Colles fracture – Historical retrospection

The author presents a short historical retrospection of the most important surgeons who studied Colles fracture, in chronological order. The author also describes the eponyms most commonly used in daily surgical practice, along with the historical figures that they are linked to.

Fracture of the distal end of the radius, in clinical practice commonly referred to as fractura radii in loco typico – although the more correct term is fractura radii in zona typica – is one of the most frequent fractures encountered by surgeons or traumatologists in their daily work. Its high incidence presents a sufficient reason for a brief historical overview, enabling a better understanding of this fracture [1],[2].

Although there are no written records, a researcher discovered a fracture with intact immobilization with wooden splints on an exhumed Egyptian mummy, similar to the type of immobilization that can still be found worldwide in the absence of modern forms of immobilization [3].

From the time of Hippocrates until the beginning of the 19^th century, fractures of the distal end of the radius were often mistakenly interpreted as dislocations of the wrist joint. In Hippocrates’ writings (5^th century BCE), only vague descriptions of forearm fractures can be found, although it is known that he distinguished between joint dislocations and fractures of certain bones [4],[5].

Ambroise Paré (1510–1590) was the first author to mention the possibility of fracture of the radius and ulna [6].

Jean Louis Petit (1674–1750) described the displacement of fragments laterally and along the length of the bone, attributing this to the action of the pronator teres muscle [7].

This type of fracture was not well understood until the end of the 18^th century, and the terms sprain, dislocation, and fracture were often confused.

Claude Pouteau (1725–1775) was the brilliant chief surgeon of the Hôtel-Dieu de Paris [1],[7]. In an article published posthumously in 1783, in Paris, Pouteau described fractures of the distal end of the radius [8]. He observed that in this type of fracture, the typical clinical signs – abnormal mobility and crepitus – are often absent, which can lead to sprains, dislocations, or diastasis of the radius and ulna being confused with one another. Pouteau described fractures of the distal end of the radius with dorsal protrusion or displacement of the distal fragment. He recognized several types of fractures, including impacted ones, wherein crepitus could not be elicited [8]. Pouteau’s article went largely unnoticed outside of France, and as a result, Abraham Colles was unaware of it when he published his paper On the fracture of the carpal extremity of the radius, in Edinburgh, in 1814 [9].

Abraham Colles (1773–1843) was a renowned Irish surgeon and Professor of anatomy at the Royal College of Surgeons in Ireland [9],[10],[11],[12],[13]. He described clearly and concisely the most commonly observed fracture of the distal end of the radius. What is somewhat surprising is that, despite being an excellent anatomist and illustrator, Colles did not accompany this publication with illustrations or an analysis of the injury mechanism. This may have led him to define the location of the fracture slightly more proximally than it actually occurs [6],[13],[14],[15],[16]. According to his understanding, the fracture is situated approximately an inch and a half (around 4 cm) from the radiocarpal joint, with a deformity of the articular surface, which makes it appear, on inspection, as a dislocation. The head of the ulna protrudes forward and inward. Swelling at the fracture site arises due to bleeding between the forearm flexor tendons. This, he explained, is why the patient experiences pain during pronation, supination, and elicited flexion. There is no crepitus nor pathological mobility. If the patient’s hand is pulled, the deformity is corrected; however, once the limb is released, the deformity reappears. Notably, Colles described a shift of the longitudinal axis of the hand toward the radial side. This article was also published in a local medical journal and thus remained largely unnoticed [9].

Baron Guillaume Dupuytren (1777–1835) had already been pointing out this type of radial fracture to his students during his lectures. In one of his studies, published posthumously in 1847, he stated that “he had observed many cases of mistakenly diagnosed fractures of the distal end of the radius as dislocations of the wrist joint” [18],[19]. Furthermore, he emphasized that fractures of the carpal end of the radius were common and that he always observed what appeared to be a dislocation of the wrist in such fractures. However, it was not actually a dislocation [20].

Jean-Gaspard Blaise Goyrand (1803–1886) was an exceptional surgeon from Aix (near Marseille) [1]. He made a distinction between epiphysiolysis and fractures of the distal end of the radius, on the one hand, and radiocarpal dislocations, on the other. He noted the prominence of the distal end of the ulna, often accompanied by an avulsion of the ulnar styloid process. He also observed that in the majority of fractures, the distal fragment was displaced dorsally, although in some cases he described displacement of the fragments toward the palm. He illustrated both types of these fractures in his works published in 1832 and 1836 [21],[22].

Auguste Nélaton (1807–1873) expanded anatomical studies of fractures by describing various injury patterns and degrees of comminution. He conducted extensive experiments regarding injury mechanisms using cadavers. He disarticulated the forearms of the deceased at the elbow and removed the olecranon. With the hand fixed, in either dorsal or volar flexion, and the forearm positioned vertically, he struck the upper part of the forearm with a hammer to induce fractures. He then dissected these resulting radial fractures and compared them to the injury mechanisms. Nélaton emphasized the importance of the small bones in the wrist region, noting that during a fall, a person typically lands on an outstretched hand in dorsiflexion. In such cases, the carpal bones absorb the impact, and the scaphoid is driven into the distal end of the radius. From this, it is clear that Nélaton supported Dupuytren’s theory of impact and counter-impact (Fr. coup et contrecoup) [23],[24].

Alfred-Armand-Louis-Marie Velpeau (1795–1866) is a particularly fascinating figure in the history of medicine. He is a striking example of how a person, through tireless work and great willpower, can rise from an uneducated shepherd to one of the greatest authorities in operative surgery. He was a manually skillful surgeon, an eloquent speaker, a perceptive diagnostician, and a diligent and knowledgeable writer, known for his perfect clarity and precision of expression. He was the first to describe the deformity that appears in fractures of the distal end of the radius as talon de fourchette, a term that English-speaking authors referred to, in 1859, as the silver fork deformity [1],[11],[25],[26].

In 1838, John Rhea Barton (1794–1871) described a dislocation fracture of the radiocarpal joint, which was later associated with him through an eponym [1],[13],[27],[28]. Barton described two types of fractures: the first with dorsal displacement of the fragments, and the second, a rarer type, with palmar displacement. Like Robert William Smith, nine years later, Barton most likely described a Colles fracture as one with dorsal displacement. He observed that the fracture usually ended unfavorably for the patient. Barton clearly described subluxation of the wrist joint as a consequence of a fracture involving the articular surface of the carpal end of the radius and emphasized that in such unfortunate falls, the radius and ulna are often fractured. However, the joint itself is not dislocated [27],[28].

In his Treatise on Fractures in the Vicinity of Joints, and on Certain Forms of Accidental and Congenital Dislocations, Robert William Smith (1807–1873) published, in 1847, a chapter on the fractures of the bones of the forearm, in proximity to the wrist joint [30]. It includes an anatomical description of Colles fracture, a description of distal radial epiphyseal separation, as well as a description of the fracture of the distal end of the radius with palmar displacement of the distal fragment and dorsal angulation – now known as a Smith fracture. Like Goyrand, Smith analyzed postmortem pathological specimens of healed fractures. However, their descriptions relate to clinical conditions and presentations, definitely contributing to the ambiguity of the term – dorsal prominence of the distal radius. Smith himself acknowledged this, stating that he could not speak with certainty about the anatomical nature of the fracture because he did not have the opportunity to examine a fresh fracture, only the skeletal forearm of a patient who had suffered the injury in his lifetime and whose fracture had already healed by the time of analysis. He described palmar displacement of the distal fragment of the radius and dislocation of the distal radioulnar joint. The fracture Smith described may correspond to what is known today as a Barton fracture, but the eponym – long since associated with Smith – also refers to what is called a reverse Colles fracture, caused by a fall onto the dorsum of the flexed hand [30],[31].

In the ensuing decades, researchers focused their efforts on anatomical dissections and experiments on cadavers in attempts to clarify the types of fractures and their relationship to injury mechanisms. Thus, M. Diday observed certain patterns in fracture lines. He believed a fracture to be the consequence of the resultant force of two separate forces, which can be mathematically calculated [32].

It was only with the discovery of X-rays, by Wilhelm Conrad Röntgen, that the precise elucidation of the pathoanatomical substrate of distal radius fractures began [33].

In October 1897, a meeting of doctors from the German Polyclinic in New York was organized. At that time, Carl Beck (1865–1911), an American surgeon, reported that he had begun using X-rays three months after Röntgen’s discovery was published in 1896, and that by the time of the meeting, he had analyzed 44 patients with Colles’ fracture. He concluded: “As far as I am concerned, I must note that no one before me had described this, so I had not seen a case in which the diagnosis was confirmed before the X-ray image – because all authors describe the presence of deformity, swelling, and tenderness in that region” [34].

Another enthusiast who used X-rays was Frederick Cotton from Boston. He published a similar study on 140 patients with fractures of the distal end of the radius and also described experimental and anatomical correlations he observed on the X-ray images [35],[36],[37].

In the first quarter of the last century (1900-1925), during the rapid expansion of motor vehicle use, the term chauffeur fracture appeared in the literature, described by Emile Coude. Namely, while manually starting a car with a hand crank, drivers often injured their hands. In literature published in the English language, the equivalent term was backfire fracture, more precisely described by H. C. Edwards in 1926 [1],[38].

The issue of distal radius fractures was further addressed by a number of researchers, including Destot, Pilcher, Mayer, Morton, Kleinschmidt, Olerud, Lidström, Ehalt, Frykman, de Bruijn, Hančević, and many others. They all recognized the great variability of distal radius fractures, as well as the differences in fragment displacement. Thus, the statement by K. Speed in 1935 – that no two Colles’ fractures are alike – best illustrates the complexity of distal radius fractures, which in everyday practice are most commonly referred to as fractura radii in loco typico [7],[39].

Concluding this brief historical overview of the understanding of radial fractures in the typical zone, it is important to acknowledge the fact that, to this day, only those eponyms that clearly define fracture types have remained in the literature, namely:

1. Colles fracture (in the literature published in English), or Pouteau-Colles fracture (in French literature)
2. Barton fracture – volar type and dorsal type
3. Smith fracture or the reverse (inverted) Colles fracture [1],[40],[41].