Intervention Review

Anaesthesia for treating distal radial fracture in adults

  1. Helen HG Handoll1,*,
  2. Rajan Madhok2,
  3. Chris Dodds3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 22 JUL 2002

Assessed as up-to-date: 5 JAN 2004

DOI: 10.1002/14651858.CD003320

How to Cite

Handoll HHG, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003320. DOI: 10.1002/14651858.CD003320.

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

  3. 3

    James Cook University Hospital, Sleep Disorders Clinic, Middlesbrough, 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 JUL 2002

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment.

Objectives

To examine and summarise the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966 to November week 2 2003), EMBASE (1988 to 2003 week 49), CINAHL (1982 to December week 1 2003), the UK National Research Register (Issue 4, 2003), Current Controlled Trials (October 2003) and reference lists of articles. We also handsearched conference abstracts from various orthopaedic meetings.

Selection criteria

Randomised or quasi-randomised clinical trials evaluating relevant interventions for these injuries (see Objectives). We excluded pharmacological trials comparing drug dosages and, with one exception, different drugs in the same class. Also excluded were trials reporting only pharmacokinetic and/or physiological outcomes.

Data collection and analysis

All trials meeting the selection criteria were independently assessed by the three reviewers for methodological quality. Data were extracted independently by two reviewers. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. Only very limited pooling of results from comparable trials was possible.

Main results

The 18 included studies involved at least 1200, mainly female and older, patients with fractures of the distal radius. All studies had serious methodological limitations, notably in the frequent failure to assess clinically important and longer-term outcomes.

Five trials provided evidence that, when compared with haematoma block, IVRA provided better analgesia during fracture manipulation and enabled better and easier reduction of the fracture, with some indication of a reduced risk of later redislocation or need for re-reduction. In contrast, haematoma block was quicker and easier to perform and less resource intensive.

There was inadequate evidence of the relative effectiveness of different methods of anaesthesia from the following comparisons, all examined within single trials only: nerve block versus haematoma block; intravenous sedation versus haematoma block; general anaesthesia versus haematoma block; general anaesthesia versus sedation; and general anaesthesia versus haematoma block and sedation.

None of the three trials evaluating three different physical aspects of anaesthesia (injection site of, or extra tourniquet, for IVRA; and technique for brachial plexus block) provided conclusive evidence for the effectiveness and safety of the novel technique.

Six trials examined the use of drug adjuncts. The addition of two different muscle relaxants and one analgesic was tested for IVRA; one sedative and hyaluronidase for haematoma block; and clonidine for brachial plexus block. All trials evaluating adjuncts failed to provide evidence on eventual clinical outcome.

A seriously flawed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of treatment by different doctors on patient outcome.

Authors' conclusions

There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction.

Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Anaesthesia for treating distal radial fracture in adults

Wrist fractures (breaks) are very common, especially in women with osteoporosis. Bone fragments may need to be put back into place. Anaesthesia is used to prevent pain during treatment and several methods are in common use. General anaesthesia involves a loss of consciousness. Regional anaesthesia involves an injection (either into a vein or into tissue surrounding nerves) to numb the injured arm. Local anaesthesia is an injection directly into the fracture site. Sedation usually involves a drug to allay anxiety and promote sleepiness. The review found there was not enough evidence from randomised trials to decide which is the best method.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

治療成年人遠端橈骨骨折病患的麻醉法

遠端橈骨骨折是臨床上非常常見的診斷,特別是患有骨質酥鬆的年長白人女性。 在徒手復位移位骨折或是在手術治療時通常都會使用麻醉。

目標

檢視並總結麻醉主要使用方式(局部血腫阻斷法、靜脈局部麻醉、局部神經阻斷法、鎮靜及全身麻醉法等)的相關療效,以及相關的治療技巧。

搜尋策略

我們搜尋了the Cochrane Musculoskeletal Injuries Group specialised register (2003年11月)、the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003年)、 MEDLINE (1966年 −2003年11月第2周),EMBASE (1988年 2003年第49周)、CINAHL (1982年2003年12月第1周)、the UK National Research Register (Issue 4, 2003年)、Current Controlled Trials (2003年10月)以及文章的參考文獻清單。 我們也從各個骨科研討會當中,以人工搜尋了研討會摘要。

選擇標準

本篇研究納入了隨機及半隨機臨床試驗來評估治療這些損傷的相關性的方法(參閱目標)。我們排除了比較藥物劑量的藥物性試驗,但有一個例外,即是使用在同一個種類中的不同藥物。 我們同樣也排除了僅顯示藥物動力學結果和/或生理學上結果的試驗。

資料收集與分析

所有符合選擇標準的試驗都被三位文獻回顧文獻回顧者獨立地檢視其試驗品質。試驗數據也由兩位文獻回顧者獨立地擷取。 我們將定量數據以使用相對風險或平均數差異一併及95%的信賴限度來呈現。 僅有非常有限的結果可從比較性試驗中被收集到。

主要結論

這18個所納入的研究包含了至少1200位主要為女性及老年人患有遠側橈骨骨折的病患。 所有的研究皆有嚴重的試驗方法缺陷,經常出現在為了要檢視臨床中重要及長期結果中的失敗。 五個試驗顯示了當與使用血腫阻斷法作比較時,靜脈局部麻醉法在骨折復位時提供了較佳的止痛效果,且使骨折的復位較好而且較容易,而未來骨頭再次脫位或需要重新復位的風險也會較低。 相反的,血腫阻斷法比較快且比較容易執行,加上較易取得。 但從以下的比較中尚不足以證明不同麻醉法之間的相對療效,每一種皆以一個試驗來檢驗:神經阻斷劑 vs. 血腫阻斷;靜脈鎮靜劑 vs. 血腫阻斷;全身麻醉vs. 血腫阻斷;全身麻醉vs.鎮靜;及全身麻醉vs.血腫阻斷加上鎮靜。 三個試驗中沒有一個是評估三種不同麻醉法的技術層面(注射部位或靜脈局部麻醉中額外的止血帶;及臂神經叢的阻斷技巧)所帶來關於新技巧的療效及安全性的特殊結果。 額外的兩個不同的肌肉鬆弛劑和一個止痛劑被拿來測試靜脈局部麻醉法;一個鎮靜劑和一個 hyaluronidase被來測試血腫阻斷法;及 clonidine被用來測試臂神經叢阻斷。 所有評估附屬物的試驗都無法從最後的臨床結果提供有力證據。 一個有嚴重缺點的研究比較了在靜脈局部麻醉法中使用 bupivacaine與prilocaine給了我們一些關於不同醫生治療病患時所產生的潛在混淆效果的提示。

作者結論

隨機試驗中證據尚不足來證明治療遠端橈骨骨折時所使用的不同麻醉方式、不同的技巧或治療中的藥物附加物的使用所帶來的相關療效。 然而,有些跡象顯示血腫阻斷法比起靜脈局部麻醉法其止痛效果較差,且復位較差。 對於治療這些骨折有這麼多的問題尚未解決,我們建議一個更完整的研究,包括未來針對麻醉方法選擇的考量。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

隨機試驗中證據尚不足以決定治療手腕骨折時何種麻醉法最佳。 腕關節骨折非常地常見,特別是患有骨質酥鬆的女性。 骨頭碎片可能需要被復位。 麻醉法用於治療時避免疼痛的產生且有幾種方法非常常見。 全身麻醉時患者會失去意識。 區域麻醉時會注射麻醉劑(注射進靜脈或周邊組織的神經)使患肢麻痺。 局部麻醉時會將麻醉劑直接注入骨折處。 鎮靜通常包括了解除焦慮及促進睡眠的藥物。 本篇研究認為從隨機試驗中並無法發現足夠的證據證明何種麻醉法最佳。