Intervention Review

You have free access to this content

Conservative interventions for treating distal radial fractures in adults

  1. Helen HG Handoll1,*,
  2. Rajan Madhok2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 22 APR 2003

Assessed as up-to-date: 21 AUG 2005

DOI: 10.1002/14651858.CD000314


How to Cite

Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD000314. DOI: 10.1002/14651858.CD000314.

Author Information

  1. 1

    University of Teesside, Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, Middlesborough, Tees Valley, UK

  2. 2

    University of Manchester, Cochrane Bone, Joint and Muscle Trauma Group, Manchester, UK

*Helen HG Handoll, Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, School of Health and Social Care, Middlesborough, Tees Valley, TS1 3BA, UK. h.handoll@tees.ac.uk. H.Handoll@ed.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 22 APR 2003

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Fractures of the distal radius are a common clinical problem affecting skeletally mature people. The young sustain this injury as a result of significant local trauma. The elderly have predisposing risks of disuse or post menopausal osteoporosis. The lifetime risk of sustaining a distal radius fracture in a white person, aged 50 years, based in the USA or Northern Europe has been estimated to be 15% in women and 2% in men (Cummings 1985). The true costs associated with the injury have been difficult to quantify as this injury is frequently treated on an outpatient basis. In a recent prospective one-year study of patients, aged 35 years and above, with Colles' fracture (a common type of distal radius fracture) treated in six centres in the UK, one in five patients were admitted to hospital, the proportion increasing with age (O'Neill 2001).

These fractures are generally closed and usually involve displacement of fracture fragments. They may be either extra-articular (leaving the articular or joint surface of the distal radius intact) or intra-articular (where the articular surface is disrupted). Numerous classifications have been devised to define and group different fracture patterns (Chitnavis 1999). Simple classifications based on clinical appearance, and often named after those who described them, remain in common use. In particular, 'Colles' fracture' is still the terminology used for a fracture in which there is an obvious and typical clinical deformity - of dorsal displacement, dorsal angulation, dorsal comminution (small fragments of bone), and radial shortening.

The most suitable method of management of this injury is not clearly defined. The final choice of treatment method will be influenced by many considerations including the nature of the fracture, bone stock and fragility, the presence of local complications (compound injury, nerve injury) or other injuries, the patient's general medical condition, the expected functional loading (activity demands), and patient motivation.

The basic treatment options available for these fractures are:

  • closed or open (including arthroscopically assisted) reduction;
  • external splintage: immobilisation or support, or both (plaster of Paris cast, brace, bandage);
  • external fixation using either pins and plaster or an external fixator;
  • percutaneous pinning;
  • internal fixation with pins, nails, screws and plates;
  • replacement of lost bone stock (metaphyseal defect) by temporary bone scaffold (bone graft) material or any other suitable substance (bone cement or substitute).

The complications from this injury are diverse and unexpectedly frequent (Altissimi 1984; Atkins 1989; Cooney 1980). Some complications are associated with the injury itself. As well as concomitant injuries to soft tissues, fracture displacement can further compromise blood vessels, tendons and nerves, with median nerve dysfunction being most common complication (Belsole 1993). Late complications include midcarpal instability and post-traumatic arthritis, which can occur several months or years after injury (Knirk 1986; Taleisnik 1984).

Complications can also result from treatment interventions and include residual finger stiffness (Gartland 1951), and pin track infection and soft tissue injury from external fixation and percutaneous pinning. Reflex sympathetic dystrophy (RSD), also referred to as algodystrophy, Sudeck's atrophy and sometimes shoulder-hand syndrome (Fernandez 1996) is a major complication requiring many months of physiotherapy to alleviate symptoms (pain and tenderness, impairment of joint mobility, swelling, dystrophy, and vasomotor instability) in serious cases. The etiology of RSD is often unclear.

The evaluation of treatment interventions is generally based on anatomical, functional and clinical outcomes and presence of complications. Anatomical restoration and residual deformity are usually based on radiological measurements such as radial length or shortening, volar tilt or dorsal angulation, radial angle or radial inclination, and the relative position of the distal ends of the radius and ulna, ulnar variance (see  Table 1). Functional and clinical outcomes usually include wrist and forearm mobility (range of movement), pain, grip strength, residual soft tissue swelling, local complications, cosmetic appearance, patient satisfaction with treatment modality and activities of daily living.

This review, which looks at conservative interventions, is one of five Cochrane reviews of interventions used in the management of these fractures. Another review is of surgical interventions, and also addresses the conservative versus surgical management question (Handoll 2005a). The other three reviews are anaesthesia interventions during manipulation of displaced fractures and surgery (Handoll 2005b), methods of closed reduction (Handoll 2005c), and rehabilitation interventions such as mobility exercises (Handoll 2005d).

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

The aim of this systematic review is to determine the most appropriate conservative treatment for fractures of the distal radius in skeletally mature people. The order and, in part, the emphasis of the review comparisons (and associated null hypotheses) set out below reflect the decision points, and associated timing, for the management of these fractures.

We aimed to test the following null hypotheses:

(1) No differences exist between outcomes from reduction, delayed reduction or no reduction of displaced fractures.

The following comparisons were made:
(a) Manipulation versus no manipulation
(b) Delayed manipulation versus immediate manipulation

(2) No differences exist between outcomes from different methods or durations (including none) of immobilisation involving plaster or brace use.

The following comparisons were made:
(a) No immobilisation (minimal support) versus immobilisation
(b) Forearm held in different positions by plaster
(c) Plaster or synthetic cast type A versus type B
(d) Forearm held in different positions by brace
(e) Brace versus plaster cast
(f) Different casting materials or techniques, or both
(g) Different durations of immobilisation

We also planned to study the outcome of different age groups and of comparable fracture groups. Neither, even distinguishing between extra-articular and intra-articular fractures, and non-displaced and displaced fractures, was possible.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Any randomised or quasi-randomised (method of allocating participants to a treatment which is not strictly random e.g. by date of birth, hospital record number, alternation) controlled clinical trials of interventions listed below were considered.

 

Types of participants

Patients of either sex who had completed skeletal growth, with a fracture of the distal radius.

The characteristics of the participants included in the trials were noted with an emphasis on age, gender and fracture type.

 

Types of interventions

All randomised comparisons of conservative interventions involving plaster cast or brace use with placebo, no intervention or an alternative cast or brace intervention, in the treatment of fractures of the distal radius. Also included are randomised comparisons evaluating the reduction of displaced fractures. Trials evaluating different techniques of reduction including the choice of anaesthesia/analgesia were excluded.

The main treatment options covered in this review were various methods of support and immobilisation such as plaster casts, wrist braces and bandages applied after closed reduction of the fracture, if done.

 

Types of outcome measures

(1) Anatomical outcome (anatomical restoration and residual deformity)
Radiological parameters include radial length or shortening and shift, dorsal angulation, radial inclination or angle, ulnar variance. Composite measures include malunion and total radiological deformity. Definitions of four of the most commonly reported radiological parameters are presented in  Table 1.

(2) Functional outcome
Range of movement (wrist and forearm mobility), pain, grip strength, activities of daily living. Also, patient functional assessment instruments such as Short Form-36 (SF-36), the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) and the Patient-Rated Wrist Evaluation (PRWE) (MacDermid 2000).

(3) Clinical outcome
Residual soft tissue swelling; early and late complications associated with distal radial fractures or their treatment, including reflex sympathetic dystrophy (RSD) and osteoarthrosis; cosmetic appearance; and patient satisfaction with treatment.

(4) Resource use
Number of outpatient attendances and other costs.

 

Search methods for identification of studies

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005) (see Appendix 1), MEDLINE (1966 to June week 1 2005), EMBASE (1988 to 2005 week 24), CINAHL (1982 to June week 2 2005), PEDro - physiotherapy evidence database (http://www.pedro.fhs.usyd.edu.au/index.html accessed 14 June 2005), OTseeker - The Occupational Therapy Systematic Evaluation of Evidence Database (http://www.otseeker.com accessed 2 June 2005) and reference lists of articles. We also searched Current Controlled Trials at http://www.controlled-trials.com (accessed June 2005) and the UK National Research Register at http://www.update-software.com/national/ (up to Issue 2, 2005) for ongoing and recently completed trials. We hand searched the British Volume of the Journal of Bone and Joint Surgery supplements (1996 onwards), and abstracts of the American Society for Surgery of the Hand annual meetings (2000 to 2004: http:/www.assh.org/), the American Orthopaedic Trauma Association annual meetings (1996 to 2004: http://www.ota.org/education/amabstracts.htm) and American Academy of Orthopaedic Surgeons annual meeting (2004 and 2005: http://www.aaos.org/wordhtml/libscip.htm). We hand searched final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003), and the British Orthopaedic Association Congress (2000, 2001, 2002 and 2003). We hand searched Orthopaedic Transactions and various supplements of Acta Orthopaedica Scandinavica. We also scrutinised weekly downloads of "Fracture" articles in new issues of 17 journals (Acta Orthop Scand; Am J Orthop; Arch Orthop Trauma Surg; Clin J Sport Med; Clin Orthop; Emerg Med Clin North Am; Foot Ankle Int; Injury; J Accid Emerg Med; J Am Acad Orthop Surg; J Arthroplasty; J Bone Joint Surg Am; J Bone Joint Surg Br; J Foot Ankle Surg; J Orthop Trauma; J Trauma; Orthopedics) from AMEDEO (http://www.amedeo.com). No language restrictions were applied.

In MEDLINE (OVID-WEB) the search strategy was combined with all three sections of the optimal MEDLINE search strategy for randomised trials (Higgins 2005) (see Appendix 2).

Similar search strategies used for EMBASE (OVID-WEB) and CINAHL (OVID-WEB) are shown in Appendix 3 and Appendix 4.

 

Data collection and analysis

We independently assessed potentially eligible trials for inclusion; any disagreement was resolved by discussion. Titles of journals, names of authors or supporting institutions were not masked at any stage. Both review authors (HH and RM) independently assessed methodological quality of included studies and any disagreement was resolved by discussion. Data were extracted by one reviewer (HH) and checked by a second reviewer (RM) for all studies.

For the first version of the review, there was no systematic return to trialists for additional details of trial methodology or data. The few instances where extra information was obtained are noted in the 'Characteristics of included studies' table. In preparation for the first update, we contacted trialists of studies only published as conference abstracts and contact authors of ongoing trials that were indicated as being completed in the UK National Research Register. For the second update, we contacted trialists of two newly identified studies for further information on their studies. For the third update, we contacted trialists of the newly identified studies and of the studies listed as ongoing in the previous update for further information on their studies. For the fourth update, we contacted trialists of the newly identified study, of the study listed as ongoing in the previous update and of the two studies in 'Studies awaiting assessment' for further information on their studies. For the fifth update, we contacted trialists of the two newly identified studies and of the newly included trial, previously in 'Studies awaiting assessment', for further information on their studies.

Quality assessment
A modification of the Cochrane Bone, Joint and Muscle Trauma Group quality assessment tool (see Group details) was used in the evaluation of the included studies. The scoring scheme for 11 aspects of trial validity, plus brief notes of coding guidelines for some items, is shown in  Table 2. The scheme was slightly modified for the first update to be compatible with that used in the surgical treatments review, as well as abiding by the Cochrane Group's requirement to rate active follow up. From the fifth update (Issue 4, 2005) of the review, the scores of the individual items were no longer summed.

Data analysis
Where available, quantitative data, both dichotomous and continuous, that were reported in individual trial reports for outcomes listed in the inclusion criteria have been presented in the graphs. Relative risks and 95% confidence intervals have been presented for dichotomous outcomes and mean differences and 95% confidence intervals for continuous outcomes. In the light of the disparate nature and general poor quality of the included studies, there was no pooling of results in this review. The statistics presented in the graphs are for reference only and should not be considered as an estimate of treatment effect.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

The two newly identified trials (Liebman 2004; Sahin 2005) considered for this, the fifth, update, have been left in 'Studies awaiting assessment'; Liebman 2004 awaits publication and Sahin 2005, located since the last search in June 2005, awaits translation from Turkish. Additional abstracts were located for both trials (Jackson 2002; Shah 2002) previously in 'Studies awaiting assessment': further information from the trialists from these two trials has not been forthcoming. We have, however, now included the former trial (Jackson 2002) but excluded the latter study (Shah 2002), which is unlikely to be anything more than the self-declared prospective comparison. As before, we note that many more study reports were checked in the process of collecting the studies for the original review and updates, but found not to meet the inclusion criteria of this review; most of the 15 excluded studies are retained primarily for illustrative purposes, mainly in terms of the scope of this review.

Summaries of the past and present trial populations of past and the present versions of this review as well as the changes between updates are presented in  Table 3.

In all, 37 trials involving comparisons of conservative interventions were included. Two trials respectively evaluated whether displaced fractures should be reduced and the timing of any closed reduction before cast application. It should be noted that the comparison of different techniques of closed reduction is covered in a separate review (Handoll 2005c). The other 35 trials examined the need for forearm immobilisation and the different methods and durations of immobilisation involving plaster cast or brace use.

The majority of the included trials were fully reported in medical journals. Trial reports of eight trials (Aladin 2001; Cornwall 2001; Gibson 1983; Ho 1986; Jackson 2002; Kongsholm 1981; McMillan 1996; Ross 1984) were only available as abstracts. De Bruijn 1987, which consisted of two studies reported as one, was a published thesis as well as a paper in Dutch.

The publication dates of the trials span 23 years; Sarmiento 1980 being the earliest. Translations were obtained for one study (Blatter 1994) published in German and one in Danish (Sorensen 1986). The trials were mostly single centre studies conducted in 11 countries, with the majority being in the UK (16 trials) and Scandinavian countries (12 trials). Notable exceptions were Jackson 2002, which was conducted in four hospitals in Canada, and Tumia 2003, which was conducted at five trauma centres in three European countries.

The 37 included trials involved a total of 4215 mainly female and older participants. Details of individual trials are provided in the 'Characteristics of included studies' table. All of the trials providing information had more female participants, mostly at least three quarters of the trial populations. Three trials (McAuliffe 1987; Millett 1995; Wahlstrom 1982) exclusively recruited female patients. Ten trials, including five of the eight trials only reported as abstracts, provided no information on age; the other three trials with abstract reports only referred to adults and a lower age limit of 18 and 40 years respectively. Fifteen trials explicitly excluded children by setting a lower age limit, and information provided for the lowest age of participants of a further 10 trials indicates that the vast majority of participants were skeletally mature. No upper age limits were explicitly applied.

The variety of descriptions used for fracture type such as Colles', displaced, undisplaced, intra-articular, extra-articular, simple, comminuted and unstable, plus the differences in the classification systems, such as Frykman or Older, when used, or radiological parameters applied (extent of radial shortening or dorsal angulation, or both) meant that a summary of the fracture types based on displacement and articular involvement could not be done. Thus, basic divisions of fractures into a) undisplaced or minimally displaced fractures and displaced fractures or b) extra-articular and intra-articular fractures could not be performed for the whole group of trials. Some trials (Aladin 2001; Ferris 1989; Gibson 1983; Ho 1986; Kongsholm 1981; McMillan 1996; Nielsen 1981) provided no information about fracture type, whilst insufficient information was provided by those others that did not either explicitly and exclusively include displaced fractures. However undisplaced fractures or minimally displaced fractures were solely included in eight trials (Abbaszadegan 1989; Christensen 1995; Cohen 2001; Davis 1987; Jensen 1997; O'Connor 2002; Stoffelen 1998; Vang Hansen 1998). Two further trials (De Bruijn 1987; Dias 1987) altered their control intervention for undisplaced fractures.

The comparisons in the 37 included trials have been grouped according to the main question, or questions, addressed by each trial. Nine trials (De Bruijn 1987; Dias 1987; Gibson 1983; Gupta 1991; Jackson 2002; Kongsholm 1981; Stewart 1984; Van der Linden 1981; Wahlstrom 1982) had more than two intervention groups. These fell inside the same comparison group for Gupta 1991, Jackson 2002, Kongsholm 1981 and Wahlstrom 1982 (all had three intervention groups); but were in different comparison groups for De Bruijn 1987 (four), Dias 1987 (three), Gibson 1983 (three), Stewart 1984 (three) and Van der Linden 1981 (five). Dias 1987 and De Bruijn 1987 allocated undisplaced fractures to a different control intervention (bandage) than displaced fractures (modified plaster cast and brace respectively). De Bruijn 1987 consisted of two trials but failed to provide separate data for the groups by individual trial. Kongsholm 1981 compared two methods of reduction, with or without anaesthesia, as well as two types of plaster cast; only the latter comparison is reviewed here. Missing baseline data for some trials prevents exact enumeration of patients in some comparison groups.

In the first version of our review, two trials in which some or all participants had surgical treatment were included as these compared conservative interventions. In the first update, one of these (Milliez 1992) was excluded as it is reviewed in our review of surgical interventions (Handoll 2005a). However, the other trial (Cohen 1997) in which 10 of the 30 participants had percutaneous pinning, has been retained even though we consider that people who had surgical treatment form a distinct group in that surgery changes the question addressed, the intervention and outcome (e.g. extra surgical complications). These reservations should be borne in mind when viewing this trial.

The following comparisons based on the two null hypotheses listed in the objectives were made.

(1) Reduction of displaced fractures

Two comparisons covering the use of manipulation were included.

(a) Manipulation versus no manipulation
Kelly 1997 tested the result of manipulation under Bier's block anaesthesia versus no manipulation in 30 people with "moderately" displaced Colles' fracture. All subsequently had plaster cast immobilisation for five weeks.

(b) Delayed manipulation versus immediate manipulation
McMillan 1996 tested the effect of delaying manipulation for one week compared with immediate manipulation in 80 people. No details of the extent of displacement of the fractures were given.

(2) Plaster or brace management

(a) No immobilisation (minimal support) versus immobilisation
Two trials (Abbaszadegan 1989; Dias 1987) compared the immediate application of elastic or crepe bandage versus plaster cast immobilisation in 177 people with undisplaced or minimally displaced fractures.

(b) Forearm held in different positions by plaster
There were six trials (Blatter 1994; Gibson 1983; Gupta 1991; Van der Linden 1981; Wahlstrom 1982: Wilson 1984) involving around 650 participants in this category.

(c) Plaster or synthetic cast type A versus type B
Some of the above set of trials also belong to this category as different plaster casts (below-elbow, above-elbow) were used to maintain wrist position. Associated with these were differences in arm mobility. Trials examining different casting materials or techniques, or both are examined in category 2f. Seven trials are reviewed in the present category. Wrist mobility was the basis of the comparison involving 90 people with displaced fractures allocated either to a standard or a modified cast allowing wrist flexibility in Dias 1987. Forearm rotation was blocked but some flexion and extension at the elbow allowed with a modified sugar-tong cast which was compared with a below-elbow cast in the 126 participants of Aladin 2001. Similar but unconfirmed restrictions to mobility are likely with the modified sugar-tong fibreglass splints that were compared with volar-dorsal fibreglass splints or cylindrical plaster casts in the 101 participants of Jackson 2002. Cornwall 2001 and Sorensen 1986 compared above-elbow with below-elbow plaster immobilisation in 227 people. Lastly, Kongsholm 1981 and Van der Linden 1981 included a comparison of a dorsal splint (back slab) with a full (circular) below-elbow plaster cast in approximately 300 people.

(d) Forearm held in different positions by brace
There were two trials (Sarmiento 1980; Stewart 1984) involving over 290 people in this group.

(e) Brace versus plaster cast
There were 11 trials (Bunger 1984; De Bruijn 1987; Ferris 1989; Gibson 1983; Ho 1986; Ledingham 1991; Moir 1995; O'Connor 2002; Ross 1984; Stewart 1984; Tumia 2003) with around 1785 participants.

(f) Different casting materials or techniques, or both
Four trials (Cohen 1997; Cohen 2001; Nielsen 1981; Rosetzsky 1982), involving 170 people, investigated the use of different materials and associated techniques for below-elbow casts. Only minimally displaced and stable fractures were included in Cohen 2001. As stated above, 10 participants of Cohen 1997 had percutaneous pinning.

(g) Different durations of immobilisation
Seven trials compared the use of plaster cast for different durations. One other (De Bruijn 1987) compared the use of a bandage versus an above-elbow functional brace for three weeks after one week of immobilisation for both groups. Four (Christensen 1995; McAuliffe 1987; Millett 1995; Vang Hansen 1998) of the seven plaster cast trials compared immobilisation for three or four versus five or six weeks. These involved 331 people. Christensen 1995 only included undisplaced fractures. One trial (Davis 1987) compared one up to two weeks versus four up to five weeks plaster immobilisation and two trials (Jensen 1997; Stoffelen 1998) compared one-week versus three-weeks plaster immobilisation. All 169 participants of these three trials had undisplaced or minimally displaced fractures.

 

Risk of bias in included studies

The quality of trial methodology based on trial reports was disappointing. The results for individual trials are presented below. Information specific to the first three items of the quality score are given in the methods section of the 'Characteristics of included studies' table.

No trial explicitly reported using a blinded method of randomisation, but concealment of allocation was considered highly likely in Cohen 2001 (use of sealed numbered and consecutively opened envelopes), Rosetzsky 1982 (randomisation was by closed envelopes, allocated according to predetermined randomisation list) and Tumia 2003 (telephone randomisation). Two other trials (Kelly 1997; Sorensen 1986) used envelopes and three others (Millett 1995; Moir 1995; Van der Linden 1981) gave some details of the method used, without reporting adequate safeguards. Twenty-one trials did not describe their method of randomisation. The remainder used quasi-randomised methods based on either dates of birth, record numbers, dates of attendance or injury, admission sequence or alternation (Christensen 1995; De Bruijn 1987; Dias 1987; McAuliffe 1987; Nielsen 1981; O'Connor 2002; Sarmiento 1980; Stewart 1984).

Clear statements or evidence of intention-to-treat analysis (item 2) were rarely presented in trial reports. Allied with this but not graded was loss to follow up. Nine trials recorded 15% or above loss to follow up, with a third and nearly two thirds of trial participants being omitted from the final analyses of Sarmiento 1980 and Ho 1986 respectively.

Blinding of outcome assessors (item 3) was only rarely reported and nowhere performed for all outcomes at all times. Total blinding of outcome assessment is unrealistic for trials testing these types of interventions but it is possible and was reported for some outcomes in nine trials. Blinded clinical assessment was done at three and six months in Stewart 1984. Functional outcomes were blindly assessed in five trials (Dias 1987; Ledingham 1991; Moir 1995; O'Connor 2002; Tumia 2003) and radiological outcomes in four trials (Cornwall 2001; Cohen 1997; Jackson 2002; Millett 1995). In the later report of Cohen 2001, assessment of movement restriction and muscle strength after cast removal was performed by a clinician who was not informed of the cast type used; however, the earlier report of the trial emphasised that blinding was not practical (Petty 1998). Independent functional assessment was reported in McAuliffe 1987.

As implied in the 'Description of included studies' section, the description of baseline characteristics (item 4) was often sparse or even non-existent. Where quantitative data were provided for all those recruited, rather than for those analysed, there often remained insufficient evidence to confirm comparability of groups. Where differences, often of fracture type, were evident, no adjustments were made.

Blinding of patients and treatment providers (items 5 and 6) is unlikely in these trials and none was claimed.

Comparability of care programmes (item 7) comprising interventions other than the trial interventions proved hard to confirm. In particular, clear differences in the type of anaesthesia used during manipulation, the variation in the timing of the interventions (both start and duration), as well as the lack of general information on the comparability of the experience of the health professional applying the interventions (operator bias), meant that most studies scored low for this item.

Linked with description of participants' characteristics were the trial inclusion and exclusion criteria (item 8) which together help to define a study population. Many trials provided sufficient criteria to define the study population. In contrast to our review of surgical treatments, an explicit description of fracture type was not necessarily required to obtain the top score for this item.

The definition (item 9), adequacy (item 10), including active follow up, as well as the appropriateness of the timing (item 11) of outcome measurement were also poor. Rather than providing data for individual functional outcomes, many trials provided overall functional assessments using often modified schemes of scoring systems which often included anatomical and clinical outcomes. The variety of schemes used is evident from inspection of the 'Characteristics of included studies' table. Length of overall follow up, when defined, ranged from five weeks (Aladin 2001; Wahlstrom 1982) to three years (Millett 1995). Seventeen studies had less than six months overall follow up and some participants of two studies (Gupta 1991; Sarmiento 1980) were followed up less than six months. Though follow up in Jackson 2002 was claimed for six months, the results available so far only pertained to follow up at 28 days.

Trial quality assessment table (Items 1-11 described in  Table 2)

(1) Reduction of displaced fractures

(a) Manipulation versus no manipulation
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 1 0 1 0 0 3 3 3 1 0 Kelly 1997

(b) Delayed manipulation versus immediate manipulation
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 0 0 0 0 0 0 0 0 0 0 McMillan 1996

(2) Plaster or brace management

(a) No immobilisation (minimal support) versus immobilisation
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 0 0 0 0 0 1 3 1 1 1 Abbaszadegan 1989
0 0 1 1 0 0 0 3 1 1 0 Dias 1987

(b) Forearm held in different positions by plaster
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 1 0 1 0 0 0 1 1 1 3 Blatter 1994
1 0 0 0 0 0 0 0 0 0 0 Gibson 1983
1 0 0 0 0 0 0 1 1 1 1 Gupta 1991
1 0 0 1 0 0 0 1 1 0 1 Van der Linden 1981
1 0 0 0 0 0 0 1 1 0 0 Wahlstrom 1982
1 3 0 3 0 0 0 3 1 1 0 Wilson 1984

(c) Plaster or synthetic cast type A versus type B
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 0 0 1 0 0 0 0 1 0 0 Aladin 2001
1 0 1 0 0 0 0 1 1 0 0 Cornwall 2001
0 0 1 1 0 0 0 3 1 1 0 Dias 1987 (repeat)
1 0 1 0 0 0 0 1 1 1 0 Jackson 2002
1 0 0 0 0 0 0 0 0 0 1 Kongsholm 1981
1 1 0 0 0 0 0 3 1 1 1 Sorensen 1986
1 0 0 1 0 0 0 1 1 0 1 Van der Linden 1981 (repeat)

(d) Forearm held in different positions by brace
1 2 3 4 5 6 7 8 9 10 11 Study ID
0 0 0 0 0 0 0 0 1 0 0 Sarmiento 1980
0 1 1 1 0 0 0 1 3 1 1 Stewart 1984

(e) Brace versus plaster cast
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 1 0 0 0 0 0 3 3 1 1 Bunger 1984
0 0 0 0 0 0 3 3 3 3 1 De Bruijn 1987
1 0 0 0 0 0 0 3 1 0 0 Ferris 1989
1 0 0 0 0 0 0 0 0 0 0 Gibson 1983 (repeat)
1 0 0 0 0 0 0 1 1 0 1 Ho 1986
1 1 1 1 0 0 1 3 1 1 1 Ledingham 1991
1 1 1 1 0 0 0 3 3 1 1 Moir 1995
0 1 1 1 0 0 3 3 3 3 0 O'Connor 2002
0 0 0 0 0 0 0 0 1 0 0 Ross 1984
0 1 1 1 0 0 0 1 3 1 1 Stewart 1984 (repeat)
3 1 1 3 0 0 0 3 3 1 1 Tumia 2002

(f) Different casting materials or techniques, or both
1 2 3 4 5 6 7 8 9 10 11 Study ID
1 0 1 1 0 0 0 3 1 1 0 Cohen 1997
3 1 0 0 0 0 0 1 3 1 0 Cohen 2001
0 0 0 0 0 0 0 1 1 0 0 Nielsen 1981
3 1 0 0 0 0 0 3 1 1 0 Rosetzsky 1982

(g) Different durations of immobilisation
1 2 3 4 5 6 7 8 9 10 11 Study ID
0 0 0 3 0 0 0 3 1 1 1 Christensen 1995
1 1 0 1 0 0 0 3 1 1 0 Davis 1987
0 0 0 0 0 0 3 3 3 3 1 De Bruijn 1987 (repeat)
1 1 0 1 0 0 1 3 3 1 1 Jensen 1997
0 1 0 1 0 0 0 1 1 1 1 McAuliffe 1987
1 1 1 1 0 0 1 3 3 1 3 Millett 1995
1 0 0 0 0 0 0 1 1 1 1 Stoffelen 1998
1 1 0 0 0 0 1 3 1 1 1 Vang Hansen 1998

 

Effects of interventions

The outcomes reported in the included trials' reports are listed in the 'Characteristics of included studies' table. These are grouped by anatomical, functional and clinical outcome. Where available, data by intervention group have been presented for complications in this table as well as graphically. In general, most continuous data, commonly presented for anatomical outcomes, were incomplete: standard deviations and, less often, denominators were missing. As noted before, functional outcomes were often combined and presented within an overall scoring system. Aside from complications, other clinical outcomes were rarely reported separately.

The poor methodological quality, the heterogeneous nature of the interventions, patient populations, and incomplete results of trials within each comparison group hinder quantitative analysis. Care must be taken in the interpretation of the results presented below, ordered by the comparisons given in the 'Description of studies' section.

(1) Reduction for displaced fractures
The use or delay in use of manipulation was evaluated in two studies (Kelly 1997; McMillan 1996) involving 110 people with displaced Colles' fracture.

(a) Manipulation versus no manipulation
Kelly 1997 compared manipulation under Bier's block anaesthesia with no manipulation in 30 people, aged 65 years or above, with moderately displaced Colles' fracture. Both groups had plaster cast immobilisation for five weeks. Initial fracture displacement, defined by radial shortening, dorsal angulation and radial tilt, was reported as comparable in the two groups, although radial tilt was statistically significantly lower in the manipulation group (mean 4.0 versus 9.5 degrees). Final displacement at plaster removal at five weeks was similar; notable was the mean loss in radial length of about two millimetres from the fracture position in both groups. Approximate values for mean values and standard deviations of these three parameters abstracted from graphs confirmed that none of the differences were statistically significant (not shown) at five weeks despite the clear post-manipulation reduction in the manipulated group. No action was taken to correct the two fractures in each group which displaced beyond the limits of the study as they were considered to have united. There were no significant differences in functional outcome, either in stiffness, grip strength, pain or overall (see Graph 01.01) at 13 weeks. Likewise, complications (see Graph 01.02) and cosmetic deformity (see Graph 01.03) whether assessed subjectively or objectively were similar in the two groups. Kelly 1997 concluded that manipulation was unnecessary in selected elderly patients with only moderately displaced fractures.

(b) Delayed versus immediate manipulation
McMillan 1996 compared the effect of delaying manipulation for one week to allow initial swelling to subside with immediate manipulation in 80 people aged over 50 years, with displaced Colles' fracture. No quantitative data were available for this trial which was only published as an abstract. McMillan reported that the anatomical results in the two groups were similar, with no increase in complications nor discomfort in the delayed manipulation group. Contact with one of the trialists resulted in no new information about this trial.

(2) Plaster or brace management

(a) No immobilisation (minimal support) versus immobilisation
Two trials (Abbaszadegan 1989; Dias 1987) tested this comparison in 177 people with minimally or undisplaced fractures. The immediate application of elastic (Abbaszadegan 1989) or crepe bandage (Dias 1987) was compared with plaster cast immobilisation for four and five weeks respectively.

Bandage use did not appear to be detrimental to anatomical outcome in either study. Abbaszadegan 1989 reported a statistically significantly lower mean radial shortening in the bandage group at eight weeks (0.15 mm versus 0.55 mm). Dias 1987 found no difference in 'bony deformity', nor was there a difference in anatomical grades between the two groups (see Graph 02.01).

Recovery of function (grip strength, range of motion) was better with less pain in the bandage group in Abbaszadegan 1989 at all times (incomplete data). Dias 1987 also reported a more rapid and sustained recovery of function by three months. Overall functional grades were better in the bandage group (see Graph 02.02) in Dias 1987. There were no significant differences in the complications occurring in either group (see Graph 02.03).

Both studies concluded that bandage use enabling earlier mobilisation was safe with a potential for a faster and better functional outcome for patients with undisplaced and uncomplicated Colles' fracture.

(b) Forearm held in different positions by plaster
There were six studies (Blatter 1994; Gibson 1983; Gupta 1991; Van der Linden 1981; Wahlstrom 1982; Wilson 1984) involving around 650 people in this category. These compared three aspects of wrist position: supination or neutral versus pronation; palmar or neutral flexion versus dorsiflexion; and no ulnar deviation versus ulnar deviation.

Supination (or neutral) versus pronation
Three trials (Gibson 1983; Wahlstrom 1982; Wilson 1984) involving around 150 people with, probably all displaced, Colles' fractures compared the wrist held by plaster in supination or neutral with that held in pronation. The extension of the plaster above the elbow in Gibson 1983 and Wilson 1984 for participants of the supinated group would have more effectively held this position than in Wahlstrom 1982 where a below-elbow plaster was used for all three groups. There were no qualitative data available for Gibson 1983 which was only published as an abstract. Gibson 1983 reported that there was no significant difference in functional outcome at 20 weeks between the two groups. There was no report of anatomical or clinical outcomes. The follow-up period in Wahlstrom 1982 was only five weeks, which probably covered the time of plaster immobilisation. Only anatomical outcome (see Graphs 03.01 and 04.01) and rereduction (see Graphs 03.03 and 04.02) were recorded for the three groups with wrists held in supination, neutral ("mid-way") and pronation respectively. Wrist anatomy after reduction held better with fewer displacements (10 degrees or above) and need for further reduction in the pronated group compared with either the neutral or supinated groups. At plaster removal, trial participants immobilised in an above-elbow plaster in supination had less loss of radial deviation and volar tilt from the reduced position (see Graph 03.01) than those in the pronated group in Wilson 1984; these differences were not statistically significant. Neither were the results of the functional assessment (see Graph 03.02). Given the lack of significant difference in either anatomical or functional outcome, Wilson 1984 who mentioned the extra effort in applying an above-elbow splint, the extra weight and cumbersome nature of this and associated finger stiffness, concluded that the above-elbow plaster with the forearm in supination could not be recommended.

Palmar or neutral flexion versus dorsiflexion
Two trials (Blatter 1994; Gupta 1991) involving 254 people with displaced fractures compared wrist positioning in either palmar flexion or neutral with dorsiflexion. Anatomical results for both trials were better in the dorsiflexion group. Overall functional outcome was also better in the dorsiflexion group as shown by the lower proportion of patients with a poor or only fair overall outcome or significant disability (see Graphs 05.01 and 05.02). Gupta 1991 reported without data, that the palmar flexion group had the most redisplacements, and more hand joint stiffness. Aside from a statistically non-significant higher proportion of problems associated with plaster wear (see Graph 05.03), mainly pressure pain encountered in the dorsiflexion group, all other outcomes in Blatter 1994 favoured the dorsiflexion group.

No ulnar deviation versus ulnar deviation
Five variations of plaster management were compared in 250 people with undisplaced and displaced fractures in Van der Linden 1981. Here ulnar deviation was compared with no ulnar deviation and a dorsal splint with a full plaster cast. Insufficient data were presented to allow confirmation of the lack of significant differences between treatment groups for both anatomical and functional results at eight-months follow up. Van der Linden 1981 concluded that the method of immobilisation (ulnar deviation or full plaster cast) was of only minor importance and that final outcome depended more on the original displacement of the fracture and success of reduction.

(c) Plaster or synthetic cast type A versus type B
Some of the above set of trials such as Wilson 1984 also belong to this category as different casts were used to maintain specific wrist positions with associated differences in arm mobility. Seven trials (Aladin 2001; Cornwall 2001; Dias 1987; Jackson 2002; Kongsholm 1981; Sorensen 1986; Van der Linden 1981) are reviewed for this category as these compared different cast types independent of wrist position.

In Dias 1987, 90 people with displaced Colles fractures requiring reduction were allocated to either a modified cast allowing greater wrist movement or to a standard plaster cast for five weeks. Dias 1987 observed an early phase of rapid deterioration in wrist anatomy, followed by a slower deterioration which continued after cast removal. 'Bony deformity' and anatomical grades (see Graph 06.01) were similar in the two groups. Overall functional grades (see Graph 06.02) were better in the modified cast group, and a faster recovery of wrist movement and resolution of wrist swelling, better grip strength and less pain were reported for this group. There was no specific mention of complications. Dias 1987 concluded that the early mobilisation of the wrist using the modified cast hastened functional recovery without adversely affecting anatomical outcome in patients with displaced fractures.

Aladin 2001 assessed radiological outcome, up to five weeks, of 126 people with 128 fractures that were immobilised in either a modified sugar-tong cast that blocked forearm rotation or in a below-elbow cast. Though there was a statistically significant difference in the mean values for dorsal angulation of the two groups, the actual difference (mean difference = 2.3 degrees) is not clinically significant (see Graph 07.01). There was no difference between the two groups in the incidence of unacceptable anatomical outcome or redisplacement at five weeks (see Graphs 07.02 and 07.03).

Jackson 2002 compared modified sugar-tong fibreglass splints versus volar-dorsal fibreglass splints versus cylindrical plaster casts in 101 adults with displaced extra-articular fractures that had been successfully reduced. Only data for radiological outcomes were presented in the two abstract reports of this trial. Though there were some discrepancies between the two abstracts, it seems likely that the results for redisplacement applied at one-week follow up. There was no statistically significant difference between the two groups in either of these outcomes for any of the three comparisons (see Graphs 08.01, 09.01 and 10.01).

Cornwall 2001 evaluated the radiological outcome, up to fracture healing, of immobilisation in an above-elbow plaster cast with a below-elbow plaster cast in 127 adults. There were insufficient data available from the conference abstract report of the trial to confirm the lack of statistically significant differences between the two groups. Sorensen 1986 compared immobilisation in a full above-elbow plaster cast with a below-elbow dorsal slab in 100 people with displaced distal radial fractures. Anatomical outcome at six weeks (see Graph 11.01) was better in the dorsal slab group, but otherwise there were no significant differences in either functional outcomes or complications (see Graphs 11.02, 11.03 and 11.04). Like Wilson 1984 (see above), Sorensen 1986 concluded that the greater ease of application of a dorsal slab made it preferable.

Kongsholm 1981 and Van der Linden 1981 compared application of a dorsal splint with a full below-elbow plaster cast. As stated above, insufficient data are available to confirm the lack of significant difference in either anatomical or functional outcomes between these two cast types in Van der Linden 1981. Neither were there data available in the Kongsholm 1981, reported only in a conference abstract, to test if the higher proportion of recurrent fracture dislocation in the dorsal splint group and the reported better end results for the circular (full plaster cast) plaster group were statistically significant.

(d) Forearm held in different positions by brace
Two trials (Sarmiento 1980; Stewart 1984) involving people with 298 fractures compared above-elbow brace which held the forearm in supination (hand faces upwards) with another brace either above-elbow holding another position (Sarmiento 1980) or a less restrictive below-elbow brace (Stewart 1984). As these comparisons were dissimilar, and even more so in the initial plaster management (above-elbow for Sarmiento 1980; back slab for Stewart 1984), these two trials are treated separately below.

Sarmiento 1980 varied the time of immobilisation in plaster and then brace according to fracture type. Anatomical and functional outcome were represented, without data, as being not significantly different between the two groups for undisplaced fractures. Of the 93 displaced fractures, only data for 71 were given for trial follow up; which varied between four to 60 weeks. Fewer fractures in the supinated group had excessive loss in anatomical position (see Graph 12.01), resulting in fewer with only fair or poor overall anatomical grades (see Graph 12.02). Overall functional outcome was also better in the supinated group (see Graph 12.03). Complications were not presented separately by treatment group but of note is that the only major complication, that of Sudeck's atrophy, occurred in a trial participant with an undisplaced fracture. The favourable results for an above-elbow supinated brace prompted others such as Stewart 1984 to test the so-called 'Sarmiento brace'.

Stewart 1984 compared the Sarmiento brace with a below-elbow brace which did not fix the hand position, for displaced fractures. Anatomically there was no difference in outcome between the two groups (see Graph 13.01). Similarly, no statistically significant differences between the two groups in functional outcomes, including poor finger flexion (see Graph 13.03), were reported. Separate data for the two groups for complications and problems of brace use were not presented.

(e) Brace versus plaster cast
No quantitative data were available for the three trials published as abstracts (Gibson 1983; Ho 1986; Ross 1984), nor for De Bruijn 1987 where the results for two separate trials involving different comparisons were lumped together. The other seven trials (Bunger 1984; Ferris 1989; Ledingham 1991; Moir 1995; O'Connor 2002; Stewart 1984; Tumia 2003) involved 1000 people, which is just over one half of the total for this general comparison. Two pairs of trials (De Bruijn 1987 and Ho 1986; Moir 1995 and Tumia 2003) tested comparable interventions. None of the other trials compared the same brace or brace application including hand position and restriction of movement. Due to the variation of the interventions under comparison and the lack of compatible outcome data, no summary data are presented for this section.

Bunger 1984 compared an above-elbow functional brace with forearm in supination versus a below-elbow plaster in 150 people. Early treatment, particularly wrist position varied according to whether the fracture was displaced and unstable. Anatomically, the brace group had better results with significantly less displacement and less subsequent reduction at two weeks (see Graph 14.09) and a better overall end result at six weeks, in particular regarding dorsal angulation (see Graphs 14.01). Improvement in functional outcomes with time was noted in both groups, a significant difference in overall functional outcome only evident at six-months follow up when more participants in the brace group had a good or excellent outcome. Early complications (see Graph 14.01), mainly neural, were similar in both cases. Without supporting data, Bunger 1984 reported that both displaced and unstable fractures showed better functional results at six months in the brace group. They proposed that the benefit arose primarily from a reduction in fracture redisplacement, a complication that occurred early in the treatment. The good results of both groups were attributed to participation in the trial.

De Bruijn 1987 and Ho 1986 compared an above-elbow backslab replaced at one week (in De Bruijn 1987), or one to two weeks (Ho 1986), by an above-elbow functional brace in supination with a below-elbow backslab in approximately 280 people with Colles' fracture. The duration of immobilisation was four weeks in De Bruijn 1987 and six weeks in Ho 1986. As explained above there are no data available to check the stated conclusion in De Bruijn 1987 that there was no place for treatment with the above-elbow functional brace. Nor are there data to examine the counter claim in Ho 1986, based respectively on the results of two thirds and one half of the trial participants, that functional bracing gave better anatomical results and improved short term functional results.

Ferris 1989 compared a four-part below-elbow brace with forearm cast in 47 people with a Colles' fracture. At splintage removal at five weeks the dorsal displacement from reduced position was less in the brace group (see Graph 14.01). The significantly enhanced functional outcome (range of movement, grip and torque strength) at five weeks in the brace groups was reported to be not significant at nine weeks. Ferris 1989 considered that the brace was well tolerated but noted the extra medical supervision required for the brace group such as for the hand swelling encountered in all brace-group participants in the first week that had required adjustment to the brace (see Graph 14.09).

Gibson 1983 compared a functional brace in supination with either a supinated above-elbow cast or pronated-elbow cast in 105 people with a Colles' fracture. They observed an earlier recovery of function in the brace group at nine weeks, which had disappeared at 20 weeks. There was no report of complications or other outcomes.

Ledingham 1991 compared a functional plaster cast brace with a standard plaster cast in 60 people with a displaced Colles' fracture. Both anatomically and functionally (see Graphs 14.02 and 12.08) the brace group was better before twelve weeks. By six months, five plaster-cast group participants compared with no brace-group participants were graded as poor or only fair in function (see Graph 14.08). Ledingham 1991 considered that there was no significant difference in function by this time. Six cases of superficial radial nerve paraesthesia (numbness) occurred in the brace group, a likely consequence of the brace used. These were transient and all resolved. Ledingham 1991 considered the brace had advantages but that it required a degree of skill and experience in its application. As a consequence, a prefabricated brace that was easier for inexperienced staff to apply was under development (see Moir 1995).

Both Moir 1995 and Tumia 2003 compared the "Aberdeen Colles' fracture brace", a prefabricated functional brace applying three-point loading, with a standard plaster cast. Despite similarities in the measurement of outcome, lack of full and compatible data precluded pooling. Separate reports of the findings of the two trials are given below.

All 85 participants of Moir 1995 had manipulation of their displaced Colles' fracture. Anatomical and functional outcomes were generally summarised as medians in the comprehensive report of this trial. Moir 1995 noted that whilst the brace group was initially less severely displaced, there were more intra-articular fractures. Both groups were reported as losing equivalent positions during splintage. The brace group was indicated as having a superior functional result at six-months follow up as well as better function (grip, pinch strength, pain, finger motion) during splintage. Complications of brace use included three cases of superficial radial nerve paraesthesia, three cases of discomfort requiring brace removal and one incorrect application (see Graph 14.09). In all, Moir 1995 concluded that this brace, which was adjustable and was intended for use by less experienced staff, was preferable. These conclusions were questioned by Moiz 1996 who pointed out inconsistency in the claims of statistical significance for pinch strength at three and six-months follow up as well as pointing out that the criterion for assessing finger movement was inappropriate for patients with plaster casts. Moiz 1996 also queried the cost implications of the brace.

Tumia 2003 extended the examination of the Aberdeen brace through a multicentre and international trial involving 339 people with minimally displaced (non-manipulated) or displaced (manipulated) fractures. The pre-publication report of this trial presented separate results for non-manipulated and manipulated fractures; these data were, however, incomplete together with a few internal inconsistencies in the report. No significant difference in anatomical scores at seven weeks was reported. Relative grip strength was reported as significantly better during brace use but not subsequently; the grip strength results for the two treatment groups were very similar at six months. Pain scores data were inconsistent between text and table in the report but appeared similar in the two treatment groups. No statistically significant differences between the two groups were reported for overall functional scores at three follow-up times. Given the similarities in anatomical and longer term functional results of the brace and plaster cast groups, Tumia 2003 highlighted the alleged ease of application of the Aberdeen brace, the superior grip strength during brace use and the avoidance of cast changes. There were insufficient data, including no cost or procedural results and no information on complications, to confirm these claims. Tumia 2003 indicated that a further development of the brace was in progress.

O'Connor 2002 compared a lightweight and removable wrist splint with a below-elbow plaster cast in 76 people with minimally displaced Colles' fracture. One person in each group required manipulation for secondary displacement (see Graph 14.09). No difference in radiological outcome at 12 weeks was reported. Participants of the splint group had greater mobility by the time of splint removal at six weeks: the differences between the two groups in extension, flexion and pronation were statistically significant (see Graph 14.03). Differences in range of movement between the two groups had disappeared by 12-week follow up (see Graph 14.04). No statistically significant differences between the two groups were reported for grip strength or in the results of a subjective assessment rating each trial participant's ability to perform 15 activities of daily living. Overall functional scores were better in the splint group at six weeks; on average the splint group had a good score whereas the plaster cast group had a fair score according to the rating system of Stewart et al (Stewart 1985). Again, there was no statistically significant difference in the functional scores by 12 weeks (see Graph 14.06). There were similar numbers of people in the two groups with specific complications. Though the clinical implications of the actual differences in visual analogue scores are not clear, the participants of the splint group tended to be less dissatisfied and found fewer problems with their splintage than those in the cast group (see Graph 14.10). Splint group participants registered slightly more pain at two weeks but slightly less at six weeks. The splint, which cost almost the same as a plaster cast, took less time to apply and could be adjusted as required: nearly half (14 out of 32) of the participants of the cast group had a change of cast during the six weeks treatment period.

Ross 1984 compared an Orthoplast functional brace in supination versus a standard plaster cast in 405 people. The anatomical difference between injured and uninjured arms was reported to be less in the brace group. As well as being younger, participants of the brace group were reported as having less pain, less disability, less weakness and better range of movement at three to four months follow up. Ross 1984 recommended the brace, but without providing supporting data.

Stewart 1984 compared a below-elbow brace or above-elbow brace in supination with a standard plaster cast in 243 people with displaced Colles' fracture. For this comparison the results of the two brace groups have been lumped together. Anatomically there was no significant difference reported for the three groups, though there were proportionally fewer people with only fair or poor overall anatomical grades in the combined brace groups (see Graph 14.02). Similarly, functional outcome including poor finger flexion (see Graph 14.05) was reported as being uninfluenced by the method used. Stewart 1984 noted the disproportionate number of return visits (38) of braced group participants compared with only three in the plaster cast group because of problems with the splintage. The report concluded that there was no reason to change from the use of standard plaster casts for uncomplicated Colles' fracture.

(f) Different casting materials or techniques, or both
Four trials evaluated materials or techniques used for below-elbow casts. Three (Cohen 1997; Nielsen 1981; Rosetzsky 1982) compared a new material applied in different way with a standard plaster or fibreglass cast. The fourth trial (Cohen 2001) compared a new casting technique, focused rigidity casting, with standard casting. The four trials emphasised different aspects of cast function or focused on different inadequacies of standard materials or techniques, or both. These latter included the heavy weight, water solubility, limited strength, poor X-ray transmission and rigidity of plaster casts and rigidity and need for cast changes for fibreglass and other standard casts. All four trials actively obtained feedback on the problems and satisfaction of cast use from trial participants, as well as discussing the relative costs of the casts involved at the time of the trial. However, there were only scant details on functional outcomes with follow up extending only up to the time of cast removal.

Polyurethane cast with "zipper" versus cylindrical plaster cast.
Rosetzsky 1982 compared immobilisation for six weeks using a below-elbow polyurethane cast with "zipper" with a below-elbow plaster of Paris cylinder cast, in 50 people with undisplaced or displaced distal radial fractures. The potential advantages of the polyurethane cast were that it was lighter, water repellent, hardened faster and enabled, as was done in the trial, reduction of displaced fractures after cast application while the cast set. The zipper also allowed some adjustment and easy removal. No specific anatomical data were reported. Fewer participants in the polyurethane group failed to retain reduced fracture position (see Graph 15.01) but there was no need in either group for rereduction of the displaced fracture. Secondary adjustment of casts resulting from problems such as restricted finger movement was similar in both groups as were the number of trial participants who noted problems, often local pressure points, during cast use (see Graph 15.01). No incidences of skin damage occurred. Rosetzsky 1982 reported that the polyurethane cast was twice as costly as a standard plaster cast and moreover required considerable practice to make and apply. Given these considerations, Rosetzsky 1982 concluded that the polyurethane cast should only be used in special cases specifically where low weight and water insolubility were prime considerations.

Hexelite (thermoplastic) bandage versus plaster cast
Nielsen 1981 compared immobilisation in a thermoplastic polyester bandage applied after heating in hot water with a standard plaster cast in 183 people, of which 55 had Colles' fractures. There was no report of anatomical or functional outcomes. Subjective complications such as pain, skin pressure, poor hand function and poor stability during cast wear, were similar in both groups with the exception of water intolerance which was, not surprisingly, worse in the plaster group (see Graph 16.01). There were more cases of skin damage in the thermoplastic group. As the thermoplastic material was eight times more expensive and more difficult to handle, without clear advantages, Nielsen 1981 abandoned its use after the trial.

QuickCast (shrinkable polymer) versus fibreglass tape cast
Cohen 1997 compared immobilisation for up to 6.5 weeks using a polymer-coated casting material which was shrunk using hot air to fit the arm against a short-arm fibreglass tape cast, in 30 people with undisplaced or displaced distal radial fractures. Percutaneous pins were used to stabilise fractures in 10 people. As indicated above, the surgical treatment of these people places them in a different category where additional considerations such as the complications of pin track infection come into play. Cohen 1997 recognised this but although randomisation was stratified by the severity of the fracture, most of the results were presented for the whole group. No significant difference between groups was observed in the final redisplacement from the reduced position (see Graph 17.01: note denominators used are for the whole group). In all, three fractures were considered to have redisplaced, one, belonging to the QuickCast group, of which required further treatment (see Graph 17.02). Similar numbers of complications occurred in both groups, although only the QuickCast group had burns resulting from the process of cast application. Trial participants considered they had marginally more problems in the fibreglass group but rated their satisfaction similarly. The key difference was that on average there was one fewer cast change in the QuickCast group, mainly as further heat could be used to reshape the cast as required. Cohen 1997 noted that QuickCast was over twice the cost of a fibreglass cast but that this would be probably outweighed by the reduction in time and labour resulting from fewer cast changes.

Focused rigidity casting versus standard casting
Cohen 2001 compared focused rigidity casting (FRC), where elasticated synthetic tape was applied to confer relative rigidity at the fracture site but more flexibility elsewhere, with standard casting in 200 people, 35 of whom had undisplaced fractures of the distal radius. Length of follow up, up to cast removal, averaged four weeks, ranging from 14 to 42 days overall. There were no cases of fracture displacement, delayed or non-union or adverse effects recorded in the limited follow-up period (see Graph 18.02). There were no statistically significant differences between the two groups in movement limitations or loss of muscle power at cast removal (see Graph 18.01). One person in each group found their cast excessively restricting and one person in the FRC group found their cast very uncomfortable but no one expressed dissatisfaction overall. Based on the results of a specially developed scoring scheme, the Bradford Plaster Index, aimed at assessing activities of daily living, satisfaction, overall functional impairment and comfort during cast use, Cohen 2001 reported that FRC-group participants perceived they were more able to perform activities of daily living and had a greater satisfaction with their ability to perform these. Separate data for distal radial fracture patients were unavailable for cast changes and adjustments (only an option for FRC). A saving in the amount of casting tape used and the facility for re-application of the same cast after examination was noted for the FRC method.

(g) Different durations of immobilisation
Seven trials compared the use of plaster cast for different durations. Four trial studies (Christensen 1995; McAuliffe 1987; Millett 1995; Vang Hansen 1998) compared three to four weeks versus five to six weeks immobilisation, one trial (Davis 1987) compared one to two weeks versus four to five weeks immobilisation and two trials (Jensen 1997; Stoffelen 1998) compared one versus three weeks immobilisation. De Bruijn 1987 compared bandage with an above-elbow functional brace for three weeks, after a week-long application of a below-elbow backslab and above-elbow backslab respectively. As explained above, De Bruijn 1987 failed to provide supporting data for the conclusions given in this trial and is not considered further in the following.

Christensen 1995 and Vang Hansen 1998 compared three-weeks with five-weeks immobilisation in a plaster back slab, in 133 people. All 33 participants of Christensen 1995 and over half in Vang Hansen 1998 had minimally displaced distal radial fractures. Both trials reported that there were no statistically significant differences in either anatomical or functional outcomes, but only data for long-term pain were available (see Graph 19.01). Aside from tendon rupture (see Graph 19.04), separate data for complications were not given.

McAuliffe 1987 and Millett 1995 included both undisplaced and displaced fracture patients, and involved 108 and 90 participants respectively. In McAuliffe 1987, fractures were remanipulated if necessary, after an initial application of a cast for one week. Immobilisation in a plaster cast was then continued for a further three weeks or five weeks. There were no significant differences reported between groups for anatomical outcomes at either three or twelve months. Overall assessments by trial participants of pain, disability and wrist mobility were comparable (see Graph 19.02). However significantly less pain and greater grip strength were reported in the early group when assessed by an independent physiotherapist. An improvement in range of movement was also noted in the early group. There was no mention of complications. Millett 1995 compared three-weeks immobilisation followed by two weeks in a flexible cast with five-weeks plaster immobilisation. Anatomical and clinical outcomes were presented at various time intervals up to three years but, as the numbers of trial participants assessed at these times were not given, only exploratory analyses could be done to test the claims in the report. Radiological examinations at three years were reported to show a statistically significant increase in the average radial tilt (2 degrees) and decreased radioulnar joint space (0.3 mm) in the five-week group, but no statistically significant difference in numbers with osteoarthritis. The regain of grip strength and wrist movement was more rapid in the early-mobilisation group. The higher joint mobility and mean grip scores in the early -mobilisation group were reported as reaching statistical significance at three and six months respectively. An exploratory analysis, based on intention-to-treat analysis, for grip strength at three and six months shows the difference between the two groups reaching statistical significance at three months (see Graph 19.03). By three years, no statistical differences between the two groups were reported in pain, grip strength, residual deformity, hand swelling, disability and overall complication rate. Millett 1995 concluded that the short-term improvement in functional recovery, lack of detrimental evidence and patient preference supported early mobilisation.

Davis 1987 compared tubigrip bandage versus plaster cast for three weeks after the application of a back slab for 7 to 13 days. Though Davis 1987 did not report radiological outcomes, there was no difference in the number of secondary fracture displacements (2 versus 3; see Graph 20.05) with the two cases of cosmetic deformity occurring in the plaster group. Short-term functional outcome was similar for pain and mean grip strength (see Graphs 20.01 and 20.02) in both groups. Overall functional outcome was superior in the bandage group, with an earlier recovery of domestic skills (incomplete data). Overall functional grades were better in the bandage group (see Graph 20.03). There was no major difference in the complications occurring in either group though more occurred in the plaster group (see Graph 20.04). Finally, Davis 1987 reported greater patient satisfaction with bandage use (see Graph 20.05) and concluded that bandage use enabling earlier mobilisation was safe with a potential for a faster and better functional outcome for people with undisplaced and uncomplicated Colles' fracture.

Based on the favourable conclusions cited in trials testing early mobilisation (Christensen 1995; McAuliffe 1987), or no immobilisation (Abbaszadegan 1989; Dias 1987), Jensen 1997 and Stoffelen 1998 went further by comparing one-week with three-weeks immobilisation in plaster in 114 people with undisplaced or minimally displaced Colles' fractures. Radiological examination of 48 trial participants at six months in Jensen 1997 showed no cases of non-union, and no statistically significant difference in excess angulation or axial radial shortening (see Graph 21.01). Functional outcome in only one participant of the three-weeks group was adversely affected by excessive angular displacement. Stoffelen 1998 reported no further displacement of fractures in either group. Final functional outcome assessed within an overall functional scoring system was similar in both groups for both trials (see Graphs 21.02 and 21.03). Additional pain was experienced by trial participants at cast removal at one week, and the need for a mild pain reliever was advised in Jensen 1997. Pain preventing the removal of plaster was not experienced by any participants of Stoffelen 1998. This trial was initially intended to compare the use of removable splints with plaster immobilisation for three weeks, but inhibiting pain experienced by patients in the first days after a fracture, prompted use of plaster immobilisation for the first week. Separate results for complications were not provided by Jensen 1997. Though more cases of algoneurodystrophy (reflex sympathetic dystrophy) occurred in the group immobilised for three weeks in Stoffelen 1998, this was not statistically significant (see Graph 21.04). Both Jensen 1997 and Stoffelen 1998 considered that undisplaced or minimally displaced Colles' fractures could be safely treated with one week immobilisation in a dorsal plaster cast, but emphasised that care had to be taken in selecting patients.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Given the frequent occurrence of distal radial fracture in adults and the general use of conservative interventions in the management of the more common types of these fractures, the overall number of randomised trials (37) evaluating various conservative treatment options and associated number of participants (just over 4200) are comparatively few. Very few trials were comparable in terms of inclusion criteria and patient characteristics, primarily fracture type, the interventions compared, overall care programs or outcome measurement. The majority of trials were methodologically flawed such that there was a real prospect of serious bias. Indeed, perhaps through under reporting, the possibility of selection, performance, exclusion or ascertainment bias, or a combination of these could not be ruled out for any trial. Much of the emphasis in this discussion inevitably refers to methodology rather than drawing out conclusions of effectiveness of the interventions under investigation.

While small trials with under 50 participants in each intervention group may provide robust evidence of effect in some areas of health care, it is unlikely that any of these small trials could provide conclusive evidence to establish the superiority of one intervention over another. Furthermore the apparent comparability of results of interventions tested within some trials should not be interpreted as evidence of no effect or no difference. Apart from trial size, the general lack of allocation concealment, the lack of assessor blinding and, less commonly, severe losses to follow-up, all serve to undermine the validity of the trial results.

Other issues which are more specific to this subject involve the severity of injury and fracture type, the execution of the interventions and associated care programmes, and the usefulness and relevance of outcome measurement.

The term 'distal radius fracture' covers a range of injuries which includes the commonly referred 'Colles' fracture. It is commonly perceived that the choice of intervention will depend to a large extent on the severity and type of injury. At a basic level, this is often viewed in terms of whether the, usually closed, fracture is displaced and whether there is articular involvement. Other factors such as patient age, comorbidity, cost, available resources and patient choice will also contribute to this decision. Thus an inadequate description of inclusion criteria, a lack of baseline characteristics presented by intervention group and/or an important but unadjusted difference in patient characteristics, do not assist an evaluation of the applicability of trial results. The variety of fracture classification systems, with associated issues of reliability and validity further complicates this area (Jupiter 1997). However, in general these trials testing conservative interventions involved closed minimally to moderately displaced Colles' fractures in the elderly for which conservative rather than surgical treatment is conventionally applied. Other types of distal radius fracture, such as those associated with major violence which may be compound in nature, or the 'reverse Colles' or Smith's fracture, are far less common and no trial specifically focused on these.

Incomplete description of trial interventions and the measures taken to provide otherwise comparable care programmes also gave rise to concern. Of particular note was the frequent lack of sufficient information to determine if there were any important differences in the timing of interventions in the context of the immediate post traumatic reaction such as swelling, the use of anaesthesia, the experience of health care workers, and general rehabilitation.

The length of overall follow up of some trials was inadequate and no trial provided a completely satisfactory presentation of outcome. In particular, the common reliance on often modified functional scoring systems and subsequent presentation by an overall score or grade, hampered interpretation of trial results. Though understandably an attractive option, the use of such unvalidated scales is questionable. Many such as those based on Gartland and Werley (Gartland 1951) were termed 'functional' despite including anatomical results. Since, in general, these latter have no proven relationship to eventual functional outcome, their inclusion will undermine a so-called summary of 'functional' outcome. Functional scales often included serious complications and some trials failed to report these separately. Finally, patient satisfaction and resource implications were rarely mentioned.

This review raised a number of fundamental questions. For example, when should a distal radius fracture be manipulated? How should the fracture be immobilised, whether with or without prior manipulation? What methods and materials should be used for immobilisation? How long should the immobilisation last? And, though not expressed in terms of a null hypothesis, should remanipulation be undertaken for any redisplacement after closed reduction and when should this take place? So far, the evidence available from randomised controlled trials is insufficient to provide answers to these questions.

Summarising the findings of this review according to the null hypotheses listed in 'Objectives' we find:

There is no conclusive evidence of difference in outcome between reduction or no reduction of displaced fractures, namely:

  • Manipulation versus no manipulation
  • Delayed manipulation versus immediate manipulation

Likewise, there is no conclusive evidence of difference in outcome between different methods of plaster and brace management listed below:

  • No immobilisation (minimal support) versus immobilisation
  • Forearm held in different positions by plaster
  • Plaster or synthetic cast type A versus type B
  • Forearm held in different positions by brace
  • Brace versus plaster cast
  • Different types of cast material
  • Different durations of immobilisation

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

 

Implications for practice

Conventionally, practitioners treating distal radius fractures in adult patients aim to restore, as best as they can, the anatomy of the broken wrist, and to control pain, allow healing, and maintain the function of uninjured joints in the limb, by applying some form of immobilisation. Many variations of reduction/immobilisation have been suggested and used accordingly. This review has failed to find evidence for important differences in outcome between these variations.

From a health policy and health care funders' perspective it seems justifiable to ask the question as to why the least costly option for managing this common fracture should not become the norm since there is no evidence available of additional benefits for the patients from the various conservative treatment regimens?

In the meantime, practitioners applying conservative management for distal radial fracture should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Patient preferences and their circumstances as well as the risk of complications of the fracture and treatment should also be considered.

 
Implications for research

Given that a distal radius fracture in adults is a common injury and given that there is very limited knowledge about the best method of treatment, either conservative or surgical (Handoll 2005a), further research is called for. However, rather than embarking on further small, single-centre and spasmodic trials which, often with inadequate methodology and reporting, are unlikely to provide the good generalisable evidence required, it is important to develop a more coherent strategy for future research. Some thoughts on this are presented below.

Systematic reviews of the main treatment choices for these fractures are now available. These cover methods of closed reduction (Handoll 2005c), conservative interventions (this review), surgical interventions (Handoll 2005a), anaesthetic technique (Handoll 2005b) and rehabilitation (Handoll 2005d). All conclude that there is a general insufficiency of evidence to inform practice. An overview of the whole treatment process thus seems warranted.

Previously we suggested that one approach to determine the way forward for future randomised trials would be a careful and comprehensive review of the management of patients with this fracture. This could serve to standardise good quality care but also would enable people to distinguish where and on what basis important treatment decisions (such as whether to reduce a fracture) are made and to allow an examination of their underlying uncertainty. We considered that reaching a consensus on the important areas of uncertainty should help to gather momentum for larger, probably multicentre, trials.

We have now completed a project that has taken our systematic review of the evidence some way along these lines (Handoll 2003a). Essentially, we placed the evidence drawn from our reviews into the context of the care decisions made within a 'typical' care programme. Then, through a consultation exercise involving key players, including several with a personal or close familial experience of these fractures, we sought to identify key treatment questions and research priorities. While we were unable to reach a consensus in this complex area, we concluded that we had provided a template for further action and that the wealth of insights gained should help to inform a future research agenda.

In the meantime, the following points should still be considered.
(1) A deeper understanding is required of patient preferences regarding outcomes of treatment, and any trade off between benefits and adverse effects of the various methods of management. This would inform debate about the most cost-effective method of managing this common injury.
(2) Future research would be facilitated by the development and adoption of a standard core data set for classification and outcome reporting for distal radial fracture.
(3) Such a dataset should include, at minimum, a basic fracture classification (non-displaced: displaced; intra-articular: extra-articular), patient preferences, validated functional and activities of daily living outcomes, preferably rated by patients, and resource use measures in addition to traditional measures such as anatomical position and range of movement.
(4) The design and reporting of any future trial should conform to the CONSORT statement (Begg 1996; Moher 2001) or any future development of it.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

We thank Noelle Murphy for her contributions in the early stages of the original version of this review. We thank Jenny Duthie for secretarial support in the original version of the review. We are grateful for the helpful comments at editorial review of the original version from the following: Bill Gillespie, Geoffrey Hooper, Gordon Murray, John Stothard, Marc Swiontkowski, Joanna Tasker. We are grateful to Bill Gillespie and Marc Swiontkowski for their helpful comments on the third update.

We thank Lesley Gillespie for her help in developing the search strategy and Leeann Morton and Bill Gillespie for their help during editorial review of the first and second updates. We thank Lesley Gillespie for her help during the editorial review of the third update.

Helen Handoll's work on the first version of the review was supported by the Chief Scientist Office, Department of Health, The Scottish Office, UK. Her work on the first and second updates was supported by East Riding and Hull Health Authority, UK; and on the fourth update, by the National Osteoporosis Society, UK.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
Download statistical data

 
Comparison 1. Manipulation versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Functional grading: poor or fair1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Redisplacement or displacement beyond study criteria
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Re-manipulation or secondary manipulation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.3 Algodystrophy (RSD)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.4 Finger stiffness
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Cosmetic deformity1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Cosmetic deformity (subjective)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Cosmetic deformity (objective)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 2. No immobilisation versus immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Functional grading2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Not excellent
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Poor or fair
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Pressure sores
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Problems with bandage / cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.3 Median nerve compression (CTS)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 3. Cast position: supination versus pronation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Mean loss of volar tilt (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Mean loss of radial deviation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.3 Mean loss of dorsal angulation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Functional grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Redisplacement (10+ degrees)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Rereduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 4. Cast position: neutral (mid-way) versus pronation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Mean loss of dorsal angulation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Redisplacement (10+ degrees)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Rereduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 5. Palmar flexion or neutral versus dorsiflexion

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Functional grading: not excellent2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Palmar flexion versus dorsiflexion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Neutral flexion versus dorsiflexion
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Functional grading: poor or fair2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Palmar flexion versus dorsiflexion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Neutral flexion versus dorsiflexion
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Discomfort (pressure pain) in plaster
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 6. Modified cast restricted mobilisation versus plaster cast immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Functional grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 7. Modified sugar-tong cast versus below-elbow cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Dorsal angulation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Unacceptable anatomical result (dorsal tilt > 10 degrees, radial shortening > 5 mm)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Redisplacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 8. Modified sugar-tong fibreglass splint versus cylindrical plaster cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Redisplacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Rereduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 9. Modified sugar-tong fibreglass splint versus volar-dorsal fibreglass splint

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Redisplacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Rereduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 10. Volar-dorsal fibreglass splint versus cylindrical plaster cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Redisplacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Rereduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 11. Above-elbow versus below-elbow plaster cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Functional grading: not excellent1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 at 12 weeks
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 at 6 months
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Functional grading: poor or fair1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 at 12 weeks
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 at 6 months
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 4 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Re-application of plaster
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.2 Delayed fracture healing
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Sudeck's atrophy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.4 Nerve compression
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 12. Braced position: supination versus pronation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Loss of volar tilt (at least 2 degrees)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Loss of radial length (at least 2 mm)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Anatomical grading: poor or fair1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Functional grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 13. Braced position: supination versus other

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Poor finger flexion1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 14. Functional brace versus plaster cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement (at splintage removal)2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Dorsal displacement/angulation (degs)
2Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Dorsal shift (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.3 Radial displacement (degs)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.4 Radial shift (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.5 Radial shortening (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Anatomical grading3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Not excellent
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Poor or fair
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Range of movement (at splintage removal)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Extension (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.2 Flexion (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.3 Radial deviation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.4 Ulnar deviation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.5 Pronation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.6 Supination (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 4 Range of movement (at 12 weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Extension (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    4.2 Flexion (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    4.3 Radial deviation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    4.4 Ulnar deviation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    4.5 Pronation (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    4.6 Supination (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 5 Poor finger flexion1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Functional assessment score (0: no problems to 33: maximum)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 at 6 weeks
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    6.2 at 12 weeks
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 7 Functional grading: not excellent2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    7.1 up to and including 3 months
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    7.2 6 months
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 8 Functional grading: poor or fair2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    8.1 up to and including 3 months
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    8.2 6 months
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 9 Complications6Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    9.1 Hand swelling during brace or cast use
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.2 Poor finger motion (in brace or cast)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.3 Discomfort necessitating removal (brace or cast)
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.4 Incorrect application of splintage
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.5 Problems with brace or cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.6 Brace or cast change
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.7 Redisplacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.8 Remanipulation, rereduction or manipulation after secondary displacement
5Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.9 Tendon rupture
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.10 Sudeck's atrophy
4Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.11 Upper limb dystrophy (temporary)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.12 Reflex sympathetic dystrophy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.13 Median neuropathy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.14 Median nerve compression (CTS)
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.15 Superficial radial nerve paraesthesia
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.16 Peripheral radial/ulnar neuropathy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.17 Ulnar nerve compression
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 10 Assessment of brace or cast use (visual analogue score: 0 to 10)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    10.1 Pain during splintage: 2 weeks (0 = no pain)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    10.2 Pain during splintage: 6 weeks (0 = no pain)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    10.3 Problems with splintage: 2 weeks (0 = no problems)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    10.4 Problems with splintage: 6 weeks (0 = no problems)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    10.5 Satisfaction with splintage: 2 weeks (0 = satisfaction)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    10.6 Satisfaction with splintage: 6 weeks (0 = satisfaction)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 
Comparison 15. Cast material: Polyurethane versus plaster

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Redisplacement or secondary displacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Rereduction or secondary reduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.3 Secondary cast adjustment
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.4 Skin damage
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 16. Cast material: Thermoplastic versus plaster

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Bandage repair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Poor stability in cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.3 Pain in cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.4 Poor hand function in cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.5 Skin pressure in cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.6 Water intolerant cast (subjective inconvenience)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.7 Skin damage
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 17. Cast material: Shrinkable polymer (Quickcast) versus fibreglass

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement (at cast removal)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Change in radial length (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Change in radial inclination (degs)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.3 Change in ulnar variance (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.4 Change in volar tiit (degs)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Burns or skin irritation from cast application
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Redisplacement or secondary displacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.3 Rereduction or secondary reduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.4 Early cast change
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.5 Discomfort at thumb base
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.6 Discomfort at cast rim near elbow
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.7 Significant skin problems
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 18. Casting technique: Focused rigidity cast (FRC) versus standard cast

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Functional impairment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Unable to function during cast wear
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Moderate or severe movement limitations at cast removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.3 Moderate or severe loss of power at cast removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Very uncomfortable cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Loss of position
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.3 Non-union
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 19. Early mobilisation (3-4 weeks) versus 5-6 weeks plaster immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain (mild with stenuous use)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Patient assessment (pain, disability, mobility): poor or fair1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 at 3 months
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 at 1 year
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Grip strength (% of non-injured hand)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At 3 months
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.2 At 6 months
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 4 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Tendon rupture
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 20. Early mobilisation (1-2 weeks) versus 4-5 weeks immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean VAS pain scores (none 0 - 20 cm)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Mean grip strength (mmHg)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Functional grading1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 4 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Withdrawal from treatment
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.2 Problems with bandage or cast
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Fracture displaced
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.4 Cosmetic deformity
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.5 Tendon rupture
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.6 Paraesthesia
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.7 Physiotherapy needed
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.8 Shoulder stiffness
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 5 Patient dislike of or non-compliance with treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 21. Early mobilisation (1 week) versus 3 weeks plaster immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Anatomical displacement1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Angulation up to 20 degrees
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Axial radial shortening
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Functional grading: not excellent1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Not excellent
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Poor or fair
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Mean functional score (100 is normal)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Pain preventing plaster removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.2 Further dislocation of fracture
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Initial symptoms of algoneurodystrophy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.4 Persistent algoneurodystrophy
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Appendix 1. The Cochrane Library search strategy

#1. RADIUS FRACTURES explode all trees (MeSH)
#2. WRIST INJURIES explode all trees (MeSH)
#3. (#1 or #2)
#4. ((distal near radius) or (distal near radial))
#5. (colles:ti or smith:ti or smiths:ti)
#6. (colles:ab or smith:ab or smiths:ab)
#7. wrist*
#8. (#4 or #5 or #6 or #7)
#9. fracture*
#10. (#8 and #9)
#11. (#3 or #10)

 

Appendix 2. MEDLINE (OVID-WEB) search strategy

1. exp Radius Fractures/
2. Wrist Injuries/
3. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).ti,ab.
4. or/1-3

 

Appendix 3. EMBASE search strategy

1. (((distal adj3 (radius or radial)) or wrist or colles$2 or smith$2) adj3 fracture$).tw.
2. Colles Fracture/ or Radius Fracture/ or Wrist Fracture/ or Wrist Injury/
3. or/1-2
4. exp Randomized Controlled trial/
5. exp Double Blind Procedure/
6. exp Single Blind Procedure/
7. exp Crossover Procedure/
8. or/4-8
9. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
10. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
11. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
12. (cross?over$ or (cross adj1 over$)).tw.
13. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
14. or/9-13
15. or/8,14
16. Animal/ not Human/
17. 15 not 16
18. and/3,17

 

Appendix 4. CINAHL search strategy

1. Radius Fractures/
2. Wrist Injuries/
3. or/1-2
4. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).ti,ab.
5. or/3-4
6. exp Clinical Trials/
7. exp Evaluation Research/
8. exp Comparative Studies/
9. exp Crossover Design/
10. clinical trial.pt.
11. or/6-10
12. ((clinical or controlled or comparative or placebo or prospective or randomi#ed) adj3 (trial or study)).tw.
13. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
14. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
15. (cross?over$ or (cross adj1 over$)).tw.
16. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
17. or/12-16
18. or/11,17
19. and/5,18

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Last assessed as up-to-date: 21 August 2005.


DateEventDescription

13 August 2008AmendedConverted to new review format.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Protocol first published: Issue 2, 1995
Review first published: Issue 2, 1999


DateEventDescription

22 August 2005New search has been performedIn this 'minor' update (Issue 4, 2005) the search for trials was updated to June 2005.

Two newly identified trials were placed in 'Studies awaiting assessment' pending full publication and translation respectively. Of two studies previously listed in 'Studies awaiting assessment', one was included and the other was excluded. Other format changes were undertaken to comply with the Cochrane Style Guide (November 2004). Graphical presentation of the results was compressed to reduce the number of graphs. There were no substantive changes made to the conclusions.

For details of previous updates, please see 'Notes'.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Rajan Madhok initiated the review, critically reviewed the studies and all review drafts. Helen Handoll located the review studies, critically reviewed the studies, contacted trialists, compiled the first draft and subsequent revisions in RevMan of the original review and the first, second, third, fourth and fifth updates. Noelle Murphy developed the protocol and was involved in the early stages of the original version, primarily quality assessment, data extraction and initial data entry into the 'Characteristics of included studies' table, but is not a named author. Helen Handoll and Rajan Madhok are guarantors of the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms
 

Internal sources

  • University of Teesside, Middlesbrough, UK.

 

External sources

  • No sources of support supplied

 

Notes

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Notes
  17. Index terms

Fourth 'minor' update
For this update, published Issue 2, 2004, the search for trials was updated to November 2003. The only newly identified study was excluded. A study previously listed as ongoing was excluded as was another study previously listed in 'Studies awaiting assessment'. There were no substantive changes made to the conclusions.

Third 'substantive' update
For this update, published Issue 2, 2003, the review comparisons were restructured to reflect the decision points, and associated timing, for the management of these fractures. Thus, the question of whether to reduce a fracture now appears first. In addition, we changed the emphasis from the use of support materials (bandages) to early mobilisation. This resulted in a new category (No immobilisation (minimal support) versus immobilisation) and the loss of an old category ((Bandage (minimal support) versus plaster cast or brace) (Handoll 1999; Handoll 2001; Handoll 2002d). Two trials (Abbaszadegan 1989; Dias 1987) from the old category appear in the new category and two trials (Davis 1987; De Bruijn 1987) were transferred to the renamed and expanded category: Different durations of immobilisation (formerly: Plaster cast for different durations).

The search for trials was extended to January 2003. Three trials were newly included, one trial is ongoing and three trials, awaiting further information from trialists, are pending assessment. Further information obtained for three trials, previously listed as ongoing, resulted in their exclusion. There were no changes made to the conclusions.

Second 'substantive' update
For this update published in Issue 2, 2002, the search for trials was extended to January 2002. Two trials were newly included, one other trial was designated as ongoing and one, awaiting further information from a trialist, was pending assessment. Two additional papers of already included trials yielded limited new results. There were no changes made to the conclusions.

First 'substantive' update
The correct version of the first update of the review was published in Issue 3, 2001. This replaced an earlier and interim version of the review which was put forward for publication in error in Issue 2, 2001. The main difference between these two versions was the extension of the search from July to December 2000 and the reformation of the search strategy.

The basic features of the first update were the inclusion of three more included trials, some modifications to quality scores of trials resulting from the slightly amended quality scoring scheme applied to the now published surgical treatment review, and some more specific pointers to future research. One previously included trial was moved to the surgical treatment review, and hence excluded from this review.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
  23. References to other published versions of this review
Abbaszadegan 1989 {published data only}
Aladin 2001 {published and unpublished data}
  • Aladin A, Earnshaw SA, Moran CG. Control of forearm rotation during nonoperative management of Colles' fracture: a prospective randomized controlled trial. Annual Meeting of the Orthopaedic Trauma Association; 2001 Oct 18-20; San Diego, California. Available at: http://www.hwbf.org/ota/am/ota01/otapo/OTA01952.htm (accessed 14/11/01).
  • Moran CG. Plaster immobilisation of Colles fracture of the wrist: a prospective randomised controlled trial of sugar-tong cast immobilisation compared to conventional Colles-type cast fixation. National Research Register. Available at: http://www.update-software.com/national/ (accessed 20/02/04).
Blatter 1994 {published data only}
  • Blatter G, Papp P, Magerl F. A comparison of 2 methods of plastic cast fixation in treatment of loco classico radius fracture. A prospective, randomized study [Ein Vergleich von 2 Gipsfixationsmethoden bei der Behandlung der Radiusfraktur loco classico. Eine prospektive, randomisierte Studie.]. Unfallchirurg 1994;97(10):534-40. [MEDLINE: 1995108589]
Bunger 1984 {published data only}
  • Bunger C, Juhl A, Rasmussen P, Solund K. Colles fracture: Functional bracing in supination versus dorsal cast in pronation [abstract]. Acta Orthopaedica Scandinavica 1982;53:312.
  • Bunger C, Rasmussen P, Solund K. Splinting of Colles' fracture. Dynamic splint in supination compared with conventional dorsal plaster splint [Skinnebehandling ved Colles' fraktur. Dynamisk skinne i supination kontra konventionel dorsal gipsskinne]. Ugeskrift for Laeger 1985;147(20):1619-22.
  • Bunger C, Solund K, Rasmussen P. Colles fracture: Functional bracing in supination versus low dorsal cast [abstract]. Acta Orthopaedica Scandinavica 1983;54:505-6.
  • Bunger C, Solund K, Rasmussen P. Early results after Colles' fracture: functional bracing in supination vs dorsal plaster immobilization. Archives of Orthopaedic and Trauma Surgery 1984;103(4):251-6. [MEDLINE: 1985071556]
  • Solund K, Rasmussen P, Borg L, Bunger C. Radiological, functional and social healing after Colles' fracture. A prospective study [Radiologisk, funktionel og social heling efter Colles' fraktur. En prospektiv undersogelse]. Ugeskrift for Laeger 1983;145(30):2289-92.
Christensen 1995 {published data only}
Cohen 1997 {published data only}
Cohen 2001 {published and unpublished data}
  • Cohen A. personal communication February 28 2002.
  • Cohen AP, Shaw DL. Focused rigidity casting: A prospective randomised study. Journal of the Royal College of Surgeons of Edinburgh 2001;46(5):265-70.
  • Martin WN, Sandhu H. Focused rigidity casting: a prospective randomised study [letter & reply]. Journal of the Royal College of Surgeons of Edinburgh 2002;47(5):713-4.
  • Petty AC. personal communication November 1 2002.
  • Petty AC, Wardman C. A randomized, controlled comparison of adjustable focused rigidity primary casting technique with standard plaster of Paris / synthetic casting technique in the management of fractures and other injuries. Journal of Orthopaedic Nursing 1998;2:95-102.
Cornwall 2001 {published data only}
  • Cornwall R, Ghillani R, Levine JJ. Displacement of distal radius fractures during cast immobilization: A randomized, prospective trial [Abstract]. 67th Annual Meeting of the American Academy of Orthopaedic Surgeons; 2000 Mar 15-19: Orlando (FL). Available at: http://www.aaos.org/wordhtml/anmt2000/sciprog/172.htm (accessed 31/08/00).
  • Cornwall R, Ghillani R, Levine JJ. Does above-elbow immobilization have a role in the closed treatment of distal radius fractures [Abstract]. 68th Annual Meeting of the American Academy of Orthopaedic Surgeons; 2001 Feb 18 - Mar 4: San Francisco (CA). Available at: http://www.aaos.org/wordhtml/anmt2001/sciprog/142.htm (accessed 20/02/04).
Davis 1987 {published data only}
De Bruijn 1987 {published data only}
  • de Bruijn HP. Functional treatment of Colles fracture. Acta Orthopaedica Scandinavica. Supplementum 1987;223:1-95. [MEDLINE: 1987266568]
  • de Bruijn HP, Volovics L, Stapert JW. Functional treatment of Colles fractures and the relation of anatomic recovery and function [Functionele behandeling van Colles-fracturen en het verband tussen anatomisch herstel en functie.]. Nederlands Tijdschrift voor Geneeskunde 1989;133(14):723-8. [MEDLINE: 1989238669]
Dias 1987 {published and unpublished data}
  • Dias JJ, Wray CC, Jones JM, Gregg PJ. The value of early mobilisation in the treatment of Colles' fractures. Journal of Bone and Joint Surgery. British Volume 1987;69(3):463-7. [MEDLINE: 1987222496]
  • Dias JJ, Wray GC, Jones JM, Gregg PJ. Minimally displaced Colles' fractures: is plaster immobilisation necessary? [abstract]. Journal of Bone and Joint Surgery. British Volume 1988;70(4):678.
Ferris 1989 {published data only}
Gibson 1983 {published data only}
Gupta 1991 {published data only}
Ho 1986 {published data only}
  • Ho ST, Ghosh U, Ho YF. A study of functional bracing in the treatment of Colles' fractures in Chinese patients [abstract]. Journal of the Western Pacific Orthopaedic Association 1986;23(2):35.
Jackson 2002 {published data only}
  • Grafstein EJ, Jackson C, Innes GD, Christensen JM, Boychuk BA, Stothers K, et al. Comparison of three immobilization techniques in the management of acute distal radius fractures [abstract]. American Emergency Medicine 2002;9(5):448-9.
  • Jackson CM, Grafstein E, McCormack RG, Goetz T, Christenson J, Innes G, et al. Comparison of techniques for immobilizing extraarticular distal radius fractures [poster 81]. Annual Meeting of the Orthopaedic Trauma Association; 2002 Oct 11-13; Toronto, Ontario. Available at: http://www.hwbf.org/ota/am/ota02/otapo/OTP02081.htm (accessed 01/11/02).
Jensen 1997 {published data only}
  • Jensen MR, Andersen KH, Jensen CH. Management of undisplaced or minimally displaced Colles' fracture: one or three weeks of immobilisation. Journal of Orthopaedic Science 1997;2(6):424-7.
Kelly 1997 {published data only}
Kongsholm 1981 {published data only}
  • Kongsholm J, Buring K, Lindh C, Duarte-Martins H. A prospective study on the treatment of Colles' fracture [abstract]. Acta Orthopaedica Scandinavica 1981;52:693.
Ledingham 1991 {published data only}
McAuliffe 1987 {published data only}
McMillan 1996 {published data only}
  • McMillan J, James P, Kumar S, Kinninmonth AWG. Delayed primary manipulation of Colles' fractures - a prospective study [abstract]. Injury 1996;27(5):376.
Millett 1995 {published and unpublished data}
Moir 1995 {published data only}
  • Moir JS, Ashcroft GP, Ledingham W, Wardlaw D. Development of a functional brace for the immediate treatment of Colles' fractures [abstract]. Journal of the Royal College of Surgeons of Edinburgh 1992;37(6):419-20.
  • Moir JS, Ashcroft GP, Ledingham W, Wytch R, Wardlaw D, Murali R. A new functional brace for the treatment of Colles' fractures [abstract]. Journal of Bone and Joint Surgery. British Volume 1993;75 Suppl 2:197-8.
  • Moir JS, Murali SR, Ashcroft GP, Wardlaw D, Matheson AB. A new functional brace for the treatment of Colles' fractures. Injury 1995;26(9):587-93. [MEDLINE: 1996142638]
  • Moiz M. A new functional brace for the treatment of Colles' fractures [letter]. Injury 1996;27(10):756.
Nielsen 1981 {published data only}
  • Nielsen K, Lauritzen J. A comparison between Hexcelite and plaster of Paris [abstract]. Acta Orthopaedica Scandinavica 1980;51:362-3.
  • Nielsen K, Lauritzen J. A new thermoplastic casting material. A comparison between plaster of Paris and Hexelite. Acta Orthopaedica Scandinavica 1981;52(1):27-9. [MEDLINE: 1981156271]
O'Connor 2002 {published data only}
  • Mullett H, O'Connor D, Doyle M, Kutty S, Laing A, O'Sullivan M. Plaster cast vs Futura splint: A prospective randomised trial in the treatment of distal radial fractures [abstract]. Journal of Bone and Joint Surgery. British Volume 2002;84 Suppl 1:11.
  • O'Connor D. personal communication November 14 2002.
  • O'Connor D, Mullett H, Doyle M, Mofidi A, Kutty S, O'Sullivan M. Minimally displaced Colles' fractures: A prospective randomized trial of treatment with a wrist splint or a plaster cast. Journal of Hand Surgery. British Volume 2002; Vol. 28, issue 1:50-3.
Rosetzsky 1982 {published data only}
Ross 1984 {published and unpublished data}
  • Ross RE, Gourevitch D, Lawton A. A prospective randomised trial of funcional bracing in Colles' fractures [abstract]. Journal of Bone and Joint Surgery. British Volume 1984;66(5):776-7.
Sarmiento 1980 {published data only}
  • Sarmiento A, Zagorski JB, Sinclair WF. Functional bracing of Colles' fractures: A prospective study of immobilization in supination vs. pronation. Clinical Orthopaedics and Related Research 1980;(146):175-83. [MEDLINE: 1980177637]
  • Zagorski JB. Functional bracing of Colles' fractures - A prospective study of immobilization in supination vs pronation [abstract]. Orthopaedic Transactions 1979;3(1):62.
Sorensen 1986 {published data only}
  • Sorensen JL, Strange KS, Bjerg Nielsen A. Bandaging of Colles' fracture with plaster of Paris. Low dorsal bracing versus high circular plaster of Paris [Gipsbandagering af Colles' frakturer. Lav dorsal skinne kontra hoj cirkulaer gips]. Ugeskrift for Laeger 1986;148(44):2825-7. [MEDLINE: 1987071224]
Stewart 1984 {published data only}
Stoffelen 1998 {published data only}
Tumia 2003 {published data only}
  • Tumia N. personal communication November 12 2002.
  • Tumia N, Wardlaw D, Hallett J, Deutman R, Mattsson SA, Sanden B. Aberdeen Colles fracture brace as a treatment for Colles fracture: A multi-centre, prospective, randomised, controlled trial. Journal of Bone and Joint Surgery. British Volume 2003;85(1):78-82.
  • Tumia NS, Wardlaw D, Hallett JP, Deutman R, Mattsson SA, Sanden B. The Aberdeen Colles-fracture brace: An alternative treatment for Colles fracture: A prospective randomized multicenter study [abstract]. Annual Meeting of the Orthopaedic Trauma Association; 2002 Oct 11-13; Toronto, Ontario. Available at: http://www.hwbf.org/ota/am/ota02/otapa/OTA02066.htm (accessed 01/11/02).
Van der Linden 1981 {published data only}
  • Van der Linden W, Ericson R. Colles' fracture. How should its displacement be measured and how should it be immobilized?. Journal of Bone and Joint Surgery. American Volume 1981;63(8):1285-8. [MEDLINE: 1982030991]
Vang Hansen 1998 {published data only}
  • Vang Hansen F, Staunstrup H, Mikkelsen S. A comparison of 3 and 5 weeks immobilisation for older type 1 and 2 Colles' fractures. Journal of Hand Surgery. British Volume 1998;23(3):400-1. [MEDLINE: 1998328472]
  • Vang Hansen F, Staunstrup H, Mikkelsen S. Three or five weeks immobilisation of Colles' fracture, Older type 1 and 2 [abstract]. Acta Orthopaedica Scandinavica Supplementum 1996;272:15.
Wahlstrom 1982 {published data only}
Wilson 1984 {published data only}
  • Wilson C, Venner RM. Colles' fracture. Immobilisation in pronation or supination?. Journal of the Royal College of Surgeons of Edinburgh 1984;29(2):109-11. [MEDLINE: 1984242572]

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
  23. References to other published versions of this review
Davison 2001 {published data only}
Earnshaw 1999 {published and unpublished data}
  • Earnshaw SA, Surendran S, Aladin A, Moran CG. Closed reduction of Colles' fracture of the wrist: a prospective randomized controlled trial of conventional manual manipulation vs. finger-trap traction [poster 13]. Annual Meeting of the Orthopaedic Trauma Association; 1999 Oct 22-24; Charlotte, North Carolina. http://www.hwbf.org/ota/am/ota99/otapo/OTP99013.htm (accessed 15/12/00).
  • Moran CG. Colles fracture trial - manipulation versus finger traps. National Research Register. Available at: http://www.update-software.com/national/ (accessed 20/02/04).
Harris 2002 {unpublished data only}
  • Harris T. Early mobilisation of Colles fracture (EMSC Trial). National Research Register. Available at: http://www.update-software.com/national/ (accessed 20/02/04).
  • Metcalfe J. personal communication August 5 2002.
Hearne 2003 {unpublished data only}
  • Hearne D. personal comminucation January 9 2004.
  • Hearne D. personal communication January 6 2002.
  • Hearne D. Short and long term effects of early mobilisation of stable fractures of the distal radius. In: The National Research Register, Issue 4, 2002. Oxford: Update Software.
  • Hearne D. To investigate the effects of early mobilisation of stable fractures of the distal radius upon the functional outcome for this type of injury. In: The National Research Register, Issue 4, 2002. Oxford: Update Software.
Kongsholm 1987 {published data only}
  • Kongsholm J, Olerud C. Neurological complications of dynamic reduction of Colles' fractures without anesthesia compared with traditional manipulation after local infiltration anesthesia. Journal of Orthopaedic Trauma 1987;1(1):43-7.
  • Kongsholm J, Olerud C. Reduction of Colles' fractures without anaesthesia using a new dynamic bone alignment system. Injury 1987;18(2):133-6.
Kowalski 2002 {published data only}
  • Kowalski KL, Pitcher JD, Bickley B. Evaluation of fiberglass versus plaster of Paris for immobilization of fractures of the arm and leg. Military Medicine 2002;167(8):657-61.
McGeoy 1986 {published data only}
  • McGeoy B, McMahon JS, Lloyd GJ. Forearm and wrist strength after Colles' fracture [abstract]. Journal of Hand Surgery. American Volume 1986;11(3):449.
Milliez 1992 {published data only}
  • Milliez PY, Dallaserra M, Defives T, el Ayoubi L, Thomine JM. Effect of early mobilization following Kapandji's method of intrafocal wiring in fractures of the distal end of the radius. Results of a prospective study of 60 cases [Influence de la mobilisation precoce apres embrochage intra-focal selon Kapandji dans les fractures de l'extremite inferieure du radius. Resultats d'une etude prospective sur 60 cas.]. International Orthopaedics 1992;16(1):39-43. [MEDLINE: 1992242042]
Moran 2002 {unpublished data only}
  • Moran CG. personal communication August 8 2002.
  • Moran CG. A prospective randomised controlled trial of pre-formed plastic brace immobilisation compared to conventional colles' cast for distal radial (Colles') fracture. In: The National Research Register, Issue 3, 2002. Oxford: Update Software.
Pool 1973 {published data only}
  • Pool C. Colles's fracture. A prospective study of treatment. Journal of Bone and Joint Surgery. British Volume 1973;55(3):540-4.
Shah 2002 {published data only}
  • Shah NH, Anderson AJ, Patel AD, Donell ST. Undisplaced distal radial fractures: do they require plaster? [abstract]. Journal of Bone and Joint Surgery. British Volume 2004;86 Suppl 3:339.
  • Shah NH, Anderson AJ, Patel AD, Donell ST. Undisplaced distal radial fractures: do they require plaster? [poster abstract G61]. Poster abstracts. Annual Congress of the British Orthopaedic Association; 2002 Sept 18-20; Cardiff (UK). London: British Orthopaedic Association, 2002:26.
Shah 2003 {published and unpublished data}
  • Shah G. personal communication January 12 2004.
  • Shah G, Lindsay JRL. Clinical outcome of distal radial fractures: soft cast vs plaster of Paris [abstract]. British Trauma Society Annual Scientific Meeting; 2003 Oct 1-3; London. 2003.
Shanker 2000 {unpublished data only}
  • Shanker UR. personal communication September 10 2002.
  • Shanker UR. Comparative study of conservative management versus primary manipulation of minimally displaced Colles' fractures in adults. In: The National Research Register, Issue 3, 2000. Oxford: Update Software.
Singhania 2001 {unpublished data only}
  • Singhania AK. Early mobilisation of wrist fractures. In: The National Research Register, Issue 4, 2000. Oxford: Update Software.
Smith 1999 {published and unpublished data}
  • Jones S, Smith I, Jones MW. Treatment of distal radius buckle fractures [abstract]. British Orthopaedic Congress 2001. Poster Abstracts 14.
  • Smith I. The management of torus fractures of distal radius. National Research Register. Available at: http://www.update-software.com/national/ (accessed 20/02/04).

References to studies awaiting assessment

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
  23. References to other published versions of this review
Liebman 2004 {published data only}
  • Liebman M, Egol KA, Koval KJ. Splint after wrist fracture: a prospective randomized study of patient comfort and efficacy [abstract]. 71st Annual Meeting of the American Academy of Orthopaedic Surgeons; 2004 March 10-14; San Francisco,CA. Available at: http://www.aaos.org/wordhtml/anmt2004/sciprog/196.htm (accessed 17/02/05).
Sahin 2005 {published data only}
  • Sahin M, Tasbas BA, Daglar B, Bayrakci K, Savas MS, Gunel U. The effect of long- or short-arm casting on the stability of reduction and bone mineral density in conservative treatment of Colles' fractures [Colles kiriklarinin konservatif tedavisinde kisa veya uzun kol alcilamanin kemik mineral yogunlugu ve reduksiyon uzerine etkisi]. Acta Orthopaedica et Traumatologica Turcica 2005;39(1):30-4.

Additional references

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
  23. References to other published versions of this review
Altissimi 1984
  • Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the distal radius. Clinical Orthopaedics and Related Research 1984;206:202-10.
Atkins 1989
Begg 1996
  • Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I, et al. Improving the quality of reporting of randomized controlled trials - The CONSORT statement. Journal of the American Medical Association 1996;276(8):637-9.
Belsole 1993
Chitnavis 1999
  • Chitnavis J. The wrist. In: Pynsent PB, Fairbank JCT, Carr AJ editor(s). Classification of musculoskeletal trauma. Oxford: Butterworth Heinemann, 1999:146-70.
Cooney 1980
Cummings 1985
Fernandez 1996
  • Fernandez DL, Jupiter JB. Fractures of the distal radius. A practical approach to management. New York: Springer-Verlag, 1996.
Gartland 1951
  • Gartland JJ, Werley CW. Evaluation of healed Colles' fractures. Journal of Bone and Joint Surgery. American Volume 1951;33(4):895-910.
Handoll 2003a
  • Handoll HHG, Madhok R. From evidence to best practice in the management of fractures of the distal radius in adults: working towards a research agenda. BMC Musculoskeletal Disorders 2003; Vol. 4, issue 27:http://www.biomedcentral.com/1471-2474/4/27.
Handoll 2005a
  • Handoll HHG, Madhok R. Surgical interventions for treating distal radial fractures in adults (Cochrane review). Cochrane Database of Systematic Reviews 2005, Issue 3.
Handoll 2005b
Handoll 2005c
Handoll 2005d
  • Handoll HHG, Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults (Cochrane review). Cochrane Database of Systematic Reviews 2004, Issue 3.
Higgins 2005
  • Higgins JPT, Green S, editors. Highly sensitive search strategies for identifying reports of randomized controlled trials in MEDLINE. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005]; Appendix 5b. In: The Cochrane Library, Issue 3, 2005. Chichester, UK: John Wiley & Sons, Ltd.
Jupiter 1997
Knirk 1986
  • Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. Journal of Bone and Joint Surgery. American Volume 1986;68(5):647-59.
MacDermid 2000
  • MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH. Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture. Journal of Hand Surgery. American Volume 2000;25(2):330-40.
Moher 2001
  • Moher D, Schulz KF, Altman DG, for the CONSORT group. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001;357:1191-4.
Moiz 1996
O'Neill 2001
Petty 1998
  • Petty AC, Wardman C. A randomized, controlled comparison of adjustable focused rigidity primary casting technique with standard plaster of Paris / synthetic casting technique in the management of fractures and other injuries. Journal of Orthopaedic Nursing 1998;2:95-102.
Stewart 1985
Taleisnik 1984

References to other published versions of this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Notes
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
  23. References to other published versions of this review
Handoll 1999
  • Handoll HHG, Madhok R. Conservative treatment of distal radial fractures in adults (Cochrane Review). Cochrane Database of Systematic Reviews 1999, Issue 2.
Handoll 2001
Handoll 2002d
  • Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults (Cochrane Review). Cochrane Database of Systematic Reviews 2002, Issue 3. [Art. No.: CD000314. DOI: 10.1002/14651858.CD000314]
Handoll 2003
  • Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults (Cochrane Review). Cochrane Database of Systematic Reviews 2003, Issue 2. [Art. No.: CD000314. DOI: 10.1002/14651858.CD000314]