Definition: Fracture at the metaphysis or the articulation of the distal radius

Mechanism: Most common mechanism is a fall on an outstretched wrist that is dorsiflexed


  • One of the most common fractures seen in the ED. >650,000 annually
  • Represent 1/6th of all fractures treated in Emergency Departments
  • Increased incidence with age; women at higher risk then men

Physical Exam

  • Variable gross wrist deformity with displacement of the hand in dorsal or volar relation to the wrist, dependent on the fracture pattern.
  • Neurovascular assessment of the hand
    • Critical to perform complete neurologic exam
    • Median nerve injury common
      • Thenar paralysis (Ape hand deformity): Inability to oppose or abduct thumb
      • Sensory loss of palmar aspect of first, second, third, and radial half of fourth fingers
  • Carpal tunnel compression syndromes are common (13-23%).
  • A full examination of the ipsilateral elbow and shoulder is required to assess for injuries caused by translated force

Colles’ Fracture (

Fracture Classification

  • Descriptive Classifications
    • Open vs Closed
    • Displacement
    • Angulation
    • Comminution
    • Loss of length
  • Eponyms
    • Colles’ (or “dinner fork” deformity):
      • 90% of distal Radius fractures
      • Extra-articular, dorsally angulated distal radius
      • Caused by fall onto hyperextended, radially deviated wrist
      • Eponym traditionally only included non-articular fractures. Currently accepted to describe intra-articular fractures
    • Common Distal Radius Fractures (

      Smith (“reverse Colles’” or “garden spade” deformity):

      • Distal volar displacement or angulation of fracture
      • Often caused by fall onto dorsiflexed, supinated wrist
      • Typically unstable and require open reduction and internal fixation (ORIF)
    • Barton
      • Intraarticular  dorsal or volar (more frequent) rim fracture
      • Extreme dorsiflexion of pronated wrist
      • Usually unstable and not easily reducible. Requires ORIF
    • Chauffer/Hutchinson:
      • Radial styloid avulsion fracture
      • Dorsiflexion and ulnar deviation causing compression of scaphoid against styloid
      • Associated w/ intercarpal ligamentous injury
      • Sugar tong splint with urgent orthopedic evaluation for likely ORIF
    • Die Cast
      • Depressed fracture of articular surface at the lunate fossa
      • Easy to miss because the carpal arc is not disrupted
      • Requires urgent orthopedic follow up for likely ORIF

X-ray Findings

  • Necessary views: AP, Lateral and Oblique
  • Review films for concomitant injuries, particularly carpal bone injuries which can easily be overlooked
  • Key Measurements:
Normal Range Acceptable in Healed Wrist
a) Radial Inclination/Tilt:

Measured on PA view by drawing a line perpendicular to the long axis of the radius and a tangential line from the radial styloid to the ulnar corner of the lunate fossa.

13-30 degrees. < 5 degree loss
b) Radial Length/Shortening:

Measured on PA view by measuring the distance from the tip of the radial styloid to the distal articular surface of the ulna.

8-18 mm < 5 mm Radial shortening
c) Volar Tilt:

Measured on Lateral view by drawing a line perpindicular to the long axis of the radius and a tangential line along the slope of the dorsal to volar surface of the radius

0-28 degrees, avg of 11 degrees Dorsal angulation of <5mm or within 20 degrees of contralateral wrist

Hematoma Block (EM News)

ED Management

  • Closed Reduction
    • All closed fractures should undergo closed reduction even if operative management is expected
      • Reduces swelling
      • Relieves nerve compression
      • Provides pain relief
    • Always target optimal fracture reduction
      • Closed reduction may be definitive management for non-displaced or minimally displaced fractures (ie. those fractures with acceptable healing parameters or those that can be reduced to those parameters)
      • Closed reduction in high risk surgical patients may be definitive, even outside “acceptable” parameters
  • Reduction technique
    • Supply adequate analgesia
      • Hematoma block
      • Systemic analgesia
      • Procedural sedation if necessary
    • Place Patient in traction with finger traps and hanging weights
    • Hyperextension Traction Reduction
    • For further guidance on reduction technique refer to the following videos:

    • Place patient in a Sugar Tong Splint w/ wrist in Neutral Position and MCP joints free
    • Repeat neurovascular exam after reduction and splinting
  • Close Orthopedic follow up for repeat imaging and decision for operative management


  • Colles’ fractures can be managed non-operatively if reduction is within acceptable anatomic limits
  • Loss of reduction and need for eventual surgical management is associated with:
    • Higher degrees of initial displacement
    • Elderly patients
    • Metaphyseal comminution
  • Potential complications of Colles’ fractures:
    • Median nerve neuropathy, sometimes requiring carpal tunnel release
    • Osteoarthritis at radiocarpal and radioulnar articulations
    • Finger/Wrist/Elbow stiffness –  minimize likelihood with aggressive occupational therapy
    • Extensor pollicis longus tendon rupture as late complication, more frequently post ORIF.
  • All distal radius fractures have potential complications that include neuropathies, tendon injuries, and osteoarthritis

Take Home Points

  • Every distal radius requires closed reduction and placement of a sugar-tong splint
  • Document a thorough neurovascular exam prior to and after reduction with particular attention to the median nerve
  • Emphasize early orthopedic surgery follow up for further management
  • Don’t miss concomitant hand, wrist, forearm and elbow injuries such as lunate dislocation, carpal fractures, or radial head dislocation.

Read More

Radiopaedia: Distal Radial Fracture

Radiopaedia: Chauffer Fracture

Orthofilms: Closed Reduction of a Distal Radius Fracture

DeAngelis MA, Wald DA. Wrist. In: Sherman SC. eds. Simon’s Emergency Orthopedics, 7e. New York, NY: McGraw-Hill; 2014. Link

Egol K et al. Handbook of Fractures. Philadelphia: Wolters Kluwer; 2015: 266-278

Petron, DJ. Distal Radius Fractures in Adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on June 8th, 2016)