Since for the first time I find myself with time in my hands I decided to dwell on exploring issues with which in the past I was involved to a major degree. Today I will discuss an issue where long-held, rigid adherence to an unchallenged tradition has forced me to challenge its validity.

My comment deals with the Colles fractures, which is one of the first subjects in orthopaedics we come into contact during our year of internship.  We learned about the ubiquitous fracture that affected a large number of older people and were told that its treatment was simple and the clinical results good.  All that was needed:  “closed reduction” and immobilization in a long arm cat for a few weeks.

It was not until late in my career that I first began to ask questions as to the etiology of the frequently observed loss of the obtained reduction. I had followed the gospel-like lessons we had learned from the British orthopaedist who forcefully stated that once the reduction had been obtained, the cast had to extend over the elbow, the forearm held in pronation and the wrist in a position of ulnar deviation and slight flexion.

One day, however, I suspected that the recommended position of the foreman in pronation in the cast was the guiltiest party. My logic was based on my understanding of the anatomy and physiology of the wrist. I reasoned that if it is true that muscles in order to function most effectively should be placed in a condition of tension then the forced pronation of the forearm would result in activation of the brachioradialis muscle, the only muscle attached to the distal radius, and in that manner recreate the deformity. The contraction of this muscle during flexion of the elbow could easily displace proximally and dorsally the distal radial fragment^{. 1}

I met with the neurologist who was performing electromyography and asked him for his advice and help. I brought him volunteer medical students and patients to have the studies conducted.  Without exceptions, every time the elbow was flexed the brachioradialis muscle contracted. In cadaver specimens, where we had created fractures that resembled the Colles fracture pattern, any pull on the muscle readily recreated the typical deformity.

Based on all that information we began to treat Colles fractures in supination and compared the results with those obtained when treated in pronation. The results were published, which indicated a lower incidence of re-displacement in the supination group. We went as far as developing a foreman brace that permitted limited flexion of the elbow, but prevented pronation of the forearm. It permitted limited flexion of the wrist but made impossible any radial deviation. ^{2, 3} I concluded that the classical position as described by Colles and faithfully accepted by the orthopaedic community was wrong.

At that time my career took a major turn toward Hip surgery following  a three-month visit to Sir John Charnley in England that resulted in my concentrating more seriously on total hip replacement and ignoring to some degree my interest in wrist fractures. I deeply regret the foolish decision since I am sure I could have been able to continue to devote time to both subjects simultaneously.

I vividly recall that during those days of romancing with Colles fractures I visited with some regularity local Nursing Homes where I followed patients I had treated surgically for various conditions. Oftentimes I took along with me one or two residents. During those visits I made it a habit to ask as many patients as possible if they had at any time in their lives sustained fractures of their wrists. As expected, many of them had. I saw many where a close look failed to indicate any deformity whatsoever. Other times I observed obvious deformities.  However, I have no recollection of a single patient who presented symptoms of osteoarthritis or complained of any serious clinical problems as a result of the deformed wrist.

No doubt, my mind was conditioned not to question the wisdom of Colles and consequently I had rigidly adhered to his well-intentioned but erroneous premise. I suspect we do this very often with many other pronouncements and treatment which overtime gain an odor of sanctity that precludes questioning. This is why I am such a strong advocate of conditioning residents to ask questions and to challenge virtually everything we teach them.

During the last two decades a great deal of enthusiasm has grown in support of open reduction and internal fixation of Colles fracture. The readers would not be surprised to hear that I have not surrendered to the new treatment modality. However, I trust I am smart enough to realize that the technique has made possible the attainment of better anatomical reduction and restoration of articular congruity and in many occasions is the treatment of chicer. 

        Approximately 10 years ago I sustained a comminuted, intraarticular Colles fracture with a severe dislocation of the radio-ulnar joint.  My hand surgeon fixed the fracture with multiple wires. When I woke up from the surgery and glanced at the radiographs I immediately commented “This will never work.” My remark was based on the recognition that the dislocated radio-ulnar joint had not been addressed. The surgeon had concentrated on reduction of the fragments in the best possible way, but ignored the dislocation of the ulna, which was the most important feature. Good fragment reduction in the presence of a dislocated radio-ulnar joint is not enough, particularly if the distal-lateral radial fragment has an oblique geometry. The reduction is easily lost when the brachioradialis contracts    . That was exactly what happened. Ten days after surgery new x-rays demonstrated the recurrence of the radial deviation of the held-together distal epiphysial bones. Soon after that I was back in surgery where a plate was used to stabilize the bony fragments.

My feeling regarding the closed treatment of Colles fractures may soon become meaningless since the current infatuation with surgery is displacing the nonsurgical treatment into the heap of history. Or maybe not. We should not be surprised if within a few years the orthopaedic profession will conclude that plating was nothing but a flash in the pan when the technique is applied to all displaced fractures and that plate fixation should be reserved for the very severely comminuted fractures with associated radio-ulna dislocation. We are already learning that the results from routine surgery are not any better than those obtained from manipulation and close reduction. Economics may the fact that triggers the arresting of the trend. Equal pay for the care of those patients may become the law of the land regardless as to whether or not surgery is performed.

REFEERENCES:

1. Sarmiento, A. The Brachioradialis as a Deforming Force in Colles’ Fractures Clin. Orthop. Rel. Res. 38:86-92, 1965.
2. Sarmiento, A., Pratt, G.W., Berry, N.C. and Sinclair, Wm. F. Colles’ Fractures – Functional Bracing in Supination. J. Bone and Joint Surg. 57A:3,311-317, 1975.
3. Sarmiento, A., Zagorski, J.B. and Sinclair, W.F. Functional  Bracing of Colles’ Fractures: A Prospective Study of Immobilization in Supination versus Pronation.  Orthop. & Rel.  Res. 146:175-187, 1980

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.