This is perhaps one of the commonest fractures in the body, occurring at all ages; when seen in growing children it is to be regarded as an epiphyseal separation rather than as a distinct fracture. It derives its name from the fact that until Colles, a Dublin surgeon, over one hundred years ago, described this injury as a fracture it had been always regarded as a peculiar dislocation at the wrist. It is produced by falls upon the hand in the hyperextended position, the force being usually transmitted through the carpus to the radial end. The name is usually limited to those fractures which occur within one and a quarter inches of the articular surface ([Fig. 303]). Here the structure of the bone is cancellous and impaction may easily occur, this being a decided feature in many of these accidents, and making replacement more difficult. The deformity which results from the fracture is characteristic and more or less uniform. This is called the “silver-fork appearance,” the lower fragment being so displaced, and usually more or less tilted, as to raise the tendons and the structures on the back of the wrist; at the same time it is usually drawn toward the radial side. The more the fragment is impacted or driven into the shaft of the bone the less easily is crepitus elicited.
The fracture is more common than is supposed, and there is no doubt but that many alleged sprains of the wrist illustrate cracks in the bone without displacement, which, nevertheless, are slow to heal and are sometimes followed by thickening and impairment of function. (See [Plate XL].)
Along with the radial fracture separation of the styloid process of the ulna may also occur, or, as Moore has shown, the process itself may perforate the internal lateral ligament so as to protrude through the skin; and the surgeon has occasionally to withdraw the styloid from the ligament which has been impaled upon it. The radio-ulnar ligament is also frequently injured, and this permits the ulna to become more prominent than normal. If the styloid has perforated the skin it lends a compound feature to the case. The interarticular fibrocartilage may also be displaced.
Treatment.
—The secret of obtaining a good result and the explanation for failures lie in the completeness or incompleteness of the reduction of the fragment. If the latter be absolutely and accurately replaced it makes but little difference what dressing is applied. On the other hand any fragment not completely restored will lead to subsequent deformity and impairment of function. Successful reduction, then, is the keynote to success, and should be accomplished at any reasonable cost. Sometimes it is not difficult, and then no anesthetic is required; sometimes it is extremely difficult, and the operator has to exert all the strength he has in his arms, aided by profound anesthesia. Moderate cases can usually be dealt with successfully under nitrous oxide gas. The surgeon grasps the hand as if to shake hands, i. e., with his corresponding hand, the elbow being firmly held by an assistant. Traction is then made upon the hand to which the fragment is affixed, while with his other hand the operator makes such pressure, rotation, or coaxing manipulation with his thumb and fingers as may assist in restoring the fragment to its place. With whatever other effort may be made traction should be combined. Forcible swaying movements, combined with hyperextension, may be necessary to dislodge an impacted fragment. Any degree of force is preferable to failure in this respect. Perfect reduction is the key of success; without it, no dressing is efficient; with it, almost anything will suffice.
Fig. 302
Comminuted but not compound fracture of wrist. (Beatson.)
Reduction once accomplished it is usually an easy matter to hold the arm in position. The writer prefers above all other means a molded plaster-of-Paris splint, which should extend from the line of the knuckles upon the palmar surface well up toward the elbow. It should be fitted neatly to the hand and forearm, bandaged comfortably upon it, while as it solidifies the surgeon should hold the hand slightly flexed to the ulnar side as well as anteriorly. When the splint is hardened and bandaged a simple sling will suffice. The hand should be dressed with the thumb pointing toward the face, while upon the back of the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme; I have seen it extend even to the shoulder after an apparently simple break ([Figs. 304] and [305]).
PLATE XL