Fracture of the distal radius is one of the most common fractures in many predominantly white and older populations (Sahlin 1990; Singer 1998). It has been estimated that a 50 year old white woman in USA or Northern Europe has a 15% lifetime risk of a distal radius fracture; whereas a white man of the same age has a lifetime risk of a little over 2% (Cummings 1985). A more recent prospective survey, conducted in six centres in the UK, of Colles' fracture in patients aged 35 years and above, reported the overall annual incidence of this fracture to be 9/10,000 in men and 37/10,000 in women (O'Neill 2001). Distal radial fractures are usually treated on an outpatient basis, with around 20% of patients (mainly older people) requiring hospital admission (Cummings 1985; O'Neill 2001).
Most fractures of the distal radius in older people result from low-energy trauma, such as a fall from standing height or less. In younger adults, these injuries are usually sustained through high-energy trauma such as a traffic accident. The pattern of incidence reflects bone loss from osteoporosis in older people as well as an increased number of falls by older women (Nguyen 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 majority of distal radial fractures are treated conservatively (non-operatively). This usually involves reduction under anaesthesia of the fracture if displaced, and forearm immobilisation in a plaster cast or brace for around six weeks. Questions over the use and timing of fracture reduction and of conservative methods used to stabilise the reduced fracture are covered in a separate Cochrane review (Handoll 2003a). A Cochrane review evaluating the main methods of anaesthesia, and associated physical techniques, used during reduction and surgical treatment is also available (Handoll 2002). Another Cochrane review examines surgical treatment, which usually involves reduction followed by either external or internal fixation, and a similar period of immobilisation (Handoll 2003b).
Reduction is defined as "the restoration of a displaced part of the body to its normal position by manipulation or operation" (Dictionary 1994). Here we focus on conservative methods - closed reduction - used to restore the anatomy of the distal radius through the repositioning of displaced bone fragments. These procedures are distinct from methods, such as plaster cast immobilisation or external fixation, used to stabilise the reduced fracture: such methods are reviewed elsewhere (Handoll 2003a; Handoll 2003b). However, methods, such as maintaining traction, of retaining the reduced position before the implementation of interventions aimed at fracture stabilisation are included in this review.
In closed reduction, often termed manipulation, the displaced fragment(s) are repositioned using various manoeuvres while the arm is under traction. The classic method of closed reduction for Colles' fractures, described by Charnley (Charnley 1999), requires two people pulling in opposite directions to produce and maintain longitudinal traction. This is termed manual reduction. Mechanical methods of reduction usually include the use of 'finger-traps', introduced by Caldwell (Caldwell 1931). In finger-trap traction the injured arm is suspended using finger traps attached to two or more fingers, and a counterweight suspended over the upper arm (Fernandez 1999). This dispenses with the need for assistants.
Movement of bone fragments resulting in loss, which may be total, of the reduced position is commonplace after closed reduction. This usually occurs within the first 10 to 14 days after initial reduction but can continue until the fracture heals at around six to eight weeks. Thus, while the evaluation of treatment interventions in this review will include the initial anatomical restoration achieved by the methods under comparison, the emphasis will be on final outcome in terms of residual deformity, functional and clinical outcome, and presence of complications. 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 the most common complication (Belsole 1993). The presence of these complications, especially median nerve compression, is often an indication for reduction.
Anatomical measurement to assess initial displacement, restoration of anatomy, loss of reduced position and final radiological deformity, is key to this review. Generally, the criteria used to determine whether displacement is sufficient to warrant reduction are based on anatomical parameters measured from X-ray films. However, a study of X-ray film measurements for healed distal radius fractures has revealed quite large margins of error ("tolerance limits") for both inter-observer and intra-observer readings (Kreder 1996). The implications of these findings are considered in our discussion of the findings of this review.
This review aims to identify and assess the evidence from randomised and quasi-randomised controlled trials of the relative effectiveness of methods used for closed reduction of distal radial fractures in adults. Where possible, we intended to make a distinction between subsequent conservative and surgical management of the fracture, and between the treatment of initial as compared with redisplaced or secondarily-displaced fractures.
Criteria for considering studies for this review
Types of studies
We considered any randomised or quasi-randomised (use of a method of allocating participants to a treatment that is not strictly random; e.g. by date of birth, hospital record number, alternation) controlled clinical trials of reduction methods used for treating distal radial fractures.
Types of participants
Skeletally mature adults with a displaced and closed fracture of the distal radius considered suitable for reduction.
The characteristics of the participants included in the trials were noted, with an emphasis on type of fracture, concomitant soft-tissue injury, age, gender and functional demands.
Types of interventions
All randomised controlled trials comparing different conservative methods of reduction for displaced distal radial fractures. We originally planned to include only trials that solely compared different methods of reduction for fractures of the distal radius. Thus we intended to exclude trials where co-interventions (such as the method of anaesthesia) or subsequent interventions (such as the method of immobilisation) up to the time of last follow up differed between the intervention groups. However, we subsequently made an exception of trials where the use or not of anaesthesia was tested concurrently with different methods of reduction. Where reported, clinician experience and speciality were noted.
Types of outcome measures
(1) Failed or inadequate reduction. This is based on at least one of the following: i) explicit reports of inadequacy or failure, ii) the need for remanipulation or change of planned treatment (e.g. recourse to surgery) or iii) secondary or re-displacement in excess of pre-specified threshold values. The non-resolution of injury related complications, specifically median nerve compression, was also considered in this outcome category.
(2) Anatomical outcome. This is based on individual radiological parameters such as radial length or shortening and shift, dorsal angulation, radial inclination or angle, ulnar variance, as well as composite measures including malunion and total radiological deformity. Definitions of four of the most commonly reported radiological parameters are presented in Table 1. Other radiological parameters, such as those associated with the displacement of articular fragments, would also have been considered (Kreder 1996).
(3) Clinical outcome. This includes 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) Functional outcome and impairment. Patient-rated 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). Other measures include return to previous occupation, including work, and activities of daily living; grip strength; pain; and range of movement (wrist, forearm and shoulder mobility). Range of movement for the wrist is described in terms of six parameters: flexion (ability to bend the wrist downwards) and extension (or upwards); radial deviation (ability to bend the wrist sideways on the thumb side) and ulnar deviation (on the little finger side); and pronation (ability to turn the forearm so that the palm faces downwards) and supination (palm faces upwards).
(5) Resource use. Hospital admission, use of assistants, anaesthetist involvement and other costs.
Search methods for identification of studies
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2007, Issue 2) (see Appendix 1), MEDLINE (1966 to June week 1 2007), EMBASE (1988 to 2007 week 24) and CINAHL (1982 to June week 2 2007). No language restrictions were applied.
Similar search strategies were used for EMBASE (OVID-WEB) and CINAHL (OVID-WEB) (see Appendix 3).
We also searched Current Controlled Trials at www.controlled-trials.com (accessed June 2007) and the UK National Research Register at www.update-software.com/national/ (up to Issue 2, 2007) for ongoing and recently completed trials.
Searching other resources
We searched reference lists of articles. We also included the findings from handsearches of 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 2006: www.assh.org/), the American Orthopaedic Trauma Association annual meetings (1996 to 2006: www.ota.org/education/archives.html) and American Academy of Orthopaedic Surgeons annual meeting (2004 to 2007: www.aaos.org/wordhtml/libscip.htm). We also included handsearch results from the final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003), EFFORT (2007) and the British Orthopaedic Association Congress (2000, 2001, 2002, 2003, 2005, 2006), and various issues of Orthopaedic Transactions and of Acta Orthopaedica Scandinavica Supplementum.
We also scrutinised weekly downloads of "Fracture" articles in new issues of 15 journals (Acta Orthop Scand; Am J Orthop; Arch Orthop Trauma Surg; Clin J Sport Med; Clin Orthop; Foot Ankle Int; Injury; 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 (www.amedeo.com).
Data collection and analysis
Both authors assessed potentially eligible trials for inclusion and disagreement was resolved through discussion. Titles of journals, names of authors or supporting institutions were not masked at any stage. The methodological quality of included studies was assessed independently by both authors and disagreement resolved through discussion. Data were extracted by one author (HH) and checked by the other author (RM).
Where possible and required, requests were sent to trialists for additional details of key items of trial methodology or data.
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. From the second update (Issue 4, 2005) of the review, the scores of the individual items were no longer summed. From the third update (Issue 4, 2007) instead of scores, each item was graded based on whether the quality criterion was met: 'Y' (met), '?' (possibly or only partially met) or 'N' (not met). The rating scheme covering 12 aspects of trial validity, plus brief notes of coding guidelines for some items, is shown in Table 2.
Where available and appropriate, quantitative data for outcomes were presented graphically. Relative risks and 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals calculated for continuous outcomes. No pooling was done in this review. Should this be possible in the future, results of comparable groups of trials will be pooled using the fixed-effect model and 95% confidence limits. Heterogeneity between comparable trials will be tested using a standard chi-squared test and considered statistically significant at P < 0.1. Note will also be taken of the I² statistic (Higgins 2003). Where there is significant heterogeneity, we will view the results of the random-effects model and present these when appropriate.
Sensitivity and subgroup analyses
Where appropriate, we planned sensitivity analyses investigating the effects of allocation concealment, assessor blinding and loss to follow up. Where data allowed, we also planned separate analyses of the outcome of subsequent scheduled conservative and operative treatment of the fracture, of initial and secondary treatment, of males and females, of different age groups (younger adults, older adults), of types of fracture (extra-articular and intra-articular fractures), and of complications evident at time of reduction. Tests of interaction would then be calculated to determine if the results for subgroups are significantly different (Altman 2003).
For this review, only limited sensitivity analyses to examine the potential effect of intention-to-treat analyses were performed; these are not presented in the Analyses.
Description of studies
No new studies were identified from the extension of the search from June 2005 to June 2007.
Three out of four eligible studies were included. Strictly, only one trial (Earnshaw 2002) met the original criteria of the review in that it solely compared two different methods of closed reduction. In the other three eligible trials, the new method of closed reduction was used without anaesthesia whereas the control group received anaesthesia during a standard method of closed reduction. As the provision of anaesthesia is a co-intervention it would have resulted in the exclusion of these trials. However, we consider the underlying question is valid and extended the scope of the review accordingly. Various reasons, including a lack of discrete outcome data, prompted us to exclude one trial (Kongsholm 1981) that was only available as a conference abstract (see 'Characteristics of excluded studies' table).
The three included studies were fully reported in medical journals. The trials were initially identified via MEDLINE (Johansson 1992; Kongsholm 1987) and the National Research Register (UK) (Earnshaw 2002). An English translation was obtained for Johansson 1992, which was reported in Swedish.
Earnshaw 2002 took place in one centre in the UK, whereas the other two trials were based in Sweden. The three studies involved a total of 404 participants with fractures of the distal radius. Participants were mainly female; the proportion ranged from 77% (Earnshaw 2002) to 91% (Kongsholm 1987). The mean ages of the trial populations were in the early to mid sixties. Both the youngest (15 years) and the oldest (94 years) participants appeared in Earnshaw 2002.
Fracture type was generally broadly defined as acute Colles' fracture. Only Earnshaw 2002 gave radiological criteria for fracture displacement meriting reduction. In all three trials, fractures were categorised according to Frykman's fracture classification scheme and both extra-articular and intra-articular fractures were included.
Plaster casts were applied after reduction in all three trials.
Further details of the individual studies are provided in the 'Characteristics of included studies' table.
The following is a brief description of the reduction methods and use of anaesthesia in the three included trials.
Earnshaw 2002 compared mechanical traction using finger traps with manual reduction in 250 people with 253 fractures. All participants were given intravenous regional anaesthesia (IVRA).
Johansson 1992 compared two methods of manual reduction in 38 people. In a novel method of reduction, participants, who lay on their stomachs, actively provided counter-traction; no anaesthesia was provided for this group. IVRA was provided for the other group of participants, who lay on their backs and were passive recipients of a more traditional method of manual reduction.
Kongsholm 1987 compared mechanical reduction involving a special device with manual reduction in 116 people. No anaesthesia was provided to trial participants undergoing mechanical traction. Haematoma block was provided for participants undergoing manual traction.
Risk of bias in included studies
Based on information provided in their trial reports, all three trials had methodological flaws. The results of the quality assessment for the individual trials are shown in Table 3 (see Table 2 for details of the quality assessment scheme). Information specific to the first three items of the quality assessment is given in the methods sections of the 'Characteristics of included studies' table. A summary of the results for individual items of quality assessment is given below.
Concealment of treatment allocation at randomisation (item 1) was not confirmed in any of the trials. Some details of the method of randomisation were only provided in Earnshaw 2002, where sealed envelopes were used.
Intention-to-treat analysis (item 2) was considered very likely in Johansson 1992 and Kongsholm 1987; no participants were lost to follow up in either trial. Earnshaw 2002 did not score for this item due to the unexplained loss of 27 participants from the trial between reporting it at a conference and at journal publication.
Aside from blinded assessment of radiographs in Earnshaw 2002, there was no report of blinding of assessors (item 3), participants (item 5) or care providers (item 6).
Only Kongsholm 1987 provided sufficient information to indicate comparability between the treatment groups in key baseline characteristics such as gender, age, fracture type and displacement, and time since injury (item 4).
Comparability of care programmes (item 7), comprising interventions other than the trial interventions, was considered likely in Kongsholm 1987. (In this trial and Johansson 1992, the different provision of anaesthesia to the two intervention groups is treated as a co-intervention rather than a confounder.) The criteria for judging comparability depended, to some extent, on the outcomes reported. For instance, both Earnshaw 2002 and Johansson 1992 failed to provide confirmation of pre-specified criteria for changes in management (surgical treatment; re-reduction).
Only Earnshaw 2002 provided sufficient details of trial inclusion and exclusion criteria to define the study population (item 8). This included giving the threshold radiological criteria for determining the need for reduction.
Good descriptions of the trial interventions were provided (item 9). This included details on the use of assistants and of the participation of the patient in the reduction process.
The definition (item 10) of outcome measurement was clear enough to give a good idea of what was recorded in Earnshaw 2002 and Kongsholm 1987. However, no trial was rated as having good quality outcome measurement (item 11). This is despite there being some indication of an active and systematic approach.
Effects of interventions
Given the differences in the comparisons evaluated by the three included trials, each trial is reviewed separately. The outcomes reported by each trial are listed in the 'Characteristics of included studies' table. Where available and appropriate, data for these outcomes are presented graphically.
Mechanical reduction using finger trap traction versus manual reduction (Comparison 01)
In the full report of Earnshaw 2002, results were available for 223 participants with 225 fractures. This differs from the 250 participants with 253 fractures reported at a conference (Earnshaw 1999). In addition, there were some discrepancies between text and graphs, as well as percentages that sometimes did not add up. Earnshaw et al did not provide any indication of the criteria for resorting to surgical treatment or indicate how many of the 56 fractures operated on by five weeks were in each group, or whether re-reduction was ever undertaken. In the absence of clarification from the lead trialist, we have noted the general consistency in the results of the two trial reports and used the data from the full report. Interpretation of Earnshaw 2002 is also hampered by some ambiguity in the description of outcome; in the following we have taken the results for acceptable anatomical position at five weeks to apply to those participants who had an acceptable position throughout: from reduction up to five weeks.
Earnshaw et al defined an acceptable radiological position as one with less than 10 degrees of dorsal angulation and less than five millimetres of radial shortening. These were the same criteria used to exclude 'undisplaced' fractures from their trial. Based on these criteria, 15 fractures in each group had an unacceptable position after reduction (see Analysis 01.01: relative risk (RR) 1.01, 95% confidence interval (CI) 0.52 to 1.96). There was no indication on whether a further reduction or surgery was offered or provided for the 30 fractures that would still be considered displaced according to the trial inclusion criteria. Dorsal angulation, radial shortening and radial angulation were reported not to differ (reported P > 0.05) between the two groups either at presentation or following reduction; visual inspection of the graphs in the 2002 trial report supports this claim. There was also no difference between the two groups in the difficulty of the reduction as rated by the performing surgeon using a visual analogue scale (see Analysis 01.02). By five weeks, under 30% of the trial population had fractures that had been reduced to and had remained in an acceptable anatomical position; the numbers of fractures with an acceptable position were similar in the two groups (see Analysis 01.03: 30/112 versus 36/113; RR 0.84, 95% CI 0.56 to 1.26). It is not clear from Earnshaw 2002, how many of the other 70% of fractures, approximately a third of which were treated surgically, had an acceptable anatomical position at five weeks.
No other outcomes were reported in Earnshaw 2002.
Manual reduction with counter-traction provided by patient versus manual reduction under anaesthesia with counter-traction provided by an assistant (Comparison 02)
Johansson 1992 compared a new method of manual reduction without anaesthesia with a more usual method using intravenous regional anaesthesia (IVRA) in 38 people. Means and standard deviations for dorsal angulation and radial shortening were calculated from the individual patient data presented in the trial report. These showed that there was no significant difference between the two groups in the radiological outcome achieved through reduction (see Analysis 02.01). No improvement was evident for one participant of the new reduction method group (see Analysis 02.02). Without anaesthesia, the new method was more painful than the usual method where IVRA was employed (mean values on a 0 (no pain) to 10 (maximum pain) scale: 5.2 versus 3.4; reported P < 0.05). However, though more people undergoing the new reduction process endured increased pain during reduction (see Analysis 02.03) and significantly more participants of this group endured increased or unchanged pain during reduction (see Analysis 02.04: 18/19 versus 11/19; RR 1.64, 95% CI 1.10 to 2.44), no participant interrupted the reduction process because of intolerable pain. It is noteworthy that after IVRA, 11 participants considered their pain was either unchanged or worse; there was no significant difference between the mean pain scores for this group before reduction and after anaesthesia (3.8 versus 3.1). By 10 days, similar numbers of fractures had redisplaced in the two groups (see Analysis 02.05: 4/19 versus 6/19; RR 0.67, 95% CI 0.22 to 1.99).
Mechanical reduction using finger traps and a dynamic device versus manual reduction under anaesthesia (Comparison 03)
Kongsholm 1987 compared mechanical reduction involving a special device versus manual reduction with haematoma block in 116 people. Patients using the dynamic device were asked to rotate (pronate and supinate) their forearm; those in the manual traction group were passive recipients of care. There was no important difference between the two groups in post-reduction radiological outcome (see Analysis 03.01); as Kongsholm et al point out, the statistically significant difference in volar angle (mean difference -1.7º, 95% CI -3.17º to -0.23º) would not generally be considered clinically significant. Statistically significantly fewer mechanical traction group patients experienced severe pain during the reduction procedure (see Analysis 03.02: 5/62 versus 19/54; RR 0.23, 95% CI 0.09 to 0.57). No participant sustained an acute nerve injury. At five weeks significantly fewer participants of the mechanical traction group had signs and symptoms of, mostly mild, neurological impairment (see Analysis 03.03: 2/62 versus 11/54; RR 0.16, 95% CI 0.04 to 0.68). The fractures of three patients with neurological impairment in the manual reduction group had undergone re-reduction, but the overall data for re-reduction in Kongsholm 1987 were not available. The difference in neurological impairment was no longer statistically significant by one year (see Analysis 03.03: RR 0.44, 95% CI 0.14 to 1.37).
Closed reduction is the key preliminary procedure of the definitive treatment for most displaced fractures of the distal radius. However, it cannot be divorced from the subsequent procedures aimed at stabilisation of the reduced position. This dependency has important implications in terms of conducting and interpreting comparisons of different methods of closed reduction. While differences, or absence of differences, in immediate outcomes (mainly, radiological measurements, resolution of injury-related or appearance of new complications, and pain) may be valid, the interpretation of longer-term outcome is problematic. Ensuring comparability of post-reduction care programmes, including the method of stabilisation, should go some way to address the issue of confounding. (The latter is where factors other than the interventions under investigation influence outcome.) Yet, even if care programme comparability is achieved, questions remain over the long-term impact of any differences in effectiveness of two methods of reduction. Such differences could be dwarfed by the effects of inadequate fracture stabilisation (resulting in the loss of the reduced position) and of complications associated with wrist immobilisation. The issue of anaesthesia adds to the complexity: the method chosen may also influence the success of the reduction and long term outcome. Again, the method of anaesthesia should be the same for both intervention groups, though an exception has been made for this review where the use or not of anaesthesia has been defined as a co-intervention.
The inherent difficulties in performing these comparisons and interpreting their results are further compounded by questions regarding the accuracy of radiological measurements. An associated issue concerns the relationship of radiological deformity with long term functional and clinical outcome. As explained in Kreder et al (Kreder 1996), there are many potential sources of errors in radiological measurement. For instance, variation in limb positioning has been demonstrated to affect the assessment of ulnar variance (the relative positioning of the distal ends of the ulnar and radius) (Palmer 1982; Yeh 2001) as well as radial and dorsal angulation (Johnson 1992). In their study of X-ray film measurements for healed distal radius fractures, which revealed quite large margins of error ("tolerance limits") for both inter-observer and intra-observer readings, Kreder et al suggested their findings represented "a conservative estimate of the variation that might be expected in clinical practice" (Kreder 1996). This has implications for the application of threshold criteria of fracture displacement for performing reduction, for measuring the success of the reduction procedure, for measuring any subsequent loss in position and radiological deformity after fracture healing. Additionally, there are implications for determining the clinical and functional significance of residual anatomical displacement and interpreting differences found in comparisons of treatment interventions for these fractures. The goal of reduction is restoration of anatomy and we anticipate that any reduction method that has become established will achieve this to a sufficient extent for commonly recorded parameters, such as dorsal angulation and radial shortening, so that any difference between methods in these outcomes will not be sufficiently large to exceed the variation in measurement resulting from other causes.
Despite the above considerations, we consider the question asked in this review - which is the best method of closed reduction for fractures of the distal radius? - is still relevant for the reasons given below.
- Closed reduction is indisputably a key procedure in the treatment of these fractures.
- Many methods of closed reduction exist and there is variation in practice. For example, Earnshaw 2002 considered that manipulation under manual traction was common practice in the UK, whereas mechanical traction using finger traps was common in the USA.
- The method of reduction may avoid or affect the need for anaesthesia; it may also influence the method of anaesthesia chosen. (Two of the included trials (Johansson 1992; Kongsholm 1987) specifically tested the use of anaesthesia.) As pointed out in Lidstrom 1959, reduction was done without anaesthesia in the past. Nowadays, anaesthesia is usually provided with the aim of not only alleviating pain during the procedure but also enabling better muscle relaxation to facilitate reduction.
- The method of reduction may affect the choice of method for fracture stabilisation. For instance, it may restrict the options for arm positioning: Earnshaw 2002 reported that it was difficult to achieve ulnar deviation and flexion while moulding of the plaster during finger-trap traction. There is insufficient evidence from randomised trials to determine whether this limitation is clinically important (Handoll 2003a).
- Different methods have different resource impacts, notably with respect to health worker involvement. Traditional methods of manual reduction require two people to provide manual traction, whereas an extra person is not required for mechanical traction. However, the application and use of mechanical devices take up resources too. In one of the included trials (Johansson 1992), the patient rather than another clinician took on the role of providing counter-traction.
- Finally, despite the difficulties in measurement and performing trials, different methods may still yield better results and be less risky, in terms of complications.
Turning now to the evidence available from randomised trials. We identified just one trial (Earnshaw 2002), with 250 participants, comparing two methods of closed reduction only. This found no statistically significant differences between mechanical reduction using finger trap traction and manual reduction in anatomical outcomes or in the surgeon's perception of the ease of reduction (see 'Results'). However, these findings need to be set into the context of the problems associated with radiological measurement, the lack of functional outcomes (promised in a future investigation) or any account of complications, the short-term follow up (just five weeks), and an absence of clarification of various aspects of methodology (including criteria for subsequent surgery) and trial results (for intention-to-treat analysis). In essence then, this trial provides little evidence for examining the relative effectiveness of these two commonly used methods of reduction. As pointed out in a commentary on the article, one finding of the trial was the high rate of fracture redisplacement associated with both methods when in combination with plaster cast immobilisation (Seiler 2002); but, again, the ultimate functional consequences of this were not revealed.
The paucity of randomised evidence evaluating methods of closed reduction may reflect that some consider "closed reduction in any form is a poor method of treatment if the goal is improvement of fracture alignment" (Amadio 2002). However, for the reasons given above, we are convinced that the question of what method is best is relevant and should be addressed through randomised controlled trials.
The two other smaller trials (Johansson 1992; Kongsholm 1987) included in this review tested whether a new method of closed reduction could also avoid the use and risks of anaesthesia. As well as expanding our review inclusion criteria to accommodate anaesthesia as a co-intervention, pain experienced during reduction is a crucial outcome in these trials.
The active role played by the patient in the new manual method of reduction of Johansson 1992 should have prevented intolerable pain, but nonetheless significantly more participants of this group experienced unchanged or worse pain compared with those given manual reduction under IVRA. More surprising is the high proportion of participants of the latter group whose pain was not diminished by IVRA. Subsequent pain was not recorded. Johansson 1992 considered the absence of significant differences between the two groups in the immediate radiological outcome or in redisplacement by 10 days showed the new method to be a valid alternative to the traditional method of manual reduction under anaesthesia. An added attraction was the relatively quick procedure that avoided the delays associated with IVRA and reduced the number of staff needed. However, the conclusion of equivalence of the two approaches is insecure due to the small number of patients in the trial, the reservations associated with radiological measurement, the short follow up, and the lack of functional outcomes or mention of complications.
Patients using the dynamic mechanical traction device without anaesthesia in Kongsholm 1987 also played an active role in reducing their fracture. Statistically significantly fewer participants in this group suffered severe pain compared with those given manual reduction under local anaesthesia (haematoma block). Kongsholm 1987 acknowledged that the number (35%) with severe pain despite haematoma block was high relative to several case series; limited evidence from our review of anaesthesia methods supports this view (Handoll 2002). No important differences in immediate radiological outcome were found but, as with the other two included trials, this should be seen in the context of an absence of functional outcome data. In a separate paper, Kongsholm 1987 reported that neither method resulted in acute nerve injury, but found that significantly fewer patients in the mechanical traction group had signs of neurological impairment, mainly finger numbness, by five weeks. The authors suggested that this was more likely to result from the haematoma block than a difference in the reduction methods. Our review of the evidence from randomised trials of different methods of anaesthesia did not identify this as a specific problem associated with haematoma block; however, data on complications were also sparse (Handoll 2002). Though there is some indication, including a claim, of care programme comparability in Kongsholm 1987, some differences in care, such as in the application of the plaster casts, are still plausible and may have influenced this result. Lastly, by one year the differences in neurological impairment were no longer statistically significant and were still not reported in the context of overall function.
Implications for practice
There was insufficient evidence from comparisons tested within randomised controlled trials to establish the relative effectiveness of different methods of closed reduction used in the treatment of displaced fractures of the distal radius in adults.
Implications for research
Research on closed reduction methods needs to be set in the context of the overall management of these fractures. There are many unresolved issues such as:
Patient characteristics and preferences, fracture type, and local expertise and resources influence treatment choices and must be considered. We suggest an integrated programme of research, which includes consideration of closed reduction methods, for the management of these fractures is the way forward. Such a programme should include the identification of gaps in the available evidence for major decision points of clinical management and prioritisation of topics for research. We have made some advance towards this in a project comprising a formal and structured consultation process involving key players, including a patient representative. These provided feedback on a comprehensive document summarising the evidence, primarily from Cochrane reviews, available for key decision points along typical care pathways for these fractures (Handoll 2003c). All research should conform to best practice in design, conduct, analysis and reporting: an awareness of various methodological issues examined in this and our other reviews should help to avoid some of the problems that undermine the usefulness of much of the research done so far in this area (Handoll 2001).
For researchers contemplating specific research on closed reduction methods for these fractures, we suggest that the choice of interventions to be compared within large randomised trials should take account of potential differences in resource use including the involvement of clinicians in the care process as well as functional outcomes and adverse events. We propose that mechanical finger trap traction versus manual traction, as tested in Earnshaw 2002, remains a suitable starting choice. Consideration should also be given to the proper evaluation of new devices or methods that are described and promoted without supporting evidence (Wise 2004). Any trials testing closed reduction methods should abide by the methodological criteria for a well-conducted and well-reported randomised trial (Altman 2001). Such trials should record full outcome, including functional outcomes, complications and all relevant costs. Since techniques of anaesthesia or reduction, or both together may influence treatment choices, and hence outcomes, researchers should be aware of the need to reflect this tension in study designs.
We thank the following for feedback at the editorial and external review of the protocol: Peter Amadio, Lesley Gillespie, Bill Gillespie, Peter Herbison, Leeann Morton, Marc Swiontkowski and Janet Wale.
We thank the following for feedback and help at the editorial and external review of the review at various stages: Peter Amadio, Joanne Elliott, Lesley Gillespie, Bill Gillespie, Peter Herbison, Lindsey Shaw, John Stothard, Jean-Claude Theis and Janet Wale.
We received unconditional funding for the first version of this review from the National Osteoporosis Society, UK.
We thank Lesley Gillespie for her help with the literature search.
Data and analyses
- Top of page
- Authors' conclusions
- Data and analyses
- What's new
- Contributions of authors
- Declarations of interest
- Sources of support
- Index terms
Appendix 1. Search strategy for The Cochrane Library (Wiley InterScience)
#1 MeSH descriptor Radius Fractures explode all trees in MeSH products
#2 MeSH descriptor Wrist Injuries explode all trees in MeSH products
#3 (#1 OR #2)
#4 ((distal near radius) or (distal near radial)) in Title, Abstract or Keywords in all products
#5 (colles or smith or smiths) in Title, Abstract or Keywords in all products
#6 wrist* in Title, Abstract or Keywords in all products
#7 (#4 OR #5 OR #6)
#8 fractur* in Title, Abstract or Keywords in all products
#9 (#7 AND #8)
#10 (#3 OR #9)
Appendix 2. Search strategy for MEDLINE (OVID-WEB)
1. exp Radius Fractures/
2. Wrist Injuries/
3. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).ti,ab.
Appendix 3. Search strategies for CINAHL and EMBASE (OVID-WEB)
Last assessed as up-to-date: 14 June 2007.
Protocol first published: Issue 3, 2002
Review first published: Issue 1, 2003
Contributions of authors
Helen Handoll (HH) initiated the review, produced the first draft of the protocol and subsequent revisions in RevMan. Rajan Madhok (RM) critically reviewed and revised the protocol.
HH located the review studies. Both review authors partook in study selection and critically reviewed the included studies. HH extracted trial details and results, which RM checked. HH contacted trialists for further information. HH compiled the first draft and all subsequent revisions in RevMan. RM critically reviewed and checked all review drafts.
For the first, second and third updates, HH undertook the search for new trials and modified the review to comply with the revised style guidelines and review methods. RM checked the revised reviews.
Both reviewers are guarantors of the review.
Declarations of interest
Sources of support
- University of Teesside, Middlesbrough, UK.
- No sources of support supplied
In the first, minor update (published in Issue 2, 2004) the search for trials was extended to November 2003. No new trials were found. Some format changes were undertaken to comply with the new Cochrane Style Guide (October 2003).
In the second, minor update (published in Issue 4, 2005) the search for trials was extended to June 2005. No new trials were found. Some format changes were undertaken to comply with the Cochrane Style Guide (November 2004). Other changes were made to comply with the Cochrane Handbook for Systematic Reviews of Interventions (March 2005).
Medical Subject Headings (MeSH)
MeSH check words
Adult; Female; Humans; Male
* Indicates the major publication for the study