Frak Turco Lles

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Copyright980by The Journal of Bone nd Joint Surgery, Incorporated

Complicationsof Colles Fractures*BY WILLIAM P. COONEY, III, M.D.t, JAMES H. DOBYNS, M.D.J, AND RONALD L. LINSCHEID, M.D.S,

ROCHESTER, MINNESOTAFrom the Department of Orthopedics, Mayo Clinic and Foundation, Rochester

ABSTRACT:atients with Colles fractures have se-rious complications more requently than is generallyappreciated. A study of 565 fractures revealed 177 (31per cent) with such complications as persistent_neuropathies of the median, ulnar, or radial nerves(forty-five cases), radiocarpal or radio-ulnar arthrosis(thirty-seven cases), and malposition-malunion thirtycases). Other complications included tendon ruptures(seven), unrecognized associated injuries (twelve),Volkmannsschemia (four cases), finger stiffness (ninecases), and shoulder, hand syndrome twenty cases).manypatients, incomplete restoration of radial lengthor secondary loss of the reduction position caused thecomplications.

Current opinion seems to be that there are no impor-tant problems relating to the treatment of Colles frac-turesz,lz,15,zl, despite admonitions,~.l~ that many atientswhohave had such a fracture are found to have permanentdisability and poor function of the hand and wrist. In ourhospitals, we have seen a steady flow of complicationswhich has significantly sharpened our awareness of themany difficulties associated with treatment. Thesedifficulties are not commonlyppreciated. In the presentstudy of patients referred to us for early and late manage-menlO, we have accumulated sufficient material to reportfigures on the incidence of complications from Collesfracture. Treatment of these complications is a separateconsideration that will not be discussed or analyzed, ex-cep~ in delineating a general approach o a specific compli-cation.

Clinical MaterialAll patients treated for Colles fractures at the Mayo

Clinic from January 1968 through December 1975 were.studied. There was a total of 565 patients. Of these, 356(63 per cent) were seen primarily at our hospitals fortreatment of the Colles fracture, while the others were re-ferred for evaluation and treatment because of complica-tions, either early (during the acute treatment of the frac-ture) or .late (with specific complications). All patientswhowere referred had had primary treatment of the frac-ture elsewhere, and any patient with a recognized compli-* Read at the Annual Meeting of The American Academy of Or-thopaedic Surgeons, New Orleans, Louisiana, February 2, 1976.? Department of Orthopedics, Mayo Clinic, Rochester, Minnesota55901. Please address reprint requests to Dr. Cooney.

cation whowas sent to us for treatment was also consid-ered to be a referral. The case histories, roentgenograms,and :follow-up data on all 565 patients were assessed withrespect to the mechanism f the injury and associated in-Juries.In evaluating and tabulating the results (Table I),used the Frykman lassification of the fracture. Type I wasan extra-articular radial fracture; Type II, an extra-articular radial fracture plus an ulnar fracture; Type II, afracture into the radiocarpal joint; and Type V, a fractureinto the radiocarpal joint plus an ulnar fracture. Type Vwas a fracture into the radio-ulnar joint; TypeVI, a frac-ture into the radio-ulnar joint plus an ulnar fracture; TypeVII, a fracture into both joints; and TypeVIII, a fractureinto both joints plus an ulnar fracture.When there were complications, we especiallystudied the method f reduction, the anesthesia, the type ofimmobilization, and the post-fracture care, and we ried tocorrelate each with the type of complication.

ObservationsIn the total of 565 cases, there were 177 seriouscomplications in 128 patients, as categorized into these

eight major types: compression neuropathy (forty-fivecase:s), arthrosis after fracture (thirty-seven cases), malun-ion after loss of reduction (thirty cases), tendon rupture(seven cases), unrecognized associated injuries (twelvecases), complications of fixation (thirteen cases), Volk-ma~tns schemic contracture (four cases), arthrofibrosisthe fingers (nine .cases), and shoulder-hand syndrome(upper-limb dystrophy) (twenty causes).Somepatients had more than one complication. Pa-tients with shoulder-hand syndromeoften had two or morepresenting complications that contributed to the dys-trophy. A tenth complication, early loss of reduction(forty-one cases), was not included in the. analysis, exceptto record its occurrence when t produced a symptomaticarthrosis or malunion.Minor complications were not recorded in this Study.They ncluded transitory radial and medianneuritis; flexorand extensor tendinitis; cast-pressure sores; pin-site irrita-tion; and stiffness of the wrist, elbow;and shoulder joints.Conservative treatment, applied early, relieved most ofthese minor complications.Complications were encountered whatever the formof fracture treatment used. Amonghe 356 patients whowere primarily treated at our institution, sixty-eight pa-

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614 w.P. COONEY, III, J. H. DOBYNS, AND R. L. LINSCHEIDTABLE I

COMPLICATIONS OF COLLES FRACTURE ACCORDING TO TREATMENT METHODSFrykman No. of No. of AnesthesiaType Complications Patients Local Block/General Unknown ImmobilizationCast Pins Unknown

I 12 9 3 3 3 8 1 0II 14 10 7 1 2 9 1 0III 2 2 1 1 0 1 1 0IV 16 12 6 6 0 9 2 1V 19 12 8 4 0 11 1 0VI 24 19 11 5 3 16 2 1VII 27 18 10 6 2 14 3 1VIII 42 32 20 12 0 26 6 0Unknown 16 14 12 0 2 12 0 2

tients (19 per cent) had seventy-eight complications.Amonghe referred patients, sixty had ninety-nine com-plications. Of the 128 patients with complications, seventy-eight had had local anesthesia and thirty-eight had hadblock or general anesthesia; in twelve cases, the type ofanesthesia was not recorded. Eighty-six patients hadclosed reduction and~ immobilization in a cast, seventeenhad primary external pin fixation, and twenty had failureof cast immobilization with secondary pin fixation. Forfive patients the types of reduction and immobilizationwere not specified. The comminuted displaced intra-articular fractures (the unstable ones, FrykmanTypes IVthrough VIII) were associated with an increased numberofcomplications, especially the more comminutedType-VIIand VIII fractures (sixty-nine of the 177 complications).For sixteen fractures, the Frykman lass could not be de-termined. The largest number of complications (74 percent) was in patients who had had injection of a localanesthetic into the fracture site, although that methodofanesthesia was used in only 56 per cent of the patijents whohad tr.eatment for Colles fracture. Complications after thereduction of displaced comminutedfractures were lesslikely to occ.ur if either general anesthesia or an axillaryblock was given, followed bYsustained traction (ten min-utes) and gentle reduction. After primary external pin-fixation techniques in seventy-five fractures there weretwenty-one complications, while after failed closed reduc-tion and secondaryexternal pin fixation in forty fractures,twenty-eight complications were encountered. There were128 complications in patients whowere treated by closedreduction and plaster-cast fixation, but that routine wasfollowed three times more frequently than the othermethods of treatment combined. The age of the patient,sex, and mechanism f injury seemed o have no relation-ship to the incidence of complications.Compressive Neuropathy

This was the most frequent single complication (7.9per cent), occurring in twenty-onepatients treated locallyand in twenty-four whowere referred to us for treatment.It was observed both acutely and late after the injury hadoccurred. Median neuropathy developed early in thirty-one patients, usually associated with reduction of the frac-ture in the emergency oomunder local anesthesia (twenty

patients). This complication was less frequent after bra-chial block or general anesthesia (eleven patients). Radialneuropathy, attributable to improper immobilization (castcompressionat the spiral groove of the humerusor on thedorsum f the hand), was diagnosed in three patients. Irri-tation from external pin fixation caused a severe radialneuropathy in two patients. Ulnar neuropathy occurred insix patients as a result of cast compression.All but five ofthe early neuropathies required no treatment and resolvedafter the offending compressing agent (cast or pin) wasremoved. The five exceptions were patients who had aneuropathy as a result of initial injury. They had im-mediate carpal-tunnel release and no permanent sequelae.Late neuropathy of the median nerve occurred inforty-one patients. All had persistent symptoms. n fouradditional patients, the median neuropathy was combinedwith ulnar neuropathy. There were no late radialneuropathies. Thirty-one of the forty-five patients requiredrelease of the carpal tunnel or Guyons anal, or both, andextensive exploration through an appropriate palmar orforearm incision was essential for adequate decompres~s!on(Fig. 1). In six patients, volar fracture fragments werefound compressing both the ulnar and median nerves andwere removed. Excessive callus formation (seven pa-tients), persistent hematomasix patients), and localizedswelling (twelve patients), usually the result of the forcedvolar flexion-ulnar deviation position (Cotton-Loder),were considered to be responsible for most of the other lateneuropathies. Eleven of the twenty-four patients whowerereferred to us and seven of the twenty-one reated primar-ily had one additional complication associated with a com-pressive neuropathy, and one referral patient had threeassociated complications.Arthrosis after Fracture

When ither painful motion of the wrist or forearmwas evident or there was a mechanical obstruction tomotion after fracture, we diagnosed the condition as ar-throsi~. It was observed n thirty-seven patients and repre-sented. 20 per cent of the complications. Radio-ulnar ar-throsi.,; (twenty-seven patients) was more commonhanradiocarpal arthrosis (ten patients). FrykmanType-VI,VII, and VIII fractures most often elicited this complica-tion. When xternal pin,fixation techniques that restored


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COMPLICATIONS OF COLLES FRACTURES 615the radial length were used to treat those fractures therewas a lower incidence of arthrosis (four patients), despitethe fact that pin fixation was the preferred treatment for themore comrninuted fractures.

Of the ten patients with radiocarpal arthrosis, ninewere treated surgically: three by dorsal ostectomy, two byproximal row carpectomy, two by arthrodesis, and two bytotal prosthetic arthroplasty of the wrist. Of the twenty-seven patients with radio-ulnar arthrosis, nineteen had apainful radio-ulnar joint that required a Darrach esectionof the distal end of the ulna (fourteen patients), a Milchprocedure (one patient), or a Silastic replacement arthro-plasty (four patients). Six other patients had symptomaticradio-ulnar subluxation with a mechanical obstruction tomotion and required Darrach excision of the distal end ofthe ulna. All twenty of the patients whohad the Darrachprocedure had improvement n motion of the wrist and, inparticular, in pronation and supination of the forearm.Ten of the twenty-one referral patients and seven ofthe sixteen primary patients had an additional complica-tion.Malposition- Malunion 1

Thirty patients had this complication, the majorityhaving been referred for treatment. Five patients had frac-tures that were not yet fully united when hey were seen fortreatment. They required early open reduction. The othertwenty-five patients required osteotomy. Malunion wasmost commonlyelated to loss of the reduction position,which commonly ccurs when he fracture is unstable andcomminuted.This loss of reduction early in the treatment

period wasa frequent problem. n this series, treatment forloss of reduction was required in 27 per cent of the 565patients. A corrective reduction was usually performed bydistraction and gentle manipulation, the patient having hadbrachial b!ock or general anesthesia. It was successful inmost patients (more than 92 per cent) when accomplishedwithin two week.s of the fracture and when he reductionwas maintained with some form of external pin fixation.Our preference was to insert in the base of the second andthird metacarpals two 2.0-millimeter (5/64-inch) Stein-mannpins oriented at 60 to 90 degrees to each other. Twoslightly larger pins(2.3 millimeters, 3/32 inch) wereplaced in the middle third of the radius. A Roger Andersonexternal-fixation apparatus attached to these pins main-tained the reduction and provided stabilization. Additionalpins or Kirschner wires were. used, as required, to secureloose fragments. When he pins applied above and belowwere inadequate to maintain ~eduction open reduction wasdone (five patients), with sa.tisfactory results.After inadequate treatment of the fresh fracture wasfollowed by malunion, the complaints of significant pain,deformity, and limitation of motion present in twenty-fivepatients led to recommendationsor corrective osteotomy.Fourteen patients had that operation at our institution.Three patients accepted the deformity or preferred not tohave surgery, and six had the operation in their home

community. Twowere lost to follow-up. In most of ourfourteen patients the corrective osteotomy was supplemen-ted by bone-grafting (Figs. 2-A through 2-D). Improve-ment in grip strength and motion was achieved in all butone of these fourteen patients, and that patient required ar-throdesis.Nine of the referral patients in this group had anadditional complication, as did one of the twelve primarypatients. Two eferral patients had two additional compli-cations.

Tendon RuptureRupture of the extensor pollicis longus was noted infive patients, and rupture of the index flexor digitorumpro-fundus or flexor pollicis longus was noted in one patient

each. The: rupture was primarily related to bone fragmentsfrom displaced fractures that abraded the tendon during theweeksafter healing of the fracture. All five patients withloss of the extensor pollicis longus tendon had rupturewithin two months rom the initial injury (two, two, three,four, and eight weeks), while in the two patients withflexor tendon rupture the rupture occurred after threemonths. All patients had either a tendon transfer or a ten-don graft.. Direct tendon repair was not possible becauseseveral centimeters of tendon substance had been lost.Associated Injuries Unrecognized Primarily

These included scaphoid fractures (four patients),radial head fractures (two patients), Bennetts fracture(one patient), and intercarpal ligament injuries (fivetients), which were recognized between two days and onemonth rom the time of the original injury. These injuriesusually were caused by the same mechanism that causedthe Colles fracture. In our series, ligament instability ofthe wrist required operative reconstruction of thescapholunate ligament in four patients. Scaphoid fracturesrequired open reduction in two patients, and radial head-fractures required excision of the radial head in two pa-tients.Complications of Fixation

Three patients with pin fixation had pin breakage thatrequired operative removal of the pins. Pin loosening withpurulent drainage occurred in eight patients, and an ulcer-ation of the area around a pin occurred in one patient. Onepatient sustained a fracture through he pin site in the distalend of the radius. Two atients had nerve irritation causedby the casL which led to sympathetic dystrophy (as will bediscussed). Casts caused other complications, as describedin the paragraphs on compressive neuropathies, Voik-manns ischemia, and shoulder-hand syndrome.Volkmanns Ischemic Contracture

This was seen in four referral patients, three of whomhad had a constricting cast that was retained despite thepatients complaints of persisting pain. Continued use ofanalgesics in two patients further masked he symptoms.

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616 w.P. COONEY, III, I. H. DOBYNS, AND R. L. LINSCHEID

Fro. 1Median neuropathy associated with Colles fracture may involve aprominent volar callus, which in this patient compressed the mediannerve proximal to the. carpal tunnel. Surgical release was extended intothe distal end of the forearm tO ensure adequate decompression.

Oneof the three patients had had an undisplaced fracture.Our treatment of these patients was difficult and pro-longed. Wevariably used nerve and muscle decompres-sion, lysis of tendons and nerves, release or lengthening of

Shoulder-Hand SyndromeThis is more appropriately called upper-limb dys-trophy or pain-dysfunction, and was a significant problemin twenty patients, sixteen of whom ad been referred.

Four patients had acute symptomswith predominant sym-pathetic components f change in skin temperature, color,and texture; pain and loss of motion in the shoulder; andstiffness of the hand or specific local trigger areas of ex-quisite pain and tenderness (or both). In one patient it wasthe result of radial-nerve irritation from pin fixation; intwo patients, from excessive wrist flexion which producedacute median neuropathy; and in one, from an unreduced,severely displaced fracture with associated disuse of thelimb. Twoof the four patients had one other complicationand two had two additional complications.The sixteen referral patients had late upper-limb dys-trophy. They had fewer sympathetic components than didthe patients with the acute condition, but had long-established clinical complaints of stiffness and disuse ofthe shoulder, stiffness of the hand, painful motion, carpal

Figs. 2-A throi~gti 2-D: Maluni0n f the distal end of the radius developed n the wrist of a forty-five-year-old farmer whohad been gored by a bull.During life-saving measures the fracture was overlooked.Figs. 2-A and 2-B: When reatment of the malunion was begun at six months, there was marked shortening and radial angulation, medianneuropathy, and weak grip. An open-wedge steotomy, a bone graft from the distal end of the ulna, and a small plate were employed o regain lengthand restore alignment of the forearm. The carpal tunnel ~,as released.

muscle-tendon units, and tendon transfers when ndicated,and the long-term results in three patients were only fair.The fourth patient had persistent pain and finally had tohave a below-the-elbow amputation.

tunnel symptoms, nd radiocarpal arthrosis. Ten of the six-teen patients had fracture malunion. Fourteen of themwere referred with long-established complaints, but im-proved on conservative treatment extending for from six


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COMPLICATIONS OF COLLES FRACTURESweeks to four months. Six of the sixteen had one othercomplication and four, two or more complications.Stiff Hands

Stiff hands from arthrofibrosis of the fingers were asevere complication in nine patients. It was manifested bypain and swelling limited to the hand, with a loss of fingermotion and occasionally a loss of motion of the wrist.Swelling and pain, particularly in the structures lined withsynovial tissue, were the most characteristic findings inseven patients. Swelling of the proximal interphalangealjoint was the major source of pain and resulted in a severeloss of motion. The factor most commonly ssociated withthe clinical symptoms nd signs was improper applicationof a cast. Stiff hands occurred most often after impropercast application (seven of nine patients in this category).lack of early motion of the hand was evident in five of thenine patients, and pre-existing degenerative arthritis waspresent in three patients. Three patients had a mildDupuytrens contraeture in the affected hand. Six of thenine patients had full recovery, and the other three hadimproved unction after conservative treatment.Multiple Complications

A study of the patients whohad multiple complica-tions that usually included the shoulder-hand syndrome e-vealed that the underlying cause of the dystrophy appearedto be a combinationof predisposing factors in conjunctionwith difficulties in treatment, such as repeated attempts at

617reduction (seven patients), improper mmobilization in thecast (four patients), poor mobilization of the joint (eightpatiients), and inadequateefforts at rehabilitation.

DiscussionSevere complications from Colles fracture continueto occur frequently. We found that there were more pa-tients than we anticipated whose complications requiredexte.nsive treatment. Possibly the percentage of complica-tions in this report is higher than in other reports becausemore than 46 per cent of the patients (sixty of 128):withcomplications were referred for treatment. We have di-vide, d the complications into nine groups, of which thelargest was the neuropathies.Compression neuropathies occurred both early(within the first two weeks) and later during the period

treatment. When he median nerve was involved, earlyrecognition was common. However, in some "patients,when he radial or ulnar nerve was compressed, the diag-nosis was delayed because the physicians failed to ap-preciate or suspect that the nerve was compressed,stretched, or irritated. This failure was especially evidentwhen ixation pins were utilized. Delay in diagnosis usu-ally lied to complications uch as a stiff handor carpal tun-nel syndrome.Medianneuropathy was identified more often in thisseries of patients than in previously reported series1,6,~,probably because there is increased recognition of thiscondition and because more patients are referred for surgi-

FIG. 2-C F~G. 2-D


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618 W. P. COONEY, tlI, J. H. DOBYNS, AND R. L. LINSCHEIDcal decompression. We agree with previous authors,16that a significant contributor to the neuropathy s the forceof fracture reduction and the position of immobilization;the higher frequencyof this complicationafter local block,with or without systemically administered analgesics,tends to support this belief.Post-fracture arthrosis was the second most commoncomplication in our patients, yet often it went unrecog-nized for some ime. Subtle forms of this arthrosis are re-sponsible for a large portion of the weaknessof grip andlimited motion that are commonlyeen after this fracture.Whenhe condition is recognized, the patient often can beimprovedby conservative measures, such as splinting, thelocal injection of steroids, and the use of salicylates.Operative treatment for radiocarpal arthrosis Was neces-sary in only nine patients in our series. The radio-ulnar ar-throsis that was seen in twenty-seven patients mostlystemmed rom the inability to obtain an adequate anatomi-cal reduction, manifested in two ways. One wasmalalignmentof the sigmoid notch of the distal end of theradius with the ulnar head, owing to radial deviation anddorsiflexion of the distal radial component.The other wasinadequate restoration of length to maintain the normal re-lationship of the radio-ulnar joint. This problemwas sig-nificant enough o require surgical treatment in nineteen ofthe twenty-seven patients. Webelieve that the commontechnique of reduction and immobilization in full prona-tion with ulnar deviation so that the distal end of the ulnaprovides stability is mechanicallyunsound, particularly indisplaced, highly Comminuted fractures. The distalradio-ulnar joint often is unstable, and any radio-ulnar sub-luxation or dislocation that exists is only increased by im-mobilizing the hand in full pronation. The end result maybe that rotation of the forearm, especially supination, be-/comes severely limited.Weagree with Sarmiento et al., and others ~,6, thatthe best position for maintaining normal alignment andminimizing deforming forces is supination. When heproper length of the distal end of the radius is difficult tomaintain, strong, protracted traction and external pin fixa-tion maybe the best form of treatment.Early loss of reduction and late collapse after Collesfracture probably are two common omplications that aretoo readily accepted by treating physicians. To us, each ofthese conditions signifies that the fracture being treated isunstable. It usually has one or more of the following characteristics: extensive comminution,markeddisplace-ment of fragments, or interposition of soft tissue -- andany one of them can lead to an incomplete reduction.We believe that whenever a fracture is unstable, noamountof residual dorsal angulation after reduction ispermissible. Adequate eduction requires that the full dor-sal length of the radius be restored and maintained. Thisrequires a stable volar buttress plus dorsal tension by tissueor an apparatus that prevents dorsal collapse. Otherwisethe force of active finger flexor and extensor tendons,combinedwith dorsal translation of the lunate, tends to

produce a proximal carpal thrust that results in a dorsacompressive force leading to collapse and displacement.Present methods of fracture reduction and cast support do not always prevent these potentially deforminforces, particularly in comminuted ractures. In unstablfractures, weprefer to use external pin fixation in order tomaintain a distracting force, prevent collapse, and allowthe volar fragments of the cortex to unite in goodpositionWe have used this methodfor patients in whom eductionof the fracture was lost after cast immobilizationand alsfor potentially unstable intra-articular fractures (FrykmTypes V through VIII), and have achieved satisfactory re-sults 3. ~Open reduction of Coltes fracture is rarely advocated, despite the need for accurate reduction of the frac-ture s. Because he functional results so closely parallel thanatomical results, it is our practice that when losed re-duction, including the use of external pin fixation, is nosuccessful, open reduction is indicated. Definite criteriafor open reduction of Colles fractures have not beecompletely formulated, but for the present the techniqushould be more strongly considered for use in youngadultin whom omminuted, unstable intra-articular fractureshave been treated unsuccessfully by closed reductiontechniques.The incidence of complications from Colles fracturesreported here does not differ significantly from the typeand frequency of problems reported by others. Frykmanoted the significant sequelae of radio-ulnar arthrosis(18.6 per cent), shoulder-hand syndrome 2 per cent),peripheral neuropathy (315 per cent) in his series of 43"cases. He found that symptoms t the distal radio-ulnarjoint weremost frequently related to fractures into the join(41 per cent) combinedwith dorsal angulation and shortening of the distal end of the radius. Lippman nd. Lidstr6had similar findings (10 per cent and 15 per cent inci-dences of radio-ulnar arthrosis, respectively) and stressedthat radio-ulnar instability was the most commonause oa poor result. Gartland and Werley reported an incidencof arthrosis of 22 per cent. In combiningboth radiocarp~and radio-ulnar arthroses, we found symptoms hat wersignificant enough o require surgical treatment in thirty-seven (6.5 per cent) of 526 patients.

Shoulder-hand syndrome was present in 1.4 per centof patients reviewed by Bacorn and Kurizke, in 3.4 percent in Rosensseries, and in 10 per cent in Lidstr6ms se-ries of 515 patients. The latter included finger-joint stiff-hess and Siidecks atrophy. Unsatisfactory results were re-ported in 67 per cent. The incidence in our series was fou(1.1 per cent) of 356 local patients. While ffected patientsare fewer in number, his complication s the most difficultto treat, and prevention by the techniques described byMobergshould be studied.

Peripheral neuropathy as a serious complication wanot noted by others to be as frequent as we have reported itto be (forty-five patients over-all and twenty-one[3.7 pecent] of patients who were primarily under our care).


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COMPLICATIONS OF COLLES FRACTURES 619Lidstr6m elieved that nerve injuries are rare after frac-tures of the distal end of the radius (slightly more hanper cent). Bacornand Kurtzke eported an incident of 0.2per cent and Schlesinger and Liss noted only one case per1,000 fractures. Webelieve that these negative reportsweredue in part to a lack of recognition andpossibly moreconcernwith treatmentof the fracture than with potentialsequelae. Lynch and Lipscomb, Frykman, Robbins, andothers5 have placed proper emphasison the causes of me-dian neuropathy nd the need for aggressive treatment incertain acute as well as late cases.Complicationsrelated to more han one factor were

common henever hree complications -- neuropathy, ar-throsis, and shoulder-hand syndrome - were present.Frykmanoundthat of eighty patients with radio-ulnar ar-throsis, five (6.3 per cent) had median europathy ndfivehad shoulder-handsyndrome.Of our twenty patients withshoulder-hand syndrome, sixteen had one or more as-sociated complications(arthrosis in ten patients, medianneuropathyn nine patients, malunion n ten patients, andsympatheticdystrophy n five patients). Evidently, thesecomplications ndothers contributedirectly to the 24 to 27per cent incidenceof poorfunctional results that has beenreported"6"~fromthe treatment f Colles fractures.

References1. BACORN,. W., and KURTZ~:E,. F.: Colles Fracture: A Study of TwoThousand Cases from the NewYork State WorkmensCompensationBoard. J. Bone and Joint Surg., 35-A: 643-658, July 1953.2. BOSACCO,. N., and TRABULSL. R.: The Colles Fracture -- Treatment by Closed Reduction, Internal Fixation and Short Arm Cast Applica-tion. In Proceedings of The American Academy f Orthopaedic Surgeons. J. Bone and Joint Surg., 57-A: 1030, Oct. 1975.3. COONEY, . P., III; LINSCHEID, . L.; and DOBYNS,. H.: External Pin Fixation for Unstable Colles Fractures. J. Bone and Joint Surg.,

61-A: 840-845, Sept. 1979.4. DARRACH,~LL~AM:artial Excision of Lower Shaft of Ulna for Deformity following Colless Fracture. Ann. Surg., 57: 764-765, 1913.5. DoBYNS,. H., and LINSCHEID,. L.: Complications of Treatment of Fractures and Dislocations of the Wrist. In Complications in OrthopaedicSurgery, edited by C. H. Epps, Jr. Vol. 1, pp. 271-352. Philadelphia, J. B. Lippincott, 1978.6. FRYKMAN,.: Fractur of the Distal Radius Including Sequelae -- Shoulder-Hand-Finger Syndrome Disturbance of the Distal Radio-UlnarJoint and Impairment df Nerve Function. A Clinical and Experimental Study. Acta Ortt~op. gcandina~ica, Supplmentum 08, 1967.7. GARTLAND,. J., JR., and WERLEY,. W.: Evaluation of Healed Colles Fractures. J. Bone and Joint Surg., 33-A: 895-907, Oct. 1951.8. KRISTIANSEN,MUND,nd G~ERSOE,~NAR: olles Fracture. Operative Treatment, Indications and Results. Acta Orthop. Scandinavica, 39:33-46, 1968.9. LIDSTR6M, NDERS:ractures of the Distal End of the Radius. A Clinical and Statistical Study of End Results. Acta Orthop. Scandinavica,Supplementum 41, 1959.10. LIPPMAN, . K.: Laxity of the Radio-ulnar Joint following Colles Fracture. Arch. Surg., 35: 772-786, 1937.11. LYNCH, . C., and LIPSCOMI~, . R.: The Carpal Tunnel Syndrome and Colles Fractures. J. Am. Med. Assn., 185: 363-366, 1963.12. MARVEL,. R., JR.: Comminuted ractures of the Distal End of the Radius Treated by Pins and Plaster Technique. In Proceedings of TheAmerican Academy f Orthopaedic Surgeons. J. Bone and Joint Surg., 57-A: 1030, Oct. 1975.13. M~L8,HENRY: uff Resection of the Ulna for Malunited Colles Fracture. J. Bone and Joint Surg., 23:311-313, April 1941.14. MOSERG,RIK: Shoulder-Hand-Finger Syndrome, Reflex Dystrophy, Causalgia [Abstract]. Acta Chir. Scandinavica, 125: 523, 1963.15. POOL, CHRISTOPHER:olles Fracture. A Prospective Study of Treatment. J. Bone and Joint Surg., 55-B: 540-544, Aug. 1973.16. RO88INS, . V.: Logical Reduction of Displaced Colles Fractures. NewYork State J. Med., 50: 2959-2962, 1950.17. ROSEN, RIK: Fractura Extremitatis Distalis Radii. Ugeskr. Laeger., 109: 603-610, 1947.18. SARMIE~qTO,t~GUSTO;RATT,G. W.; BERRY, . C.; and S~NCLAm, . F.: Cg~lles Fractures. Functional Bracing in Supination. J. BoneandJoint Surg., 57-A: 311-317, April 1975.19. SI-IECK, MAx:Long-Term ollow-up of Treatment of Comminuted ractures of the Distal End of the Radius by Transfixation with KirschnerWires and Cast. J. Bone and Joint Surg., 44-A: 337-351, March 1962.20. SC8LES~NGER,. B., and L~ss, H. R.: Fundamentals, Fads and Fallacies in the Carpal Tunnel Syndrome. Am.J. Surg., 97: 466-470, 1959.21. SMAI.LL,G. B.: Long-Term ollow-up of Colles Fracture. J. Bone and Joint Surg., 47-B: 80-85, Feb. 1965.

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Frak Turco Lles