Injury (1992) 23, (8), 529-532 Printed in Great Britain 529

Long-term prognosis of displaced Colles’ fracture: a IO-year prospective review

J. Field, D. Warwick, G. C. Bannister and A. G. F. Gibson University Department of Orthopaedics, Southmead Hospital, Bristol, UK

In all, 85 per cent of Colles’ fracfures are clinically satisfac~oy after 10

years. Clinical results improve little afkr 3 months. Disphcti intra- articular fracture, wrist deformity and algodystrophy are associated with

an unsatisfactory outcome.

Introduction

Colles (1814) wrote that, following the fracture he described, ‘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 throughout life’. While there are many reports of complica- tions (Cassebaumm, 1950; Cooney et al., 1980; Altissimi et al., 1986), most studies have been retrospective and because of this few have been able to test Colles’ hypothesis that function would recover with time.

Cassebaum (1950) found a higher prevalence of good results in different cohorts of patients examined after 2-15 years than after 3-6 months, but LidstrGm (1959) recorded the converse.

The aims of this study were to establish:

1. The long-term prognosis of Colles’ fracture. 2. Whether patients improved with the passage of time. 3. The factors associated with an unsatisfactory

outcome.

Materials and methods

In 1981, 100 consecutive patients with displaced unilateral Colles’ fractures were treated by closed reduction under intravenous regional anaesthesia and cast immobilization for 5 weeks. No fracture was remanipulated. All patients received physiotherapy, the duration of which was gover- ned by individual need. The mean age on presentation was 61 years and 10 months (range 17-88 years). Patients were assessed by Saxmiento et al’s (1975) modification (Table I) of Gartland and Werley’s (195 1) scoring system after 5 weeks, 12 weeks and 10 years. After 10 years, patients were assessed specifically for pain on an analogue scale (Hus- kisson, 1974) and grip strength using the Jamar dynamome- ter (Bechtol, 1954). Algodystrophy was assessed by the criteria described by Atkins et al. (1989). Cosmetic deform- ity was recorded both objectively and subjectively. The

0 1992 Butterworth-Heinemann Ltd 0020-1383/92/080529-04

early and late examinations were performed blind by different authors.

Anteroposterior and lateral radiographs of both wrists were performed on all patients on presentation and on 51 at long-term review. Fractures were recorded as being intra- or extra-articular on presentation, and wrists assessed for

Table I. Modified Gartland and Werley scoring system to evalu- ate the end results of headed Colles’ fracture

Result Points

Residual deformity Residual dorsal tilt Radial deviation of hand

Maximum

Subjective evaluation Excellent - No pain, disability, or motion limitation Good - Occasional pain, slight limitation, no disability Fair-Occasional pain, some limitation, some disability Poor - Pain, limitation of movement, marked disability

Maximum

Objective evaluation Loss of dorsiflexion < 45” Loss of ulnar deviation < 30 Loss of supination < 50 Loss of palmar flexion < 30 Loss of radial deviation < 15” Loss of circumduction Pain in the distal radioulnar joint

Maximum

Complications Arthritic change

Minimal Moderate Severe

Nerve complications Poor finger function Grip strength < 50% normal side Poor finger function

Maximum

Point range on a deduction scale Excellent Good Fair Poor

: 2-3

6

5 3 2 1 1 1 1

14

1 2 3 l-3 l-2 1 l-2

14

o-2 3-8 9-20

21 +

530 Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 8

degenerative changes on late films. Osteoarthrosis was graded by the presence of joint space narrowing, osteo- phytes, articular sclerosis and periarticular cysts. If one of these changes was present the degenerative change was graded as mild, if two moderate, if three or more severe. Of the original 100 patients, 35 had died, five could not be traced and five refused assessment stating that their wrists were symptom free. After 10 years, 55 patients were assessed clinically. The mean age was 68 years and 10 months (range 26-90 years). There were 21 fractures of the right wrist and 34 of the left; 50 patients were right handed.

Statistical analysis Data were analysed by the 1’ test with Yates’ correction and the Spearman Rank test.

Results

Clinical (Tubks II III) Using Gartland and Werley’s (1951) criteria, 89 per cent of patients had satisfactory results after 3 months and 85 per cent after 10 years. More patients had excellent wrists after 10 years (P<O.Ol). Between 3 months and 10 years, 23 patients (42 per cent) improved, 21 (38 per cent) remained the same and ll(20 per cent) deteriorated by no more than one grade.

Pain. After IO years, 31 patients (56 per cent) were pain free and three patients (7 per cent) experienced discomfort of 30 per cent or more as recorded on a pain analogue scale.

Grip strength. Grip strength was greater in the fractured wrist in eight patients (15 per cent), the same on each side in 25 (46 per cent), reduced by less than 50 per cent in 14 (25 per cent) and more than SO per cent in the remaining eight.

Grip strength was not influenced by hand dominance. There was no correlation between overall function and grip strength.

The Gartland and Werley (1951) score is a demerit system devised by an orthopaedic surgeon and radiologist with 17 of the 40 possible demerit points allocated for objective range of movement. It may be flattering, because to achieve a poor result a patient would have to complain of pain, stiffness, restricted activity, have a deformed wrist, have lost dorsiflexion and supination and have severe osteoarthritic change in the joint.

The prevalence of reduced grip strength in this study is the highest reported, and as grip strength correlates poorly with the functional score, this indicates that grip strength alone is a poor indicator of hand function.

In all, 44 per cent of patients in this study complained of pain, which may relate to the pain analogue scoring method. The only other study to use this technique (McQueen and

Caspers, 1988) recorded pain in 23 per cent of patients, none of whom had intra-articular fractures. The vast majority of cases in this series experienced minimal discomfort.

In previous series, algodystrophy occurred in between 0.1 per cent (Bacom and Kurtzke, 1953) and 10 per cent (Lidstrom, 1959). When separate components of algodys- trophy were identified (Atkins et al., 1989), 25 per cent of patients were affected after 9 weeks. A similar proportion of patients with one or more features of algodystrophy was found in this study after 10 years, suggesting that they may not resolve with time. As all patients received physio- therapy, it is not possible to appraise its value.

The proportion of patients with objective evidence of wrist deformity is almost identical to that reported in previous series (bidstrom, 1959; Smaill, 1965). As in Smaill’s (1965) series, there were fewer subjective complaints of wrist appearances than objective, the findings in this study support Colles’ (1814) original premise.

The greater prevalence of osteoarthrosis after displaced intra-articular fractures has been found in previous series (Grasby and Trick, 1929; Gartland and Werley, 1951; Lidstrom, 1959). The finding of similar osteoarthrosis in the

Table II. End results of 55 cases of healed Colles’ fracture assessed using the modified Cartland and Werley scoring system

TabIeIV. Subjective and objective assessment of cosmetic deformity 10 years after Colles’ fracture (number of cases)

Total cases

End result 5 weeks 1.7 weeks

Excellent 1 (2) 10 (18) Good 11 (20) 39 (71) Fair 37 (67) 6(tl) Poor 6(11) 0

Figures in parentheses are percentages.

10 years

26 (47) 21 (38) jp8

6(ft) 2 (4)

Deformity Subjective Objective

None 31 20 Moderate 21 31 Severe 3 4

Objective criteria Severe: Dinner-fork deformity, prominent ulnar styloid, radial deviation at the wrist. Moderate: Prominent ulnar styloid, minimal wrist swelling.

Table III. End results of 55 cases of Colles’ fracture depending on fracture type

Fracture type

Result

Excellent Good Fair Poor

Extra-articular Intra-articular (N=29) (N=26)

5 weeks 9 weeks 10 years 5 weeks 9 weeks 10 years

1 6 18 0 4 6 7 19 8 4 19 13

19 4 2 18 3 4 2 0 1 4 0 1

Field et al.: Long-term prognosis of displaced Colles’ fracture 531

opposite uninjured wrist demands fuller explanation. The phenomenon has been demonstrated in the untraumatized knee after meniscectomy (Doherty et al., 1984, and it would suggest that either patients have a predisposition to develop osteoarthrosis or that some humeral agent is activated by trauma causing osteoarthrosis at a distant site.

Carpal instability after 10 years did not correlate with functional outcome, although Bickerstaff and Bell (‘1989) have suggested such an association.

Smaill (1965) reported that most patients had remained the same clinically from 2-3 months after removal of the plaster. While the same proportion in this study had satisfactory wrists after 3 months and 10 years, over 60 per cent of patients had changed a grade, twice as many improving as deteriorating.

This study confirms that intra-articular fractures and wrist deformity (Bacom and Kurtzke, 1953; Lidstriim, 1959; Smaill, 1965), are associated with an unsatisfactory outcome, but identifies algodystrophy as an additional major factor.

Cosmetic deformity (Table IV). There was objective evi- dence of cosmetic deformity in 64 per cent, while subjec- tively 44 per cent of patients complained of the appearance of their wrists. This difference is significant (PC 0.05). In the majority, the deformity was no worse than moderate, less than 7 per cent of all cases being severe. Both objective and subjective deformity correlated with the Gartland and Werley (195 1) functional score (P < 0.01).

Algodystrophy. In all, 15 patients (27 per cent) exhibited one or more of the four components of algodystrophy - namely, pain, swelling, finger stiffness and vasomotor motor instability (Atkins et al., 1989). Twelve patients (22 per cent) had a more painful hand on the affected side. One patient showed swelling, two demonstrated finger stiffness and nine (16 per cent) showed evidence of vasomotor instability. Of the 15 patients with features of algodystrophy, four had stiff fingers after 6 weeks and six after 12 weeks. All those with finger stiffness after 12 weeks demonstrated features of algodystrophy at 10 years (PC 0.001).

General complications. Two had Dupuytren’s contracture; one patient had rupture of the extensor pollicis longus tendon and one other patient had distal radioulnar pain relieved by a Darrach’s procedure (all these patients show- ing evidence of algodystrophy).

Radiological

Osteoarthrosis. While 17 patients (33 per cent) had osteoarthrosis in the radioulnar and radiocarpal joints, this prevalence and severity correlated closely with carpometa- carpal arthritis in the same hand (PC 0.001). The prevalence and severity of osteoarthrosis was similar in fractured and uninjured wrists (PC 0.001). Osti?arthrosis occurred slightly more frequently in displaced intra-articular fractures.

Carpal instability. Of injured wrists, 7 per cent demon- strated instability on a single lateral radiograph in ulnar deviation (Taleisnik and Watson, 1984), but all had a satisfactory functional result.

Deterioration and unsatisfactory results. Eight (31 per cent) wrists with intra-articular fractures deteriorated by one grade between 3 months and 10 years on the modified Gartland and Werley (1951) score, compared with 10 per cent of extra-articular fractures (PC 0.05).

The prevalence of components of algodystrophy was significantly greater in patients who deteriorated than in

those whose wrists improved with the passage of time (PC 0.05).

Of the eight unsatisfactory results, six showed evidence of algodystrophy and seven of osteoarthritis. Of the patients with algodystrophy, 50 per cent had unsatisfactory results compared with 28 per cent of those with osteoarth- ritis.

Deterioration was not associated with fracture of the ulnar styloid.

Discussion

The reported outcome of Colles’ fracture varies according to the assessment criteria used and fracture types in the different series reported.

The Gartland and Werley (195 I) scoring system has been the most widely used (Gartland and Werley, 1951; Cole and Obletz, 1966; Sarmiento et al., 1975; Altissimi et al., 1986; Stewart et al., x985), and was employed to permit compari- son with other studies.

Acknowledgement

The authors would like to thank Dr David Prothero for his statistical advice.

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Paper accepted 14 April 1992.

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Rpqmts for reprints should be uddrmd to: Mr J. Field, University Department of Orthopaedics, Southmead Hospital, Westbury-on-

Trym, Bristol BSIO 5NB, UK.