Emergency Medicine Australasia (2009) 21, 298303

doi: 10.1111/j.1742-6723.2009.01200.x

ORIGINAL RESEARCH

Emergency department management of

Colles-type fractures: A prospective
cohort study
emm_1200

298..303

William Blakeney and Laurence Webber

Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia

Abstract
Objective:

To assess radiographic outcomes from ED reduction of Colles-type fractures.

Design:

Prospective cohort.

Setting:

One tertiary hospital in Western Australia.

Participants:

All patients (184) between ages 2185 years, presenting to ED with Colles-type fractures
between 1 April 2006 to 31 July 2008. Fractures were divided into two groups. Those with
15 dorsal angulation were classified as minimally displaced and those with >15 dorsal
angulation were classified as displaced.

Main outcome
measures:

Radiographic analysis of the dorsal angle on post-reduction and 6 week post-fracture

X-rays. A combined end-point of poor outcome, as defined by either poor radiological result
and/or progression to surgery.

Results:

In the group of patients with displaced fractures, 69 of 114 (61%) went on to have an
operation or a poor radiographic outcome versus 8 of 48 (17%) in the group with minimally
displaced fractures, an absolute difference of 44% (95% CI 3057%). Patients who had a
minimally displaced fracture with an adequate reduction went on to have a satisfactory
6 week X-ray in 37 of 43 cases (86%; 95% CI 7596%). Patients who had a displaced
fracture and an adequate reduction had a satisfactory 6 week X-ray in 42 of 86 cases (49%;
95% CI 3859%). Patients who had a displaced fracture and an inadequate reduction had
a satisfactory 6 week X-ray in only 3 of 22 cases (14%; 95% CI 028%).

Conclusion:

The study highlights the importance of the initial on arrival and post-reduction X-rays in
the ED. Displaced fractures are more likely to go onto poor outcome, as are inadequately
reduced fractures. Medical officers working in ED should be aware of the importance of
measuring the dorsal angle. They should be referring patients with >15 dorsal angulation
to orthopaedics early. Reduction should not be accepted until the dorsal angle has been
adequately corrected.

Key words:

Colles fracture/radiography, fracture fixation, fracture/radiography, radius prognosis, treatment outcome.

Correspondence:

Dr William Blakeney, 42/105 Colin Street, West Perth, WA 6005, Australia. Email: blakeney@gmail.com

William Blakeney, MB BS, Orthopaedic Surgery Registrar; Laurence Webber, MB BS, General Surgery Registrar.

2009 The Authors

Journal compilation 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Management of Colles-type fractures

Introduction
Patients with distal radius fractures frequently present
to ED for assessment and management.1,2 The most
common type of distal radius fracture is the Colles-type
fracture (distal radius fracture within 2.5 cm of the wrist
with dorsal angulation of the distal fragment). This type
of fracture usually occurs following a fall on an outstretched hand. It occurs in all ages and sexes, but
typically in middle-aged to elderly women.
It is common practice within Western Australia when
a patient presents to the ED with an uncomplicated
Colles-type fracture for that patient to be dealt with
entirely by ED medical officers and then to be referred
to orthopaedics fracture clinic to be seen in 12 weeks.
This practice reduces the patient burden on the orthopaedic team. If, however, there is any indication that the
patient is likely to have an adverse outcome from the
fracture, it would be beneficial to have that patient
identified at an early stage.
The largest study of distal radius fractures produced
several complex formulae to predict radiographic
outcome using up to six independent variables.3 Other
studies have also come up with many different variables
predictive of poor radiographic outcome.46 These
studies, however, all include the predictive value of the
measurement of the dorsal angle. The dorsal angle (see
Fig. 1) is a quick and easy measurement to take from the
lateral X-ray of the wrist. In the often time-scarce setting
of a busy ED, it would be most valuable for the ED
medical officer to be armed with one simple predictor of
outcome, and therefore indicator for early orthopaedic
referral.

It has long been known that good anatomical reduction at follow up, evaluated by standard radiographic
criteria, equates with the best long-term functional
outcome.7,8 Studies have looked at many different
radiographic measurements for assessment of these
fractures.912 The measurement on follow-up X-rays that
is most closely associated with good functional outcome
is the dorsal angle. It is fair to hypothesize that the
initial dorsal angle on the ED X-rays might be associated with the dorsal angle at 6 week follow up. If this
proves to be the case, then the initial X-rays of the
fracture will give the treating doctor a good indication
of the likely outcome and potentially allow early identification of patients with certain fracture parameters
who might benefit from early orthopaedic referral and
consideration of intervention.
This prospective cohort study followed all patients
presenting to a tertiary hospital ED with a Colles-type
fracture requiring manipulation.

Method
Selection of study population
The patient cohort was selected from patients presenting to Sir Charles Gairdner Hospital (a tertiary hospital
in Perth, Western Australia). All patients upon discharge from the ED routinely receive one or more ICD
10 categorizations. The patients with the primary diagnostic codes S52.50 injury-+fractures/closed-+upper
limb-+radius-lower and/or S62.8 injury-+fractures/
closed-+upper limb-+wrist-wrist entered into the
hospitals Emergency Department Information System
(EDIS), were eligible for the study. The hospital unit
numbers of patients with these diagnostic codes were
flagged in the electronic radiology database automatically building a work list. This enabled us to capture all
patients presenting with a Colles-type fracture without
creating extra work for ED staff, and effectively provided an operator-blinded study.

Inclusion/exclusion criteria

Figure 1.

Measuring the dorsal angle.

Patients included in the final analysis group were aged

between 21 and 85 years with radiological evidence of a
Colles-type fracture (distal radius fracture within 2.5 cm
of the wrist with dorsal angulation of the distal fragment). Patients included must have had their fractures
manipulated. The decision to manipulate the fracture
was at the discretion of the treating ED medical officer.

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299

W Blakeney and L Webber

Patients with radiological evidence of intra-articular

fractures, open fractures or previous fracture malunion
were excluded from the study.
All fractures were immobilized in a standard plaster
of Paris back-slab after reduction.

Radiological evaluation
The radiographs of patients meeting these criteria were
de-identified and transferred to an image storage disc.
The degree of dorsal or volar tilt was measured (using a
vectorial goniometer) on the initial pre-reduction film,
the post-reduction film and the 6 week post-fracture
follow-up films.
For those patients who required further manipulation, if the initial post-reduction film was deemed
unsatisfactory, measurements were recorded from the
final post-reduction X-ray before discharge from the
ED.
All films were viewed using a high-resolution
monitor and IMPAX X-ray viewing software (identical
to that used by the staff in the ED). To determine the
degree of angulation, we first drew in the long axis of
the distal radius, then drew a line touching the most
distal points of the radial articular surface visible on
the lateral film. Second, we used an automated goniometric tool to measure the angle between these lines
and recorded positive values as dorsal displacement
and negative values as volar displacement (see
Fig. 1).
Fractures were divided into two groups. Those with
15 dorsal angulation were classified as minimally
displaced and those with >15 dorsal angulation were
classified as displaced.

Statistical methods
Comparison was made between the numbers achieving
the above outcomes in both minimally displaced and
displaced groups. We used Fishers exact test to determine whether the differences observed were significant.

Ancillary analyses
We separately placed the patients into two groups
based on adequate or inadequate reduction in the ED,
defined by the same reduction criteria as above, and
compared the final outcomes in these two groups.
Patients were then stratified by adequacy of reduction to see if the initial X-ray was still predictive of
outcome.

Blinding
All those involved in clinical care of patients were
blinded to the study.
X-rays were de-identified, thus blinding the investigators before measuring.

Sample size
We thought that a 25% difference in outcome between
the two arms would be important to detect. Assuming
that the minimally displaced group would have a good
outcome in 90% of cases, with a power of 0.9 and
significance level of 0.05, we would need 53 patients in
each arm.

Results
Reduction criteria
Post-reduction films that demonstrated dorsal angulation of <10 and volar angulation <20 were defined as
adequately reduced. Those films that demonstrated
dorsal angulation of 10 or volar angulation of 20
were deemed inadequately reduced.

Outcomes
1. Radiological result at 6 weeks as determined by the
above reduction criteria.
2. A combined end-point of poor outcome, as defined by
either poor radiological result and/or progression to
surgery.
300

Patient recruitment for the study occurred from 1 April

2006 to 31 July 2008. Of the cases identified by the
computer-tagging system, 184 were Colles-type fractures that fit the study inclusion and exclusion criteria.
The mean age of the sample was 58.2 years (SD 19.6),
of which 82.1% were female.
Of the 184 patients included in the study, 8 were
referred directly to orthopaedics. The flow chart (Fig. 2)
explains the flow of patients throughout the study.
Within the 176 fractures manipulated by ED staff, only
5 were re-manipulated when reduction was deemed
unsatisfactory. Fifty-five (31.2%) were classified as
minimally displaced (dorsal angulation (DA) 15) and
121 (68.8%) classified as displaced (DA >15).

2009 The Authors

Journal compilation 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Management of Colles-type fractures

Patients included in the study

N=184

Excluded (n= 8)
Referred directly to orthopaedics
Manipulated by ED staff (n=176)

Minimally displaced (n=55)

Displaced (n=121)

Allocation

Lost to follow up (n=7)

Lost to follow up (n= 7)

Underwent surgery before 6 week

follow up (n=4)

Underwent surgery before 6 week

follow up (n=29)

Follow up

Analysed (n= 44)

Analysed (n= 85)

6 week X-ray

Figure 2.

Patient flow.

Table 1.

Main outcomes
Minimally displaced

6 week follow-up X-ray (%)

Combined end-point (%)

P-value

Displaced

Good

Poor

Good

Poor

40 (91)
40 (83)

4 (9)
8 (17)

49 (58)
45 (40)

36 (42)
69 (61)

Of the patients who had 6 week follow-up X-rays,

40 of the 44 patients (90%) with minimally displaced on
arrival X-rays had satisfactory X-rays at 6 weeks, contrasted with 49 of 85 patients (58%) with displaced on
arrival X-rays. This represents an absolute difference of
33.3% (95% CI 2047%) (Table 1).
When using the combined end-point of patients who
went to theatre plus those with poor radiological
outcome, the two groups were further polarized. Forty
of the 48 patients (83%) in the minimally displaced

<0.001
<0.001

group now had a good outcome compared with 45 of 114

(39%) in the displaced group, an absolute difference of
44% (95% CI 3058%).
We evaluated the effect of reduction on 6 week X-ray
outcome in both minimally displaced and displaced
initial fractures. There is a significant difference in outcomes between the groups. Patients who had a minimally displaced fracture, with an adequate reduction
went on to have a satisfactory 6 week X-ray in 37 of
43 cases (86%; 95% CI 7696%). Patients who had a

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Journal compilation 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

301

W Blakeney and L Webber

displaced fracture and an adequate reduction had a

satisfactory 6 week X-ray in 42 of 86 cases (49%; 95%
CI 3859%). Patients who had a displaced fracture and
an inadequate reduction had a satisfactory 6 week X-ray
in only 3 of 22 cases (14%; 95% CI 028%).
If we look only at the post-reduction X-ray and
compare this with the 6 week X-ray and combined
outcome (including patients who went to theatre), the
results were also significant. Seventy-nine of the 128
(61.7%) patients with adequate reduction had a good
outcome versus only 6 of the 25 with inadequate reduction (24%). Of the patients who had a 6 week X-ray,
83 of 111 (74.8%) with adequate reduction had a satisfactory appearance, whereas only 6 of the 18 (33%)
with inadequate reduction did (P < 0.001).
Within the minimally displaced group, 52 (95%) were
adequately reduced, compared with 97 (80%) in the
displaced group (P = 0.01). Alarmingly, 27 patients who
had inadequate reduction were discharged to orthopaedic follow up. Of the 55 patients in the minimally
displaced group, only 20 had a dorsal angle between
1015; that is, the other 35 would have satisfied the
criteria for adequacy of reduction before manipulation.

Discussion
Our results show that there is a significant difference in
outcomes between minimally displaced fractures and
displaced fractures. Of the patients with displaced fractures, 61% went on to have an operation and/or a poor
radiographic outcome versus 17% in the minimally displaced group, an absolute difference of 44% (95% CI
3058%). Removing the patients who went on to have
an operation, there was still a large difference. Ninety
point nine per cent of patients in the minimally displaced group had satisfactory radiographic outcome,
contrasted with 58% of patients in the displaced group,
an absolute difference of 33% (95% CI 2047%).
A minimally displaced fracture that is adequately
reduced will have a good outcome in 86% of cases (95%
CI 7697%). A displaced fracture with adequate reduction will have a good outcome in 49% of cases (95% CI
3859%). If, however, adequate reduction of a displaced
fracture is not achieved, a poor outcome is almost inevitable, with only 14% (95% CI 028%) having a satisfactory outcome.
The present study assumes that satisfactory 6 week
X-ray alignment equates with good functional outcome.
There have been many studies comparing follow-up
X-rays of Colles-type fractures with functional outcome
302

that support this. A 1951 study first noted that the

dorsal angle on the follow-up X-ray has the greatest
bearing on the eventual functional result.7 A study of
2000 Colles-type fractures in 1953 equated functional
loss with poor anatomical outcome.8 More recent studies
have all found a large dorsal angle, using the cut-off of
10, to be associated with poor functional outcome.912
There have also been studies that have failed to
demonstrate an association between good function and
radiographic outcome.13,14 These studies, however, have
been looking specifically at an elderly population. In an
elderly population, for numerous possible reasons, good
outcome is related to many other factors apart from
X-ray appearance. For this reason, we excluded anyone
over 85 years old. Our study populations demographics
compares favourably with the former studies in terms of
both mean age and sex proportions. We believe that it is
fair to conclude that the patients in our study with a
good radiographic result will go on to have good function. It would, however, be advantageous to follow up
the present study population with formal functional
assessment.
The results shows that minimally displaced fractures
are more likely to satisfy the reduction criteria. Many of
the minimally displaced fractures that were manipulated in ED, however, would have satisfied the criteria
for adequacy of reduction before manipulation. The
decision to manipulate was at the discretion of the treating ED medical officer, who presumably thought that a
better reduction was possible. Many post-reduction
X-rays were deemed acceptable by ED staff when in fact
they were not adequately reduced. Worryingly, only
five patients were re-manipulated in the ED whereas
27 were discharged to orthopaedic follow up without
having been adequately reduced. There were no guidelines for which fractures to manipulate and which to
accept. It has been demonstrated in a recent study that
many ED junior medical officers do not know how best
to assess displacement of Colles-type fractures.15 ED
registrars, residents and occasionally even interns were
the staff dealing with these fractures in the study. These
results stress the importance of either having guidelines
or simply educating ED junior medical officers on which
fractures to reduce, which reductions to accept and
which to refer.
The study highlights the importance of the initial on
arrival and post-reduction X-rays in the ED as predictors of outcome. Medical officers working in ED should
be aware of the importance of measuring the dorsal
angle. They should be referring patients with >15
dorsal angulation to orthopaedics early, as this group is

2009 The Authors

Journal compilation 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Management of Colles-type fractures

5.

Hove LM, Solheim E, Skjeie R, Sorensen FK. Prediction of secondary displacement in Colles fracture. J. Hand Surg. 1994; 19B:
7316.

6.

Lafontaine M, Hardy D, Delince P. Stability assessment of distal

radius fractures. Injury 1989; 20: 20810.

Competing interests

7.

Gartland JJ, Werley CW. Evaluation of healed Colles fractures.

J. Bone Joint Surg. Am. 1951; 33: 895907.

None declared.

8.

Bacorn RW, Kurtzke JF. Colles fracture: a study of two thousand

cases from the New York state workmens compensation board.
J. Bone Joint Surg. Am. 1953; 35: 64358.

9.

Gliatis JD, Plessas SJ, Davis TRC. Outcome of distal radial fractures in young adults. J. Hand Surg. 2000; 25B: 53543.

more likely to have poor outcome. A good reduction is

still important though and should not be accepted if the
dorsal angle has not been adequately corrected.

Accepted 31 May 2009

10. McQueen M, Caspers J. Colles fracture: does the anatomical result

affect the final outcome? J. Bone Joint Surg. Br. 1988; 70: 64951.

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