Percutaneous pinning for treating distal radial fractures in adults

  • Review
  • Intervention

Authors

  • Helen HG Handoll,

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

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  • Manesh V Vaghela,

    1. University Hospital of Hartlepool, Department of Orthopaedics and Trauma, Hartlepool, UK
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  • Rajan Madhok

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

Background

Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture.

Objectives

To evaluate the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

Selection criteria

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning.

Data collection and analysis

Two authors independently assessed and extracted data from the included trials. Some pooling of data was undertaken for one comparison.

Main results

Thirteen trials, involving 940 generally older adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. Factors affecting the applicability of trial evidence included inconsistent fracture classification, variations in outcome assessment and incomplete reporting.

Six heterogeneous trials compared percutaneous pinning with plaster cast immobilisation. Across-fracture pinning, used in five trials, was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group. One quasi-randomised trial found an excess of complications after Kapandji pinning.

Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across-fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation.

Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material.

Two small trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One trial found duration of immobilisation after trans-styloid fixation did not have a significant effect on outcome. More complications occurred in the early mobilisation group after Kapandji pinning in the second trial.

Authors' conclusions

Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.

摘要

背景

經皮穿刺鋼釘固定治療成年人之橈骨遠端骨折

橈骨遠端骨折是常見的臨床問題。經皮穿刺鋼釘固定是重要的手術方式,其方式是經由皮膚插入鋼釘來固定骨折處。

目標

研究目的在評估使用經皮穿刺鋼釘固定治療成年人橈骨遠端骨折之隨機臨床試驗所得到之實證。

搜尋策略

搜尋Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006)、 Cochrane Central Register of Controlled Trials、MEDLINE, EMBASE及其他資料庫、會議發表及期刊引用文獻等等。無特定之語言限制。

選擇標準

選擇條件為成年人橈骨遠端骨折之隨機或準隨機臨床試驗,並包含有比較經皮穿刺鋼釘固定與保守治療方式、或不同方法之經皮穿刺鋼釘固定之研究。

資料收集與分析

由兩名作者分別評估及摘錄所囊括之臨床試驗,並作匯整比較。

主要結論

共有十三個臨床試驗,包括有940位老年人患有往背側移位和淺在或明顯之橈骨遠端骨折。這些臨床試驗之研究方法缺點包括了分組隱匿及不完整之結果評估。影響研究證據引用之因素包括有不一致的骨折分類方法、結果評估方法之差異及不完整的報告。 六個不同來源的臨床試驗比較經皮穿刺鋼釘固定與石膏固定方式之差異。5個臨床試驗以鋼釘貫穿骨折處之固定方式有效地改善解剖結構,且普遍而言僅有輕微併發症。在使用鋼釘穿刺的組別有著相似或較佳的功能恢復。有一個準隨機臨床試驗發現在Kapandji方法有異常高的併發症。 另有三個試驗比較不同方式的鋼釘穿刺固定,其中兩個發現:比起貫穿骨折處之固定方式,Kapandji方法有著較高之併發症比率。而另一個試驗乃在比較改良式Kapandji方法及Willenegger方法之差異,但證據不足。 兩個小型試驗比較可吸收骨釘及金屬鋼釘之差異,發現前者有較高之併發症比率。兩個小型試驗比較手術後石膏固定一週及六週之差異。其中之一發現在使用穿鋼釘越莖突之固定時,石膏固定時間之長短並不影響治療結果。而另一試驗則發現在使用Kapandji方法時,較短的術後固定時間有較高的併發症比率。

作者結論

儘管有部份證據支持經皮穿刺鋼釘固定之方法,但其真正角色及使用方法則有待確立。而Kapandji方法及可吸收骨釘之使用有較高之併發症比率,引發普遍使用的疑慮。

翻譯人

本摘要由林口長庚醫院陳昭宇翻譯。

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

總結

經皮穿刺鋼釘固定治療成年人之橈骨遠端骨折 就老年人而言,腕部骨折(橈骨或尺骨遠端,或兩均骨折),可能來自跌倒時,腕部反折過度伸展所致。常見治療方式包括骨折復位及石膏固定。對於嚴重位移之骨折,則可以考慮手術治療。經皮穿刺鋼釘固定為方法之一。手術時乃利用鋼釘穿越皮膚,將骨折固定在適當的位置直到癒合。大多數的方式是利用鋼釘貫穿骨折處將骨塊固定在一起,Kapandji方法則使用鋼釘置於可支持末端骨塊。本文回顧隨機臨床試驗中所提出有關使用經皮穿刺鋼釘固定的方法或不同方法間之比較與實證。 在十三個臨床試驗中總計包括940位具有或淺在不穩定骨折之老年人。由於方法學上之缺點,例如隨機取樣及結果評估方法之不足等,無法排除發生嚴重誤差之可能。 六個臨床試驗比較經皮穿刺鋼釘固定與石膏固定治療之差異,其中五個試驗使用鋼釘貫穿骨折處,有較佳之解剖結構之恢復;而其中三個似乎也呈現較佳之功能恢復。普遍而言,貫穿骨折處之固定方式的併發症極其輕微;而使用於其餘臨床試驗之Kapandji方式,比起保守治療,則有著較高之併發症比率。有兩個臨床試驗比較Kapandji方式及貫穿骨折處之固定方式。有兩個臨床試驗使用兩種特殊鋼釘固定方式,並與可吸收骨釘作比較。兩者皆發現使用可吸收骨釘,相較於金屬鋼釘,有著較高之併發症比率。有兩個臨床試驗比較術後石膏固定一週及六週之差別。其中一個臨床試驗發現使用貫穿骨折處之固定方式,術後固定時間之長短並不影響結果。相反地,其他臨床試驗則發現,以Kapandji方式,較短的術後固定時間,有較高之併發症比率。 文獻回顧結果顯示有一些證據支持經皮穿刺鋼釘固定方式的使用。但是,其真正的角色及使用方法則有待確立。而Kapandji方法及可吸收骨釘之使用有較高之併發症比率,在普遍使用上仍存有疑慮。

Plain language summary

Percutaneous pinning for treating distal radial fractures in adults

In older people, a 'broken wrist' (from a fracture at the lower end of one of the two forearm bones) can result from a fall onto an outstretched hand. Treatment usually involves reduction (putting the broken bone back into position) and immobilising the wrist in a plaster cast. Surgery may be considered for more seriously displaced fractures. One type of surgery is percutaneous pinning. This involves the insertion of pins through the skin (percutaneous) to hold the bones in a proper position while they heal. In most pinning methods, wires are placed across the fracture and used to fix the fragments together. In Kapandji pinning, the wires are placed to support the distal (lower end) fragment. This review looked at the evidence from randomised controlled trials testing the use of percutaneous pinning or comparing different aspects of percutaneous pinning.

Thirteen trials, involving 940 generally older adults with potentially or evidently unstable fractures, were included. Because of weak methodology such as using inadequate methods of randomisation and outcome assessment, the possibility of serious bias cannot be ruled out.

Six trials compared percutaneous pinning with plaster cast immobilisation. Pinning involving across-fracture fixation, used in five of these trials, improved anatomical outcome; and in three trials it appeared to improve function too. The complications associated with across-fracture fixation were generally minor. Kapandji pinning, used in the remaining trial, was associated with an excess of complications compared with conservative treatment. Three other trials compared different methods of pinning. Two of these found some evidence of an increased complication rate with Kapandji pinning compared with across-fracture methods. Two trials using two very different pinning techniques compared biodegradable (dissolvable) pins or wires versus metal pins or wires. Both trials found a significant excess of complications associated with the use of the biodegradable material. Two trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One of these trials found the duration of immobilisation after across-fracture pinning did not have a significant effect on outcome. In contrast, more complications occurred in the early mobilisation group after Kapandji pinning in the other trial.

The review concluded that there is some evidence to support the use of percutaneous pinning. However, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.

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