Optimal Splinting for Colles Fracture
For Colles fractures, immobilize with a splint or cast holding the wrist in dorsiflexion (wrist extension) and the forearm in supination, as this position demonstrates the lowest incidence of fracture redisplacement and superior functional outcomes compared to traditional palmar flexion positioning.
Splint Position and Technique
Wrist Position
- Position the wrist in dorsiflexion (extension) rather than palmar flexion, as this reduces redisplacement rates, particularly of dorsal tilt, and produces better early functional results 1
- Palmar flexion immobilization has a detrimental effect on hand function and is a main cause of fracture redisplacement 1
- Maintain slight ulnar deviation to counteract the typical displacement pattern 2, 3
Forearm Position
- Immobilize the forearm in supination rather than pronation, as this prevents the brachioradialis muscle from displacing the reduced fracture 2
- The brachioradialis muscle attaches to the distal radius and functions as an elbow flexor when the forearm is pronated, making it the primary culprit in loss of reduction 2
- In type II fractures, supination positioning achieved 85% excellent/good results versus 67% in pronation 2
- In type IV (unstable) fractures, supination achieved 85% excellent/good results versus only 40% in pronation 2
Splint Configuration
- Apply an above-elbow splint initially (approximately 11 days) extending from the base of fingers to above the elbow with the elbow at 90 degrees 2
- Use a splint with radial and dorsal indentations to maintain reduction while keeping the wrist in neutral or dorsiflexed position 4
- After initial immobilization period, transition to a forearm brace that permits elbow flexion but prevents pronation and limits the last 15 degrees of elbow extension 2
Specific Splint Type Recommendation
The integrated retainer pad splint is superior to traditional bamboo curtain splints, demonstrating:
- Shorter operation time for application 3
- More stable fracture fixation with less reduction loss during treatment 3
- Better maintenance of volar inclination, ulnar deviation, and radial height on radiographs 3
- Higher excellent/good functional outcome rate (96% vs 80%) 3
Critical Pitfalls to Avoid
- Never immobilize in palmar flexion, as this traditional Cotton-Loder position increases redisplacement risk and impairs hand function 1
- Avoid pronation positioning, which activates the brachioradialis and destabilizes the fracture 2
- Do not use simple below-elbow immobilization initially for displaced fractures, as proximal control is necessary 2
Fracture-Specific Considerations
For Unstable Fractures (Type IV with axial compression)
- Closed rereduction of axial compression is rarely successful—only 7 of 105 cases achieved permanently acceptable position 5
- High age and dorsal comminution further worsen prognosis for maintaining reduction 5
- Consider surgical fixation early rather than repeated closed reduction attempts for fractures with significant axial compression 2, 5
For Minimally Displaced Fractures (Type I and III)
- Either supination or pronation positioning produces equivalent results 2
- Standard immobilization in dorsiflexion with neutral forearm rotation is acceptable 1
Follow-Up Protocol
- Obtain radiographs at approximately 3 weeks to assess for loss of reduction 6, 7
- Initiate active finger motion exercises immediately to prevent stiffness 7
- Monitor for skin irritation and muscle atrophy during immobilization 7
- Overall, 90% of properly immobilized Colles fractures achieve excellent or good functional results with conservative management 2