What is the recommended treatment for a patient presenting with a Colles fracture, including reduction and management of potential complications?

Treatment of Colles Fracture

Immediate Reduction Technique

For acute Colles fracture reduction, either manual manipulation or finger-trap traction achieves equivalent initial reduction success (87% satisfactory rate), though both methods result in substantial redisplacement during cast immobilization in the majority of cases. 1

Reduction Method Selection

• Manual manipulation and finger-trap traction produce identical radiographic outcomes with no significant differences in radial angle, dorsal tilt, or radial shortening immediately post-reduction or at follow-up. 1
• Manual reduction techniques (including the "handshake technique" or closed unassisted methods) can be performed by a single physician without equipment in under 10 minutes, making them practical for emergency settings. 2, 3
• Acceptable reduction is defined as dorsal tilt <10 degrees and radial shortening <5 mm. 1

Critical Limitation of Closed Reduction

• Despite successful initial reduction in 87% of cases, only 50-57% maintain acceptable alignment at one week, and merely 27-32% remain acceptable at five weeks, regardless of reduction technique used. 1
• Fractures with axial compression (with or without dorsal angulation) have particularly poor outcomes with closed rereduction—only 7 of 105 cases achieve permanently acceptable position. 4
• High age and dorsal comminution significantly worsen prognosis for maintaining reduction. 4

Immobilization Strategy

Percutaneous crossed-pin fixation followed by cast immobilization produces significantly better anatomical and functional outcomes compared to cast immobilization alone. 5

• For unstable fractures or those at high risk of redisplacement (elderly patients, dorsal comminution, axial compression), percutaneous pinning should be strongly considered over cast-only treatment. 5, 4
• Cast immobilization alone is associated with substantial redisplacement rates during the immobilization period. 1

Post-Reduction Management

Early Mobilization Protocol

• Begin range-of-motion exercises for fingers and hand immediately after immobilization to prevent edema and stiffness. 6
• When immobilization is discontinued, initiate aggressive finger and hand motion exercises. 6
• Avoid prolonged immobilization beyond what is necessary, as it accelerates muscle weakness and increases thrombosis risk. 7, 8

Rehabilitation Program

• Implement early post-fracture physical training and muscle strengthening as the patient tolerates. 6, 7
• Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20%. 7, 8
• Identify individual functional goals before developing the specific rehabilitation plan. 6

Prevention of Subsequent Fractures

Pharmacological Treatment (For Patients >50 Years)

All patients over 50 with a Colles fracture should be started on oral bisphosphonates (alendronate or risedronate) as first-choice agents, as these reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51%. 6, 9

• Bisphosphonates are preferred because they are well-tolerated, cost-effective (generics available), and physicians have extensive experience with them. 6
• Prescribe for 3-5 years initially, with longer duration for patients remaining at high fracture risk. 6, 9
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (intravenous) or denosumab (subcutaneous) as alternatives. 6

Essential Adjunctive Therapy

• All patients must receive calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20%. 6, 7, 9
• Avoid high pulse dosages of vitamin D as they increase fall risk. 6, 7, 8
• Calcium supplementation alone without bisphosphonates has no demonstrated fracture reduction effect and should not be used as monotherapy. 6, 7, 9

Non-Pharmacological Interventions

• Implement smoking cessation and alcohol limitation to improve bone mineral density and reduce fall risk. 6, 7
• Establish weight-bearing exercise programs to improve BMD and muscle strength. 7, 8
• Address environmental fall hazards in the home and review medications that increase fall risk. 7, 8

Systematic Follow-Up Protocol

Implement a five-step Fracture Liaison Service (FLS) approach: identify the patient with recent fracture, invite for fracture risk evaluation, perform differential diagnosis, initiate therapy, and establish systematic follow-up. 6, 7, 8

• A dedicated coordinator (typically a nurse) should organize diagnostic investigations and interventions under supervision of an orthopedic surgeon or endocrinologist. 8
• Monitor regularly for medication tolerance and adherence, as long-term adherence is typically poor outside structured programs. 6, 7
• Use risk communication and shared decision-making to improve adherence, which reaches up to 90% in FLS programs versus standard care. 6

Critical Pitfalls to Avoid

• Do not rely solely on cast immobilization for unstable fractures—consider percutaneous pinning for elderly patients, those with dorsal comminution, or axial compression. 5, 4
• Do not delay osteoporosis treatment in patients over 50 with confirmed Colles fracture, as this represents a sentinel fragility fracture. 7, 8, 9
• Do not use calcium or vitamin D alone without bisphosphonates in patients with established fragility fractures. 6, 7, 9
• Do not allow prolonged immobilization beyond acute pain control needs, as this accelerates bone loss and muscle weakness. 7, 8
• Do not expect closed reduction alone to maintain alignment—anticipate redisplacement in 70-73% of cases by five weeks and plan accordingly. 1