What is the acute management of a Colles' (distal radius) fracture?

From the Guidelines

The acute management of a Colles' fracture involves prompt pain control, fracture reduction, and immobilization, with a focus on opioid-sparing protocols and patient-centered decision-making, as recommended by the American Academy of Orthopaedic Surgeons (AAOS) and the American Society for Surgery of the Hand (ASSH) 1.

Key Components of Acute Management

• Administer appropriate analgesia, such as ibuprofen 400-600mg or acetaminophen 1000mg, potentially combined with an opioid like oxycodone 5-10mg for severe pain, while considering opioid alternatives like local anesthetics, nonsteroidal anti-inflammatory agents, and nonpharmacologic interventions like ice, elevation, compression, and cognitive therapies 1.
• Apply ice to reduce swelling and elevate the affected limb above heart level to minimize edema.
• Perform closed reduction under adequate anesthesia, typically using a hematoma block with 5-10ml of 1% lidocaine injected into the fracture site, or procedural sedation.
• Immobilize the wrist in slight flexion and ulnar deviation using a sugar-tong or volar splint, extending from below the elbow to the palmar crease, allowing for finger movement.

Post-Reduction Care

• Maintain the splint for 1-2 weeks until swelling subsides, after which definitive treatment (typically cast immobilization for 4-6 weeks or surgical fixation for unstable fractures) is implemented.
• Assess neurovascular status before and after reduction, monitoring for complications like acute carpal tunnel syndrome.
• Encourage early finger range of motion exercises to prevent stiffness while the fracture heals.

Patient-Centered Decision-Making

• Consider the patient's age, functional demands, values, preferences, and rights when making treatment decisions, as emphasized by the AAOS and ASSH guidelines 1.
• Discuss the risks and benefits of different treatment options, including conservative and surgical management, to ensure informed decision-making.

From the Research

Acute Management of Colles' Fracture

The acute management of a Colles' (distal radius) fracture involves several treatment options, including:

• Closed reduction and immobilization in a cast 2, 3
• Functional bracing, which allows for early return of function while maintaining fracture reduction 3
• Percutaneous crossed-pin fixation followed by plaster of Paris cast immobilization 4
• Closed reduction with either manual manipulation or finger-trap traction 5

Treatment Methods

The choice of treatment method depends on the complexity and type of fracture. Some studies suggest that:

• Functional treatment in supination may be more desirable than in pronation, as it can reduce the incidence of re-displacement 6
• Percutaneous crossed-pin fixation may provide better anatomical and functional end results compared to conventional plaster of Paris cast immobilization 4
• Closed reduction with finger-trap traction or manual manipulation can produce satisfactory reductions, but most fractures redisplace substantially during the period of cast immobilization 5

Key Considerations

When managing a Colles' fracture, it is essential to consider the following:

• The goal of treatment is to return the patient to normal function 2
• The majority of Colles' fractures can be treated conservatively with closed reduction and immobilization in a cast 3
• Surgical treatment may be necessary for fractures that are not likely to render satisfactory functional and cosmetic results with non-surgical means 6