# Upper Limb Orthotics/Colles' Wrist Fracture
## Describe your case study

The patient, Nancy, is a 65 year old retired female who suffered a colles’ fracture on her right arm following a slip on a wet floor, onto her outstretched hands. She has had no previous wrist fractures. However has recently been diagnosed with osteoporosis. The injury was classified as a 23-A2 fracture according to the Muller AO Classification system, a closed transverse fracture with a minimally displaced distal fragment. No surgery was required and it was deemed appropriate for conservative treatment. It was placed in a POP backslab initially, to let the swelling reduce before a volar wrist splint was applied.
She enjoys gardening and regularly plays lawn bowls. She volunteers with the country women’s association and would like her wrist to be able to cope with the demands for an event in 10 weeks.

## Written information
### Evidence

A true Colles’ fracture as defined by Abraham Colles' is a fracture of the distal radius within 2.5 cm of the wrist joint with the distal fragment dorsally displaced. However this term can also be applied to similar fractures that are outside this original definition (Summers, 2005). In elderly patients, it is usually a product of low energy trauma, such as a fall onto outstretched hands and is the most common fracture type in people over the age of 40 (Apley & Solomon, 1993). Nguyen et al (1993) report that it is an instinctive response to put a hand out when falling as this saves injury to the face. Complications can arise from both the fracture and treatment and most commonly include median nerve compression, ligament damage, loss of motion or malunion (Turner, Faber & Athwal, 2007).Turner et al (2010) reported that skin injury was also quite common, especially in elderly patients as overlying skin can be quite thin and could be traumatized during the fracture manipulation. Once the wrist has been fractured, it increases the risk of another wrist fracture threefold and doubles the risk of another osteoporotic fracture occurring. The distal radius is commonly injured as it has the thinnest area of compact bone (Lindsay 1990 & Russell et al. 1990).
Sànchez-Riera et al (2010) state that osteoporosis, the systematic skeletal disease which causes low bone mass and deterioration of bone tissue is often responsible for fragility fractures in the hip, distal radius and ankle regions. The prevalence of osteoporosis increases with age and occurs when bone resorption exceeds bone formation (Nieves, Mosner & Silverstein, 2012). The most useful methods for estimating fracture risk are bone mineral density testing using dual energy x ray absorptiometry and consideration of clinical factors such as gender, age or previous fractures (Sànchez-Riera et al, 2010). If an individual aged 50 or older scores −2.5 T-score or less than the mean BMD value in young females, which is measured at the lumbar spine, hip or femoral neck, osteoporosis may be diagnosed. Age is the most important clinical risk factor and it has been shown that the risk of fracture increases with age and it rises dramatically from 50 to 80 years of age (Sànchez-Riera et al, 2010).

### Orthotic treatment options

The primary goal of orthotic management is to immobilize the fracture so that healing can occur in the correct alignment and so that the patient can return to normal function as soon as possible (Blakeney, 2010). For this type of fracture, there are many differing opinions and reviews on what position the wrist should be placed in when casting. As a result there is no one definitive treatment. Gupta (1991) has shown that casting the wrist in dorsiflexion has the lowest incidence of the fracture displacing compared to neutral or palmar flexion. However the wrist position can be dependent on the mechanism of injury.
Typically, a below elbow plaster cast is applied as the primary immobilization as it allows some room for swelling after an acute injury. In this case, less layers of plaster would be used for elderly patients to ensure the cast is lightweight (Drozd, Miles, & Davies, 2009). In this case, the initial position of the wrist is slightly extended, between 10 and 20 degrees and in slight ulnar deviation. Upon re-alignment of the distal fragment using a closed reduction technique in this case, some form of padding is layered on the wrist to act as barrier between the skin and the cast (Salvi, 2011). During a 10-day follow-up the original plaster cast may be removed and replaced with a secondary cast such as a thermoplastic volar brace. In a study conducted by Khudairy, Hirpara, Kelly &Quinlan (2012), thermoplastic splints were used to immobilize Colles’ fractures. Patient satisfaction was high and there was no deterioration in radiological outcomes. Fibreglass is also an option, although in this case the use of thermoplastic will be much lighter in weight.
Closed reduction and cast immobilization is the most used form of treatment for minimally displaced, stable fractures, such as this case. Conservative management is also acceptable for unstable fractures in the elderly or those considered too frail to undergo surgery (Blakeney, 2010). Multiple studies have examined the different methods of casting and materials used and anatomical outcomes such as return to function, malunion rates and decreases in angulation. A prospective randomized trial compared the use of plaster casts and prefabricated fibroelastic splints. It concluded that there was no significant difference between casts in terms of anatomical outcome or pain levels, however the splint group scored better in cast satisfaction and had lower complication rates. The lightweight splint also provided a more economic efficient option and allowed faster restoration of function and mobility (O’ Connor et al, 2003). Another study looked at the differences in using a dorsal splint or a complete cast in the first 10 days after the fracture. It was concluded that there was decrease in dorsal angulation in the dorsal cast and the complete cast increased the radial length. However these results were considered to be too small to influence clinical results (Wik, Aurstad & Finsen, 2009).
In addition to conservative management of the wrist fracture, osteoporosis also needs to be treated. One option, vitamin D supplementation with calcium has been shown to reduce the risk of a fracture in patients aged over 65 years and increase bone mineral density (Blakeney, 2010).

### Comparison of orthotic treatment options

There are many options involved with the stabilization of the distal radius, which include internal surgical techniques such as volar locking plating and percutaneous Kirschner wiring External fixation techniques, wrist bridging or nonbridging are also available, however the age, bone density and fracture classification of each patient are important factors when considering these techniques (Blakeney,2010) . Functional and anatomical outcomes such as radial length, angulation of the distal fragment, mobility and complications are important factors when assessing the success of each treatment (Atroshi et al, 2006). Colles’ fractures in osteoporotic bone have greatly reduced stability which means that surgical fixation is more difficult. The fixation technique used, either pins, wires or plates cannot gain a reliable hold in the bone and this tends to lead to the fracture becoming displaced (Blakeney, 2010).
Fractures of the distal radius have been treated with external fixation techniques since the 1940s and are now more commonly used with unstable fractures. There are two main techniques of external fixation; wrist bridging, where the distal pins are inserted across the wrist joint and into the second metacarpal to immobilize the joint and nonbridging, where distal pins are only inserted into the radius and allows for wrist movement (Blakeney, 2010). The external fixation techniques were compared and it was found that the range of motion at the wrist and forearm 4 weeks after fixation removal was nearly identical, although radial shortening was significantly less with the nonbridging technique. The main weakness of using external fixation are the complications involved, such as pin track infection (Atroshi et al, 2006).
It was thought that internal fixation devices have a much weaker hold in osteoporotic bone and were more likely to loosen and lose fracture alignment. However with the introduction of the fixed-angle locking plate, this has changed the treatment of distal radius fractures in the elderly. The fixed-angle locking screws lock into the plate and don’t rely on any connection with the screw thread in the bone, which reduces the bone instability factor.(Blakeney, 2010). The biggest inconveniences with this technique are the cost involved and the need for a second operation to remove the plates (Maire et al, 2013).In a study conducted by Lee, Wei, Cheng, Hsu, & Huang, (2012) comparing the use of volar plates and percutaneous wiring, it was found that the use of plating increased stability of the fracture and that the reduction of the fracture was maintained better. The cohort of participants were between the ages of 50 and 70 years of age and in both groups of fixation techniques, low complication rates and high union rates.
Surgical treatment of Colles’ fractures remains controversial. Few authors recommend orthopaedic treatment as the first option(Maire et al, 2013 & Chung, Shauver & Birkmeyer, 2009), not only because it is badly tolerated by the patient, but also due to the increased costs involved. Few authors recommend external fixation techniques which is also badly tolerated and can involve secondary infection complications. Many surgeons recommend surgical pinning, which is quick and inexpensive, however this technique may not work well with elderly patients (Maire et al, 2013).
In a patient such as this one, with multiple comorbidities, conservative management is a safer option and is likely to provide similar clinical outcomes as other surgical techniques. Even if malunion occurs, functional outcomes in elderly patients are still acceptable. In between these two options, treatment decisions need to take into account more than the type of fracture and include patient goals, patient preference medical comorbidities and surgeon familiarity with techniques (Blakeney, 2010). Minimally displaced Colles’ fractures such as this case, are common in elderly individuals and have substantial implications on health resources. Results suggest that a lightweight splint offers an acceptable, comfortable and cheaper alternative to a plaster of Paris cast and also allows faster restoration of function without an increased risk of malunion (O’ Connor et al, 2003)

## Search Strategy

The following databases were used for the collection of these articles: Cinahl, Cochrane, Proquest, Medline and Google Scholar. Search terms such as “colles’ fracture management”, osteoporosis, osteoporosis and women, distal radius fracture, elderly, aged etc.