COLLES FRACTURE: DOES THE ANATOMICAL RESULT

AFFE#{128}T THE FINAL FUNCTION?

MARGARET MCQUEEN, JEANETTE CASPERS

From the Princess Margaret Rose Orthopaedic Hospital, Edinburgh

Thirty patients who had sustained a Colles’ fracture at least four years previously were examined
functionally and radiographically. Seventeen had a good radiological result and 13 were considered to have
malunion. Functionally the displaced group performed significantly worse than the undisplaced group. We
conclude that malunion of a Colles’ fracture results in a weak, deformed, stiff and probably painful wrist.

A Colles’ fracture is one of the most common fractures their fracture by a fall on to the outstretched hand and
encountered by the orthopaedic surgeon, and at times had undergone similar initial treatment by manipulation
one of the most challenging. Since it was first described under regional anaesthesia and immobilisation in a
by Abraham Colles in 1814, there has been continuing forearm plaster for five to six weeks. Follow-up ranged
controversy about the best method of treatment. A from four years to six years nine months (mean five years
central issue throughout has been the relationship one month). Thirteen patients had fractured the domi-
between the final anatomical and the final functional nant and 1 7 the non-dominant wrist.
result. Standard anteroposterior and lateral radiographs of
In 1950, Cassebaum stated that few patients had both wrists were taken and measurements of dorsal
pain more than a year after a Colles’ fracture even in the angulation and radial shift were recorded (Van Der
presence of considerable deformity, and that no person Linden and Ericson 1981). On the basis of these
who had a Colles’ fracture more than five years old had measurements the 30 patients were divided into two
any serious functional complaints. This optimism has groups. Group 1 included the patients whose fractures
been echoed by some authors (Mason 1953 ; Older, united with 10#{176}
or less of dorsal angulation and less than
Stabler and Cassebaum 1965; Benjamin 1982) and 2 mm of radial shift. There were 1 7 patients in this
challenged by others (Frykman 1967; Saito and Shibata group, 16 women and one man, their average age being
1983; Melone 1986). Most of these opinions have been 67 years. Group 2 included 13 patients with dorsal
based on either subjective or single objective tests of angulation ranging from 12#{176}
to 34#{176}
and more than 2 mm
hand and wrist function. of radial shift. All were women and their mean age was
This paper aims to assess objectively the functional 71 years.
results of Colles’ fractures in relation to the final The function of both hands and wrists was tested by
anatomical results. one author (JC), who had no prior knowledge of the
radiological measurements. The tests used were based on
a recent review of assessment of hand function (Dent,
MATERIALS AND METHODS
Smith and Caspers 1985).
Thirty patients who had sustained a Colles’ fracture at Grip strength was assessed using the Jamar dyna-
least four years previously were reviewed. None had mometer (Bechtol 1954) and the Musur-Grieve spring
radiological extension of the fracture into the radiocarpal balance (Musur-Grieve 1984) with interchangeable
joint. There were 29 women and one man with an age handles to allow assessment of hook, cylinder, key chuck
range of 56 to 86 years (mean 69 years). All had sustained and pinch grips. Grip endurance was tested on the latter
apparatus using the hook grip. Manual dexterity was
assessed using the Jebsen test (Jebsen et al. 1969)
supplemented by the Moberg test performed with the
M. McQueen, FRCS, Lecturer
J. Caspers, BS, OTR, Senior Occupational Therapist eyes open (Moberg 1956).
Princess Margaret Rose Orthopaedic Hospital, Fairmilehead, Edin-
burgh EH1O 7ED, Scotland.
The ability to perform both unilateral and bilateral
Correspondence should be sent to Miss M. McQueen.
activities of daily living such as lifting weights, turning
keys, using scissors, etc., was assessed and scored
© 1988 British Editorial Society of Bone and Joint Surgery
0301-620X/88/4135 $2.00 according to the amount of difficulty in performing these
J Bone Joint Surg [Br] 1988;70-B:649-5l.
activities (Sheehan, Sheldon and Marks 1983). The range

VOL. 70-B, No. 4, AUGUST 1988 649

650 M. MCQUEEN, J. CASPERS

of movement (flexion/extension, pronation/supination, The difference between the two groups was statisti-
radial/ulnar deviation) was measured in both wrists cally significant (x2 13.3, p<O.OO1).
using a goniometer. The unaffected wrist was taken as
Tests of strength - the Musur-Grieve spring balance. In
the normal range for each patient. Sensation and motor
Group 1 , 16 of the 17 patients had normal strengths of all
power in the median nerve distribution also were tested.
different types of grip as compared with the normals
Pain was assessed using an analogue scale which
published by Swanson, Goran-Hagert and de Groot
was then divided into three equal parts representing
Swanson (1984) and compared to the opposite side ; the
mild, moderate and severe pain. An analgesic history
exception was again in the patient with median nerve
was also taken. Finally the examiner’s assessment of
compression. In Group 2 only seven of the 13 patients
cosmetic deformity was recorded. Statistical analysis was
had normal grip strengths and endurance. Of the other
performed using the chi-squared test.
six patients, four had very poor endurance of grip, two
had weakness of all types of grip and three had weakness
RESULTS of one or more types of grip. The difference between the
two groups was statistically significant (j2 9.8,
The results are summarised in Table I.
p<O.Ol).
Tests of strength-Jamar Dynamometer. In Group 1 the,

“undisplaced “ group, 15 of 17 patients had grip Tests of dexterity. In both groups all the patients
strengths within the normal range for age, sex and performed the Jebsen test within the time limit. The
dominance in both hands (Bechtol 1954). One patient maximum time taken for any one test in Group 1 was 9.5
had reduced grip strength bilaterally with only 10 kg in seconds and 12.4 seconds in Group 2. Similar results
the dominant unaffected right hand and 9 kg in the non- were seen in the Moberg test with the eyes open. One
dominant affected left hand. This patient had osteo- patient in Group 1 took 10 seconds longer to perform the
arthritis of the proximal interphalangeal joints. One test with the dominant affected hand ; not surprisingly,
patient had a 17% reduction in grip strength in the this was the patient with median nerve compression.
dominant affected hand but also had signs and symp- Activities of daily living. In Group 1, 16 of the 17 patients
toms of median nerve compression. had no difficulty whatsoever with either unilateral or
bilateral activities of daily living. The patient with
Table I. Percentage of normal results in each group for each test median nerve compression had difficulty with all
activities.
Group 1 Group 2 Statistical Eight of the 13 patients in Group 2 had no difficulty
Test Good position Malunion significance
with the activities of daily living. Three of the others had
Jamar Dynamometer 88 31 pczO.00l difficulty with one or two of the tests, mainly those
Musur-Grieve spring 94 54 p<O.Ol involving strength, e.g., lifting a weight in a bucket. Two
balance patients had considerable difficulty with these tests ; both
Activities of daily 94 62 p<O.OS had sustained fractures in the dominant hand and now
living use the non-dominant hand for the activities of daily
Range of movement 88 31 p<O.Ol living. Again there was a statistically significant differ-

Pain 88 62 NS
ence between the two groups (x2 4.88, p<O.OS).

Median nerve function. One patient in each group had

Cosmesis 88 8 p<O.OOl
sensory deficit in the median nerve distribution. The
patient in Group 1 also had clinically detectable motor
weakness.
In Group 2 only four of the 13 patients with
malunion had normal grip strength in the affected hand Range of movement. In Group 1, 15 of the 17 patients had
allowing for age, sex and dominance. In five patients the similar ranges of movement in both wrists, with no more
grip strength in the non-dominant fractured wrist was than 10#{176}
difference in any measurement. The patient
more than 30% less than the dominant non-affected side. with median nerve problems had lost 30#{176}
ofextension but
Bechtol (1954) has stated that the non-dominant hand other movements were normal. One other patient lacked
may be as much as 30% weaker than the dominant, 45#{176}
of supination and 20#{176}
of pronation ; radiologically
although most subjects have only 5 to 10% differences. there were degenerative changes in the distal radio-ulnar
Four of our patients had fractured the dominant wrist joint. However, four other patients in this group had
and in all of these the grip strength was less than that on radiological evidence of radio-ulnar joint degeneration,
the non-dominant side and below the lower limit of although they had normal rotation.
normal. The weakest grip was 5 kg in a dominant In Group 2, only four of the 1 3 patients had similar
affected wrist which had a residual dorsal angulation of ranges of movement in both wrists. Five patients had
28#{176}
; this was 48% of the grip in the non-dominant reduction in pronation/supination of more than 20#{176},
the
unaffected side. worst patient having only 45#{176}
ofeach. Seven patients had

THE JOURNAL OF BONE AND JOINT SURGERY

 COLLES FRACTURE: DOES THE ANATOMICAL RESULT AFFECT THE FINAL FUNCTION? 651

a reduction of between 20#{176}

and 40#{176}
in the flexion/exten- able to median neuropathy but only one patient in each
sion arc of movement. Four patients had lost 15#{176}
to 35#{176}
of group showed evidence of median nerve symptoms or
radial/ulnar deviation. signs. Stiffness and deformity are not surprising follow-
The difference between the two groups reached ing malunion and it is agreed that dorsal angulation will
statistical significance (j2 12.44, p<O.Ol). restrict the flexion/extension arc.
Pain. Two ofthe patients in Group I complained of pain. Our study demonstrates that malunion of a Colles’
In one patient this was graded as mild on the analogue fracture results in a weak, deformed, stiff and probably
scale and she required no analgesia. The second patient painful wrist with a likelihood ofdifficulty in performing
with pain had median nerve symptoms and graded her the normal activities of daily living. It is therefore
pain as moderate. Five patients of the 1 3 in Group 2 had
essential to strive for as anatomically accurate a result as
pain. Three of these graded their pain as severe and
possible in order to ensure minimal functional deficit.
required regular analgesia. One patient considered her
No benefits in any form have been received or will be received from a
pain to be moderate and one mild. commercial party related directly or indirectly to the subject of this
The difference in incidence of pain between the two article.

groups was not statistically significant although no

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