M. F. Marsh,

Mr L. G. Symons

and

Miss

P. 1. Keith

for their

considerable

assistance

REFERENCES
COLLES,

A.

(1814): 10, A. F. 182.

On (1952): and

the

Fracture

of

the

Carpal of 651.

Extremity the Distal of

of

the

Radius. of the End

Edinburgh Radius of the Treated Radius Meeting Fractures.

Medical by

and Ulnar

Surgical Pinning. British British of Bone British British

Journal,
DEPALMA,

Comminuted Joint Surge E. ColleSs WERLEY, Bellis

Fractures y, 34-A, (1929):

End the

Journal
EDWARDS,

of Bone

H.,

and

CLAYTON,

Fractures Section (1951):

Lower

in Adults.
of B.M.A. Journal

Medical
FAIRBANK,

Journal, H. A. Journal,

i, 61. Fracture: C. W. of Orthopaedics, Evaluation of Healed Centenary Colles i, 268.

T. (1932):

Medical
GARTLAND,

J. J., Jun.,
Joint Surgers, Journal, E. B. R. D., and Journal, Whitchurch MedicaiJournal, (1932): Colless ii,268.

and

and
GIRDLESTONE,

33-A, 895. G. R. (1932): ColIess

ii, 268. TRICK, i, 391. (1932): ii, 268. Fracture: Fracture.

Fracture:

Section

of Orthopaedics,

Centenary

Meeting of Colless
Centenary

of B.M.A. Fractures.
Meeting British of

Medical
GRASBY,

S. R. (1929):
Colless Section

An Investigation
Fracture: Section

of the End-Results
of Orthopaedics, Meeting

Medical
HOWELL,

B.M.A. Medical

British
JONES,

of Orthopaedics, British Journal

Centenary of Surgery,

of

B.M.A.

Journal,
MAYER, PAGE,

J. H. (1940): C. M. (1932):
Journal, ii, 268.

Colless

Colless Colless

Fracture: Fracture. with

20,

Section
British

ofOrthopaedics,
MedicalJournal, of Treatment of

27, 629. Centenary Meeting

ofB.M.A.

British

Medical

PLATT,

H. (1932):
M. G. (1962): W.,

ii, 288. Comminuted Journal Discus ofBone Articulanis Fractures and of Joint the Distal End 44-A, of 337. of the

SCHECK,

Long-term
PARSONS,

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Radius
TAYLOR,

by Transfixation
and and Joint Surgery,

Kirschner
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Wires
The

and
Role

Cast.
of the

Surgery, Fracture.

C. L. (1938):

in Colles

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VOL.

47 B,

NO.

1,

FEBRUARY

1965