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Closed reduction methods 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: 20 JAN 2003

Assessed as up-to-date: 14 JUN 2007

DOI: 10.1002/14651858.CD003763


How to Cite

Handoll HHG, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003763. DOI: 10.1002/14651858.CD003763.

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: 20 JAN 2003

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Characteristics of included studies [ordered by study ID]
Earnshaw 2002

MethodsMethod of randomisation: use of sealed envelopes, stratification by age
Assessor blinding: yes for radiographs
Intention to treat: problems, 27 participants more in conference abstract
Lost to follow up: not known, but could be 27 (11%)


ParticipantsQueen's Medical Centre, Nottingham, UK
250 participants with 253 Colles' fractures
Inclusion criteria: acute dorsally displaced (Colles' type) distal radial fractures.
Exclusion criteria: undisplaced fracture (<10 degrees dorsal angulation and <5 mm radial shortening), open fracture, palmarly angulated fracture, unable to give written consent. Marked comminution or displacement of articular surfaces considered for primary external or internal fixation.
Classification: Frykman (extra- and intra-articular)
Sex: of 223: 172 female (77.1%)
Age: of 223: mean 61 years; range 15-92 years
Assigned: 126/124 [mechanical / manual]
Assessed: 112/111 (112/113 fractures?)


InterventionsTiming of intervention: not known, but acute fractures. All had IVRA using 40 ml 1% prilocaine, with tourniquet around upper arm at 100 mmHg. Below-elbow Colles-type plaster cast - cast split immediately then overwrapped at fracture clinic at around 1 week. Instructions given for plaster cast care; and finger, elbow and shoulder exercises. Casts worn for 5 weeks.
(1) Mechanical traction. Finger traps applied, by the on-call junior doctor, to patient's thumb, index and long fingers. Forearm suspended vertically from intravenous stand, with elbow flexed to 90 degrees. 10-15 lb (4.5-6.8 kg) of traction weights suspended from upper arm. Reduction assessed after 5 minutes by portable fluoroscopy. Manual pressure applied if necessary to complete reduction.
(2) Manual reduction. Traction applied along axis of arm to disimpact fracture by the on-call junior doctor pulling on hand and counter-traction at elbow provided by plaster-room nurse. Wrist fully deviated ulnarly and flexed to 15 degrees. Fracture reduced by manual pressure on dorsoradial aspects of distal fracture fragment. Reduction confirmed by portable fluoroscopy.


OutcomesLength of follow up: 5 weeks
(a) Failed or inadequate reduction: difficulty in performing reduction, unacceptable reduced position
(b) Anatomical: redisplacement, unsatisfactory position, surgical treatment
(c) Clinical: no mention
(d) Functional: no mention
(e) Resource use: no costs. Some mention of health care worker involvement.


NotesLetters sent to Mr Earnshaw on 22 May and 6 June 2002 regarding methodology, numerical discrepancies, criteria for surgery and information on a future investigation referred to in the trial report.

The on-call junior doctor was a senior house officer (UK hospital doctor grades).


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Johansson 1992

MethodsMethod of randomisation: not stated
Assessor blinding: no mention, unlikely
Intention to treat: likely
Lost to follow up: none


ParticipantsHuddinge Hospital, Huddinge (Stockholm), Sweden
38 participants
Inclusion criteria: displaced Colles' fracture, written consent.
Exclusion criteria: senile patient, age <18 years.
Classification: Frykman (extra & intra-articular)
Sex: 33 female (87%)
Age: mean 65 years; range 25-85 years
Assigned: 19/19 [new / standard]
Assessed: 19/19


InterventionsTiming of intervention: not known, but acute fractures. Dorsal plaster cast applied after reduction.
(1) New manual reduction method without anaesthesia. Active participation of patient who lies on their stomach. Doctor holds patient's hand and patient asked to provide counter-traction through an active adduction of the upper arm (particularly from m. latissimus dorsi). Doctor probes or feels fracture site with his or her thumb and when the fracture is pulled out the doctor grabs the patient's arm with his or her other hand and asks the patient to relax in order to reduce the distal fragments. Procedure takes half a minute.
(2) Manual reduction under intravenous regional anaesthesia with traction and counter-traction applied by two people for 2-5 minutes followed by manipulation of the distal fracture fragment. Patient lies on back - passive involvement. Procedure 20 minutes after IVRA with 5-10 mg/ml injection of Citanest (prilocaine hydrochloride)


OutcomesLength of follow up: 10 days
(a) Failed or inadequate reduction: change in method; no change in radiological parameters
(b) Anatomical: dorsal angulation, radial shortening, redisplacement
(c) Clinical: pain during reduction or anaesthesia
(d) Functional: no mention
(e) Resource use: no costs. Timing and number of health care workers involved for each procedure.


NotesTranslation from Swedish by Ulla Hipkin


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Kongsholm 1987

MethodsMethod of randomisation: not stated
Assessor blinding: no mention, unlikely
Intention to treat: likely
Lost to follow up: none


ParticipantsSolleftea Hospital, Solleftea or University Hospital, Uppsala, or both hospitals, Sweden
116 participants
Inclusion criteria: fresh Colles' fracture.
Exclusion criteria: not stated
Classification: Frykman (extra & intra-articular)
Sex: 105 female (91%)
Age: mean 62 years; range 19-86 years
Assigned: 62/54 [mechanical / manual]
Assessed: 62/54


InterventionsTiming of intervention: not known, but acute fractures. Short-arm plaster cast applied with arm in supination and wrist in neutral (with regards to flexion and extension) after reduction.
(1) Mechanical reduction using a dynamic bone alignment device designed by the trial authors. Patients placed supine on an operating table that is rigged with the dynamic reduction device. All 5 fingers of the fractured arm placed in Chinese finger traps and forearm vertically suspended with elbow flexed at right angles. Upper arm cuff, connected to the apparatus by a tension spring, applied over the upper arm. Gentle traction was applied across the fracture and gradually increased to 10-14 kg. Patients asked to pronate and supinate their forearm. No anaesthesia used. Reduction monitored using image intensifier; time for reduction usually 10-15 minutes. Generally no manipulation. Plaster cast applied before removal of apparatus.
(2) Manual reduction under local haematoma block (8-10 ml of 1% lidocaine). Five minutes after injection, fracture reduced by manual traction and with direct pressure on distal fragment. Counter-traction applied by assistant, and plaster cast applied by a third assistant.


OutcomesLength of follow up: 12.8 months
(a) Failed or inadequate reduction: acute nerve injury
(b) Anatomical: volar (dorsal) angulation; radial length, re-reduction
(c) Clinical: pain during reduction; neurological impairment
(d) Functional: no mention
(e) Resource use: no costs. Timing and number of health care workers involved for each procedure.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Kongsholm 1981This trial, reported only in a conference abstract, randomised 106 patients to one of three interventions:
(1) mechanically applied continuous traction without anaesthesia then circular plaster cast;
(2) manual reduction under local infiltration anaesthesia then dorsal plaster splint;
(3) manual reduction under local infiltration anaesthesia then circular plaster cast.
No discrete results were available in the short conference abstract report of the trial. While the results for pain at reduction could be deduced, the lack of information on participant characteristics, the interventions and trial methods hindered any meaningful interpretation. We were unable to locate the trialists to request further information.

 
Comparison 1. Finger trap traction versus manual traction

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

 1 Failed reduction (unacceptable position)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Difficulty of reduction (visual analogue scale: 0 (none) to 10 cm (impossible))1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Continuing acceptable position at 5 weeks (Note, positive outcome)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 2. Manual reduction with active patient versus manual reduction + anaesthesia (IVRA)

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

 1 Post-reduction radiological measurements1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

 2 Failed reduction: unchanged radiological position1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Increased pain during reduction1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Increased or unchanged pain during reduction1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Redislocation by 10 days1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 3. Dynamic mechanical traction versus manual reduction + haematoma block

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

 1 Post-reduction radiological measurements1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Volar angle (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Radial length (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Severe pain during reduction1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Neurological complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

    3.2 Neurogical signs and symptoms at 5 weeks
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.3 Neurogical signs and symptoms at 1 year
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Table 1. Definitions of key radiological parameters

ParameterDefinitionNormal value

Dorsal angulation (dorsal or volar or palmar tilt)Angle between a) the line which connects the most distal points of the dorsal and volar cortical rims of the radius and b) the line drawn perpendicular to the longitudinal axis of the radius. Side view of wrist.Palmar or volar tilt: approximately 11-12 degrees.

Radial lengthDistance between a) a line drawn at the tip of the radial styloid process, perpendicular to the longitudinal axis of the radius and b) a second perpendicular line at the level of the distal articular surface of the ulnar head. Frontal view.Approximately 11-12 mm.

Radial angle or radial inclinationAngle between a) the line drawn from the tip of the radial styloid process to the ulnar corner of the articular surface of the distal end of the radius and b) the line drawn perpendicular to the longitudinal axis of the radius. Frontal view.Approximately 22-23 degrees.

Ulnar varianceVertical distance between a) a line drawn parallel to the proximal surface of the lunate facet of the distal radius and b) a line parallel to the articular surface of the ulnar head.Usually negative variance (e.g. -1 mm) or neutral variance.

 
Table 2. Methodological quality assessment scheme

ItemsGradesNotes

(1) Was the assigned treatment adequately concealed prior to allocation?Y = method did not allow disclosure of assignment.
? = small but possible chance of disclosure of assignment or unclear.
N = quasi-randomised, or open list or tables.
Cochrane code (see Handbook): Clearly yes = A; not sure = B; clearly no = C.

(2) Were the outcomes of participants who withdrew described and included in the analysis (intention to treat)?Y = withdrawals well described and accounted for in analysis.
? = withdrawals described and analysis not possible, or probably no withdrawals.
N = no mention, inadequate mention, or obvious differences and no adjustment.

(3) Were the outcome assessors blinded to treatment status?Y = effective action taken to blind assessors.
? = small or moderate chance of unblinding of assessors, or some blinding of outcomes attempted.
N = not mentioned or not possible.

(4) Were important baseline characteristics reported and comparable?Y = good comparability of groups, or confounding adjusted for in analysis.
? = confounding small, mentioned but not adjusted for, or comparability reported in text without confirmatory data.
N = large potential for confounding, or not discussed.
The principal confounders considered were type of fracture, time since injury, existing complications (e.g. medial nerve compression), presence of other acute fractures, gender, age and whether primary or secondary displacement.

(5) Were the participants blind to assignment status after allocation?Y = effective action taken to blind participants.
? = small or moderate chance of unblinding of participants.
N = not possible, or not mentioned (unless double-blind), or possible but not done.

(6) Were the treatment providers blind to assignment status?Y = effective action taken to blind treatment providers.
? = small or moderate chance of unblinding of treatment providers.
N = not possible, or not mentioned (unless double-blind), or possible but not done.

(7) Were care programmes, other than the trial options, identical?Y = care programmes clearly identical.
? = clear but trivial differences, or some evidence of comparability.
N = not mentioned or clear and important differences in care programmes.
Examples of clinically important differences in other interventions were: differences in anaesthesia (except where the use of anaesthesia was a co-intervention), subsequent treatment (surgery, plaster cast), clinician experience and speciality (fully trained orthopaedic surgeons, others). Also considered were the presence or absence of pre-specified criteria for repeat reduction or change of management.

(8) Were the inclusion and exclusion criteria for entry clearly defined?Y = clearly defined (including type of fracture).
? = inadequately defined.
N = not defined.

(9) Were the interventions clearly defined (including who provided the care)?Y = clearly defined interventions are applied with a standardised protocol and care providers identified.
? = clearly defined interventions are applied but the application protocol is not standardised or care providers identified.
N = intervention or application protocol, or both are poorly or not defined.

(10) Were the outcome measures used clearly defined?Y = clearly defined.
? = inadequately defined.
N = not defined.

(11) Were the accuracy and precision, with consideration of observer variation, of the outcome measures adequate; and were these clinically useful and did they include active follow up?Y = optimal.
? = adequate.
N = not defined, not adequate.

(12) Was the timing (e.g. duration of surveillance) clinically appropriate?Y = optimal. (> 1 year)
? = adequate. (3 months - 1 year)
N = not defined, not adequate. (< 3 months)

 
Table 3. Quality assessment results for individual trials (see Table 03 for scheme)

Study IDEarnshaw 2002Johansson 1992Kongsholm 1987

ItemsGradesGradesGrades

Item 1: Allocation concealment???

Item 2: Intention-to-treat analysisNYY

Item 3: Outcome assessor blindingYNN

Item 4: Comparable baseline characteristics??Y

Item 5: Participant blindingNNN

Item 6: Treatment provider blindingNNN

Item 7: Identical care programmes??Y

Item 8: Clearly defined inclusion criteriaY??

Item 9: Cleary defined interventionsYYY

Item 10: Well defined outcome measuresY?Y

Item 11: Optimal outcome assessment???

Item 12: Optimal timing of follow up (> 1 year)NNY