Populations and Risk Factors
- Most frequent forearm fracture overall
- Adults over 50, particularly postmenopausal women with osteoporosis
- Younger adults following high-energy falls (snowboarding, skating, cycling)
- FOOSH (fall on an outstretched hand) is the primary mechanism
- History of previous fragility fracture increases risk
Causes and Pathophysiology
- Mechanism: FOOSH transmits axial load through the extended wrist. The force drives the distal radial fragment posteriorly and superiorly
- Posterior displacement creates the "dinner fork" deformity — the hand appears displaced dorsally relative to the forearm
- "Pushed elbow" complication: Impact force transmitted proximally can cause the radial head to sublux against the capitulum — often missed until the wrist cast is removed and elbow stiffness is discovered
- Soft tissue consequences: Fracture swelling within the carpal tunnel (Zone IV) can compress the median nerve, producing acute carpal tunnel syndrome. Prolonged immobilization (6-8 weeks) leads to capsular adhesions, forearm muscle atrophy, and loss of accessory joint play
- CRPS risk: Complex regional pain syndrome can be triggered by the fracture or surgery — pain disproportionate to the injury stage with vasomotor and trophic changes
Signs and Symptoms
- Dinner fork deformity: Hand displaced posteriorly relative to the forearm
- Sharp, localized tenderness at the distal radius. Aggravated by any wrist movement
- Rapid edema and ecchymosis (bruising) at the wrist
- Crepitus if fragments are mobile
- Elbow pain or "pushed elbow" sensation from proximal radial head subluxation
- Numbness or tingling in the median nerve distribution if CTS develops
- Red flags: Median nerve symptoms developing after fracture — urgent referral; pain disproportionate to healing stage with vasomotor changes — suspect CRPS
CMTO Exam Relevance
- Recognize the dinner fork deformity as the hallmark sign
- FOOSH mechanism in an older adult with osteoporosis is the classic presentation
- Know the "pushed elbow" complication (proximal radial head subluxation), often missed until cast removal
- Post-immobilization assessment focuses on secondary impairments: capsular tightness, muscle atrophy, loss of joint play
- Screen for CRPS and CTS as complications
Massage Therapy Considerations
- During immobilization: Rigorous massage to the fracture site is contraindicated. Massage elsewhere addresses compensatory patterns (shoulder and neck tension from cast carriage)
- Post-immobilization: Massage restores pliability, mobilizes adhesions, addresses muscle atrophy and contractures. Multidirectional friction (once subacute/chronic) mobilizes scar tissue at fracture and surgical sites
- Sequencing: Address shoulder and neck compensations first, then forearm muscles, then wrist joint mobilization (proximal-to-distal)
- Focus: Equalize tension in the forearm rotators. Restore forearm supination
- Safety: Be vigilant for CRPS (pain out of proportion to stage). Screen for CTS with Phalen and Tinel tests
- Heat/cold: Moist heat pre-treatment post-cast to improve tissue pliability. Cold post-treatment for reactive inflammation
Key Takeaways
- Colles fracture is the most common forearm fracture, caused by FOOSH, presenting with the classic dinner fork deformity
- The "pushed elbow" (proximal radial head subluxation) is a frequently missed accompanying injury
- Post-immobilization rehabilitation must address capsular adhesions, muscle atrophy, and loss of joint play
- Screen for CRPS and carpal tunnel syndrome as secondary complications
- Massage during immobilization focuses on compensatory patterns. Post-immobilization focuses on restoring tissue mobility