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VO L. 70 -B , N o. 4 , A UG UST 1988 64 9

COLLES FRACTURE : DOES THE ANATOM ICAL RESULT

AFFE#{128}T THE FINAL FUNCT ION ?

MARGARET M CQUEEN , JEANETTE CASPERS

F rom the Pr incess M argare t Ro se O rth opa ed ic H o sp ita l, E d in burgh

Thir ty patien ts w ho had su sta in ed a C o lles ’ frac tu re a t least fo u r years p rev iou sly w ere exam in ed

fun c tio na lly and rad io graph ica lly . S even teen had a good rad io log ica l re su lt and 13 w ere con sid ered to hav e

m alu n ion . F un ctio na lly th e d isp laced grou p perfo rm ed sign ifican tly w o rse than th e und isp la ced g roup . W e

conc lude tha t m a lun ion of a C o lle s ’ fra ctu re resu lts in a w eak , d efo rm ed , s tiff an d probab ly p a in fu l w ris t.

A C olle s’ frac tu re is o ne o f the m ost com m on frac tu res

encoun te red by the ortho paed ic surgeon , an d a t tim es

on e of th e m ost cha lleng in g . S in ce it w as firs t de sc rib ed

by A braham C olles in 1814 , th ere has been con tin u ing

con troversy abou t the best m etho d of trea tm ent. A

cen tra l is sue th roughou t has been the re la tio nsh ip

b etw een the fin al ana tom ical an d the fina l func tion al

resu l t .

In 19 50 , C asseb aum stated tha t few p a tien ts had

pa in m ore than a year a fte r a C olles’ frac tu re even in the

p re sence o f co nsid erab le de fo rm ity , and tha t no pe rso n

w ho h ad a C olle s’ fractu re m o re than fiv e yea rs o ld h ad

any serious func tiona l com pla in ts. T his o p tim ism has

b een echo ed by som e au tho rs (M ason 1953 ; Old e r ,

S tab le r and C assebaum 1965 ; B en jam in 1982 ) an d

ch allenged by o thers (F rykm an 1967; S aito and Shiba ta

1983 ; M elo ne 1986). M o st o f these op in io ns h av e b een

based on e ith er sub jec tive o r s ing le o b jec tive tests o f

hand and w rist fu nc tio n .

T h is paper a im s to assess o b jective ly the func tiona l

resu lts o f C o lle s’ frac tu re s in rela tio n to the f ina l

ana tom ica l resu lts .

M ATER IA LS AND M ETHODS

T hir ty pa tien ts w ho had su sta ined a C o lle s’ frac tu re a t

leas t fo u r yea rs p rev io usly w ere rev iew ed . N one had

rad io log ica l ex tens ion of th e fractu re in to the rad io ca rpa l

jo in t. T he re w ere 29 w om en and on e m an w ith an age

ran ge o f 56 to 8 6 y ea rs (m ean 69 yea rs) . A ll had su sta ined

M . M cQu een , FRC S, L ectu rer

J . C aspers, B S , O TR , Sen ior O ccupa tio nal Th erap is t

Prince ss M argaret R ose O rth op aed ic Ho sp ital , Fairm ileh ead , Ed in -

bu rgh EH 1O 7ED , Scotland .

C orre spond ence should be sent to M iss M . M cQ ueen.

© 1988 B ritish Ed ito rial S ociety of B one and Join t S urg ery

0 301 -6 20X /88 /4 135 $ 2 .00

J Bone Join t Su rg [Br] 1988;70-B:649-5l.

the ir frac tu re by a fall on to the ou tstre tched hand and

had und ergo ne sim ila r in itia l treatm en t by m an ipu la tion

un de r reg io na l an aesth es ia an d im m ob ilisa tion in a

fo rea rm p laste r fo r fiv e to s ix w eeks. F o llow -up rang ed

from fo ur years to six years n in e m on ths (m ean fiv e yea rs

o ne m on th ). T h ir teen p atien ts had frac tu red the dom i-

nan t and 1 7 the non -dom inan t w rist.

S tanda rd an terop oste rio r an d la te ra l rad iog raph s o f

bo th w ris ts w ere taken and m easu rem en ts o f do rsa l

ang u la tion and rad ial sh if t w ere reco rd ed (V an D er

L in den and E ric son 1981) . O n the b as is o f the se

m easu rem en ts the 30 pa tien ts w ere d iv ided in to tw o

grou ps. G ro up 1 in clu ded the pa tien ts w hose fractu re s

un ited w ith 10# {176}r le ss o f d o rsal angu latio n and le ss th an

2 m m of rad ia l sh ift. T h ere w ere 1 7 p atien ts in th is

grou p , 16 w om en and on e m an , the ir ave rage age be ing

67 yea rs . G rou p 2 inc luded 1 3 pa tien ts w ith d orsa l

an gu la tio n rang ing from 1 2#{176 }o 3 4#{ 176 }nd m ore than 2 m m

of rad ia l sh ift. A ll w ere w om en and the ir m ean ag e w as

71 years.

The func tion o f b o th hands and w rists w as te sted by

on e au tho r (JC ), w ho h ad no prio r kn ow led ge of the

rad io lo g ica l m easu rem en ts . T he te sts used w ere based on

a recen t rev iew of as ses sm en t o f hand fu nc tion (D en t,

Sm ith an d C aspe rs 198 5) .

G rip streng th w as asse ssed u sing the Jam ar d yn a-

m om ete r (B ech to l 19 54) and the M u sur-G riev e sp rin g

ba lan ce (M usu r-G rieve 1984) w ith in te rchan geab le

hand le s to a llow assessm en t o f h ook , cy linde r, k ey chuck

an d p in ch grip s . G rip endu rance w as te sted on the la tter

ap pa ra tus usin g the h ook grip . M anua l dex te rity w as

assessed usin g the Jebsen test (Jebsen e t a l. 196 9)

supp lem en ted by the M ob erg te st p e rfo rm ed w ith th e

ey es op en (M oberg 1956) .

The ab ility to p er form both un ila tera l and b ila tera l

ac tiv itie s o f d aily liv in g such as lif ting w e igh ts , tu rn ing

keys, u sing sc isso rs , e tc ., w as assessed and sco red

acco rd ing to the am oun t o f d iff icu lty in pe rfo rm ing these

ac tiv itie s (S heehan , S h eld on an d M arks 19 83) . T he ran ge

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65 0 M . M CQ UEE N, J . C AS PE RS

THE JOU RN AL O F B O NE A ND JO IN T SUR GERY

of m ovem en t (f lex ion /ex ten sion , p ron atio n /su p ina tion ,

rad ia l/u ln ar dev ia tion ) w as m easu red in bo th w ris ts

usin g a g on iom e ter . T he una ffec ted w rist w as tak en as

the no rm al rang e fo r each p atien t. S en sa tion and m o to r

pow er in th e m ed ian ne rve d istr ibu tion a lso w ere te sted .

P a in w as as ses sed using an ana log ue sca le w h ich

w as th en d iv ided in to th ree equ a l pa r ts rep resen ting

m ild , m ode ra te an d seve re pa in . A n an alg es ic h is to ry

w as a lso tak en . F ina lly th e exam ine r’s a sse ssm en t o f

co sm e tic de fo rm ity w as reco rded . S ta tis tica l ana lys is w as

p erfo rm ed usin g the ch i-squ a red tes t.

R E S UL T S

T he re su lts are sum m arised in T ab le I.

T ests o f s treng th -J am ar D ynam om eter . In G roup 1 , th e

“und isp laced “ gro up , 15 o f 17 pa tien ts had grip

s treng th s w ith in th e no rm a l ran ge fo r age , sex an d

dom in an ce in bo th hand s (B ech to l 19 54 ). O ne p atien t

had redu ced grip streng th b ila tera lly w ith o n ly 10 kg in

the dom inan t una ffec ted righ t h an d and 9 kg in the non -

dom inan t a ffec ted le ft han d . T h is pa tien t had osteo -

ar th r itis o f th e p rox im a l in te rph alan geal jo in ts . O n e

pa tien t had a 17% reduc tio n in g rip s treng th in the

dom inan t a ffected hand bu t a lso h ad sig ns and sym p -

tom s of m ed ian n erve com press ion .

T ab le I. P e rcen ta ge o f n orm a l r esu lts in each group fo r each te st

Tes t

Group 1

G ood po sit ion

G roup 2

Malunion

Statist ical

signif icance

J am ar D yn am om ete r 88 31 p czO .0 0l

M usur-G rieve springbalance

94 54 p<O .O l

A ctiv ities of d aily

liv ing

94 62 p<O .O S

R ange of m ov em ent 88 31 p<O .O l

P ain 88 62 N S

C osm esis 88 8 p<O .O O l

In G rou p 2 on ly fo u r o f the 13 p atien ts w ith

m a lun ion h ad norm a l g rip stren g th in th e a ffected hand

a llow ing fo r age , sex an d dom inance . In f ive pa tien ts the

g rip streng th in th e non -d om in an t frac tu red w rist w as

m o re than 30% less than th e d om in an t no n-affec ted side .

B echto l (1954 ) has s ta ted tha t the non-dom in an t hand

m ay be as m uch as 3 0% w eake r th an the dom inan t,

a lthou gh m ost sub jec ts h av e o n ly 5 to 10% diffe ren ces.

Fou r of our p atien ts h ad frac tu red th e dom inan t w ris t

an d in all o f th ese the g rip streng th w as le ss th an tha t on

the no n-dom inan t side an d be low the low er lim it o f

no rm a l. T he w eak es t g r ip w as 5 kg in a dom inan t

affec ted w rist w h ich had a res idua l do rsal an gu la tion o f

28# {176}th is w as 48% of th e g rip in the no n-d om in an t

una ffec ted side .

T he d iffe rence b etw een th e tw o g ro ups w as sta tis ti-

c ally s ig nific an t (x 2 13 .3 , p<O .O O1) .

Tes ts o f s tr en gth - th e M usur -G rieve sp r ing ba lan ce . In

G roup 1 , 16 of th e 1 7 pa tien ts had n orm a l stren g ths o f all

d iffe ren t typ es o f g rip as com pared w ith the n orm a ls

p ub lish ed by Sw anson , G oran -H age rt and d e G ro o t

Sw anso n (1 98 4) and com pared to the op pos ite sid e ; th e

ex cep tio n w as ag ain in the pa tien t w ith m ed ian ne rv e

com pression . In G ro up 2 on ly sev en of the 13 pa tien ts

had norm a l g rip s treng ths an d en durance. O f the o the r

six pa tien ts , fou r h ad ve ry po or endu rance o f g rip , tw o

had w eakness o f all ty pes o f g rip and th ree had w eakn ess

o f o ne o r m o re types o f g rip . Th e d iffe ren ce be tw een the

tw o g ro ups w as sta tis tic ally sign if ican t (j2 9 .8 ,

p <O .O l ) .

Tes ts o f d ex ter ity . In b oth grou p s a ll th e patien ts

pe rfo rm ed th e Jebsen te st w ith in the tim e lim it. T he

m ax im um tim e tak en fo r any one te st in G rou p 1 w as 9 .5

seco nds an d 12 .4 seco nds in G ro up 2 . S im ila r resu lts

w ere seen in th e M ob erg tes t w ith the eyes o pen . O n e

pa tien t in G ro up 1 too k 10 second s lo nge r to p erfo rm th e

tes t w ith the d om in an t a ffected hand ; n ot s ur pr is in gly ,

th is w as the pa tien t w ith m ed ian ne rv e com pression .

A c tiv itie s o f d aily liv ing . In G rou p 1 , 16 of the 17 pa tien ts

had no d iff icu lty w ha tsoeve r w ith eith er un ilate ral o r

b ila tera l ac tiv itie s o f da ily liv ing . T he pa tien t w ith

m ed ian n e rve com p ressio n h ad d ifficu lty w ith all

act iv i t ies .

E igh t o f th e 1 3 pa tien ts in G rou p 2 had no d ifficu lty

w ith th e ac tiv itie s o f da ily liv ing . T hree o f th e o th ers had

d ifficu lty w ith o ne or tw o o f the tes ts , m a in ly th ose

in vo lv ing stren g th , e .g ., lif ting a w e igh t in a b ucke t. T w o

pa tien ts had consid erab le d ifficu lty w ith these te sts ; both

h ad susta in ed frac tu res in the dom inan t hand an d now

u se the no n-dom inan t han d fo r th e activ ities o f d aily

liv ing . A ga in the re w as a sta tis tica lly sign ifican t d iffe r-

en ce be tw een the tw o g rou ps (x 2 4 .8 8 , p< O.O S).

Median nerve fun c tion . O ne pa tien t in each g roup h ad

senso ry d eficit in the m ed ian ne rv e d istrib u tion . Th e

p atien t in G roup 1 a lso had clin ica lly de tec tab le m oto r

weak n es s .

R ang e of m ov em en t. In G roup 1 , 1 5 o f th e 17 pa tien ts h ad

sim ila r ranges o f m ovem en t in b o th w ris ts , w ith n o m ore

than 10# {176}iffe ren ce in an y m easu rem en t. T he pa tien t

w ith m ed ian ne rve p ro b lem s had lo st 30 #{176}fex tension b u t

o the r m ovem en ts w ere n orm a l. O ne o th er pa tien t lacked

45#{176}f sup ina tion and 20#{176 }f p rona tio n ; rad io log ical ly

the re w ere d eg en e ra tive changes in th e d ista l rad io -u lna r

jo in t. H ow ev e r, fo u r o the r pa tien ts in th is g ro up had

rad io log ica l ev id en ce o f rad io -u ln ar jo in t degene ratio n ,

a lthou gh th ey had norm a l ro ta tion .

In G rou p 2 , on ly fou r o f th e 1 3 pa tien ts h ad sim ilar

rang es o f m ovem en t in bo th w ris ts . F ive pa tien ts had

redu ctio n in p ron atio n /su p ina tion of m ore th an 20# {176} ,he

w o rst p atien t hav ing o n ly 45#{176}feach . S even pa tien ts had

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CO LLES FR A CTUR E: DO ES THE A NA TO M ICA L R ESU LT AFFECT THE FIN AL FU N CT ION ? 65 1

VOL . 70-B , N o . 4 , A UG UST 1988

a redu ctio n of be tw een 20#{176 }nd 40#{176}n the fle xio n/e xte n-

sio n a rc o f m ov em en t. F our pa tien ts had lost 15 #{176 }o 35# {1 76}f

rad ia l/u lna r d ev ia tio n .

T he d iffe ren ce be tw een th e tw o grou ps reached

sta tis tic a l s ign if ican ce (j2 12 .44 , p<O .O l ) .

Pain . Tw o ofth e pa tien ts in G roup I com p la in ed o f pa in .

In on e pa tien t th is w as g raded as m ild on th e ana lo gue

sca le and sh e req u ired no ana lgesia . T he seco nd pa tien t

w ith pa in had m ed ian n erve sym p tom s an d g raded he r

pa in as m ode ra te . F ive p atien ts o f th e 1 3 in G rou p 2 had

pa in . T hree of these graded the ir p ain as severe and

requ ired regu la r ana lgesia . O ne p atien t co nsid ered he r

pa in to b e m oderate an d on e m ild .

Th e d ifference in inc iden ce o f pa in be tw een the tw o

group s w as no t statis tica lly sign ifican t a lthou gh no

allow an ce w as m ad e fo r th e seve rity o f pa in in th e

analysis .

C o sm e tic a sse ssm en t. F if teen pa tien ts in G ro up 1 w ere

co nsid ered by the exam in er to have a no rm a l ap pearance

o f the w ris t ; th e o th er tw o pa tien ts had a m ild co sm e tic

de fo rm ity . In G roup 2 only one pa tien t had no cosm etic

de fo rm ity ; th e o the r 12 had m ild to m ode rate de fo rm ity .

Th e d iffe ren ce in cosm e tic ap pearance be tw een th e

tw o group s w as statis tic a lly s ig n if ican t (j2 19 .2 ,

p <O .OO1 ) .

D ISCUSS ION

These re su lts show clea rly th an a m a lun ited C o lle s’

frac tu re re su lts in sign if ican t func tion a l d ef ic it. T he tw o

gro ups w ere com parab le ap art from the rad io lo g ical

positio n o f the un ited frac tu re. T he sligh tly h ig he r ag e o f

the m alu n ited g roup is p robab ly because o ld er pa tien ts

have an inc rea sed like lihoo d o f m a lun io n (M cQ ueen ,

M acL aren and C ha lm ers 1 986 ).

P rev io us au th o rs have based fun ctio na l asses sm en ts

on a va riety o f m e tho ds. S om e au tho rs do n o t de fine th eir

m e thod s o f a sse ssing fun ctio n (C assebaum 1950 ; Old e r

et al. 19 65 ; B en jam in 1982) w hile o th ers confine th eir

fu nc tion al a sse ssm en t to su b jectiv e cr ite ria and rang e o f

m ovem en t (G artland and W erley 1951 ; M ason 1953 ;

G reen an d G ay 1956 ). M ore recen tly som e au th o rs have

inc lud ed grip pow er in the ir a sse ssm en t (F rykm an 1967 ;

C ooney , D obyn s and L insche id 1980 ; S a ito and Sh ib ata

1983 ; M elone 1 986 ) bu t n one o f th ese have repo rted a

com preh en sive func tion a l a sse ssm en t. T he w eakness o f

g rip fo llow ing m a lun io n is p ro bab ly d ue to p a in and to

bo ny sh orten ing w h ich p laces the flexo r tend ons at a

m echan ica l d isadv an tag e.

Th e source o f p ain is d iff icu lt to e stab lish . I t h as

p rev iou sly been sugg ested tha t its m a in so urce is th e

dista l rad io -u lnar jo in t (F rykm an 1967) or th e rad iocar -

pa l jo in t (C oon ey et a l. 1 98 0). H ow ev er , o f ou r G rou p 2

pa tien ts w ith pa in on ly on e had rad io log ica l ev id ence o f

rad io -u ln a r jo in t ch an ges. N o pa tien t h ad degen era tive

changes in the rad iocarpa l jo in t. Pa in m igh t be a ttribu t-

ab le to m ed ian neuropa th y bu t o n ly o ne pa tien t in each

grou p show ed ev idence o f m ed ian n erve sym p tom s or

sign s. S tiffne ss and d efo rm ity a re n o t su rp ris ing fo llow -

ing m alu n ion and it is ag reed tha t d o rsal an gu la tion w ill

re str ict th e f lex ion /ex tens ion a rc .

Our study dem on stra te s th a t m a lun ion o f a C olle s’

frac tu re resu lts in a w eak , d efo rm ed , stif f an d prob ab ly

pa in fu l w ris t w ith a like lihoo d ofd iff icu lty in pe rfo rm ingthe n orm a l ac tiv itie s o f da ily liv in g . It is the re fo re

es sen tial to s trive fo r a s an a tom ica lly accu ra te a re su lt as

pos sib le in o rde r to ensu re m in im a l func tion al de fic it.

N o bene fits in any form hav e been received o r w ill be receiv ed from a

com m ercial p arty re lated d irec tly o r indirec tly to the subje ct o f th is

ar t icle .

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