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Percutaneous pinning for treating distal radial fractures in adults

  1. Helen HG Handoll1,*,
  2. Manesh V Vaghela2,
  3. Rajan Madhok3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 18 JUL 2007

Assessed as up-to-date: 15 MAY 2007

DOI: 10.1002/14651858.CD006080.pub2


How to Cite

Handoll HHG, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD006080. DOI: 10.1002/14651858.CD006080.pub2.

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 Hospital of Hartlepool, Department of Orthopaedics and Trauma, Hartlepool, UK

  3. 3

    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: 18 JUL 2007

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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. Index terms

Note: This is one of five reviews that will cover all surgical interventions for treating distal radial fractures in adults. Each review will provide updated evidence for one of the several surgical categories that were presented together in the previously published review (Handoll 2003a). Following publication of the five reviews, Handoll 2003a will be republished as an 'umbrella' review summarising the evidence for surgical treatment for these fractures.

Description of the condition: distal radial fracture in adults
Fractures of the distal radius, often referred to as "wrist fractures", are common in both children and adults. They are usually defined as occurring within three centimetres of the radiocarpal joint of the radius, where the lower end of the radius interfaces with two (the lunate and the scaphoid) of the eight bones forming the carpus (the wrist). The majority are closed injuries, the overlying skin remaining intact.

In this review, we consider the treatment of distal radial fracture in adults only, in whom they are one of the most common fractures, predominantly in white and older populations in the developed world (Sahlin 1990; Singer 1998; Van Staa 2001). In women, the incidence of these fractures increases with age, starting at around 40 years of age. Before this age, the incidence is higher in men (Singer 1998). In contrast, between 60 to 94 years of age, females predominate. A recent multi-centre study in the United Kingdom of patients aged 35 years and above with Colles' fracture (see below) reported an annual incidence of 9/10,000 in men and 37/10,000 in women (O'Neill 2001).

Young adults usually sustain this injury as a result of high-energy trauma, such as a traffic accident. In older adults, especially females, the fracture more often results from low-energy or moderate trauma, such as falling from standing height. This reflects the greater fragility of the bone, resulting from disuse or post menopausal osteoporosis. It has been estimated that, at 50 years of age, a white woman in the USA or Northern Europe has a 15% lifetime risk of a distal radius fracture whereas a man has a lifetime risk of just over two per cent (Cummings 1985). More recent estimates (Van Staa 2001) of the lifetime risks of radius or ulna fracture at 50 years of age are similar: 16.6% for women versus 2.9% for men.

Distal radial fractures are usually treated on an outpatient basis with estimates of around 20% of patients (mainly older people) requiring hospital admission (Cummings 1985; O'Neill 2001). This figure will include all people receiving surgery.

Classification
Surgeons have classified fractures by anatomical configuration or fracture pattern, to help in their management. Simple classifications were based on clinical appearance and often named after those who described them. In the distal radius, the term "Colles' fracture" is still used for a fracture in which there is an obvious and typical clinical deformity (commonly referred to as a dinner fork deformity) - dorsal displacement, dorsal angulation, dorsal comminution, and radial shortening. The introduction of X-rays and other imaging methods made it clear that the characteristic deformity may be associated with a range of different patterns of fracture which may be important in determining the outcome of treatment, and therefore the way in which treatment is conducted. For example, the fracture through the distal radius in a Colles' fracture may be extra-articular (leaving the articular or joint surface of the radius intact) or intra-articular (the articular surface is disrupted, sometimes in a complex manner). Numerous classifications have been devised to define and group different fracture patterns (Chitnavis 1999). One of the most commonly used is that of Frykman which distinguishes between extra-articular fractures and intra-articular fractures of the radiocarpal and radio-ulnar joints, and the presence or absence of an associated distal ulnar fracture (Frykman 1967). Another commonly used system is the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) system (Muller 1991) which divides the fractures into three major groups: group A (extra-articular), group B (simple/partial intra-articular), and group C (complex/complete intra-articular). These three groups are then subdivided yielding 27 different fracture types. Other classification systems have attempted to link fracture type more directly with fracture management. For instance, Cooney 1993 proposed a 'Universal Classification' based on fracture displacement, articular involvement, reducibility (whether the fracture can be reduced; that is whether the bone fragments can be put back in place) and stability (whether, once reduced, the fragments will remain so).

Description of the intervention: percutaneous pinning
In the last century, most distal radial fractures in adults were treated conservatively, by reduction of the fracture when displaced, and stabilisation in a plaster cast or other external brace. Clinicians have recognised for many years that, particularly in older people with weakened bones from osteoporosis, the results of such conservative treatment are not consistently satisfactory (for an updated review of the evidence: see Handoll 2003b). This has resulted in attempts to develop other strategies involving surgery aimed at more accurate reduction and more reliable stabilisation of these fractures.

One such strategy is percutaneous pinning, which involves the percutaneous (through the skin) insertion of pins, which may be threaded, and wires. This is less invasive and, usually, technically simpler than open surgery, where the fractured bone is exposed to direct view. For percutaneous pinning, the reduction of the fracture is closed (see Handoll 2003c); although pins - such as Kirschner wires - may be used to manipulate the fracture fragments. In a comprehensive account of percutaneous pinning of fractures of the distal radius, Rayhack 1993 refers to a "myriad of options, decisions and questions that must be addressed". These decisions include: the reduction technique; the method and extent of skin incision; the use and type of radiographic control; the configuration of the pins; the number, size and type of pins; whether the pin ends are left exposed out of the skin or not; and the type and duration of immobilisation after pinning. Later decisions involve the timing and methods for pin removal. A variety of different pinning techniques or methods have been described in the literature (Fernandez 1999; Rayhack 1993). In many of these, pins are placed in the bone and used to fix the distal radial fragment(s). In contrast, in Kapandji's double intrafocal technique (Kapandji 1988), and subsequent developments of this technique, pins are used to manipulate and then support or 'buttress' the distal radial fragment(s).

Complications
Complications from this injury are diverse and frequent (Altissimi 1986; Atkins 1989; Cooney 1980). Some 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). 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, which may be due to faulty application of plaster casts (Gartland 1951), and pin track infection and soft tissue injury from percutaneous pinning. Complex regional pain syndrome type 1, generally termed reflex sympathetic dystrophy (RSD), but 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, vasomotor instability) in serious cases. The etiology of RSD is often unclear.

Why it is important to do this review
Percutaneous pinning is one of the key methods for surgical fixation of distal radial fractures. It is attractive because it is minimally invasive and relatively simple and quick to perform compared with the other surgical methods employed for these fractures. It is unclear whether percutaneous pinning produces superior results to conservative treatment, and if so, what is the best method to achieve this. The answers to these questions are likely to depend particularly on fracture configuration and bone quality.

 

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. Index terms

We aimed to evaluate the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in skeletally mature people.

We aimed to compare the relative effects (benefits and harms) of the following for adults with these injuries.

  • Any method of percutaneous pinning versus conservative treatment involving plaster or brace use.
  • Any method of percutaneous pinning versus any other method of percutaneous pinning.
  • Any technique or type of material or device used for percutaneous pinning versus any other technique or type of material or device at surgery or post-operatively.
  • Any type or duration of post-operative immobilisation versus any other type or duration of immobilisation including none.
  • Any method or timing of pin or wire removal versus any other method or timing of pin or wire removal including no removal.

We considered these effects primarily in terms of patient-assessed functional outcome and satisfaction, and other measures of function and impairment, pain and discomfort, the incidence of complications, anatomical deformity and use of resources.

We planned to study the outcomes in different age groups and for different types of fractures, especially whether they are extra-articular or intra-articular.

 

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. 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 percutaneous pinning for treating distal radial fractures in adults were considered.

 

Types of participants

Patients of either sex who have completed skeletal growth, with a fracture of the distal radius. Percutaneous pinning may be considered as primary treatment or take place after the failure of initial conservative management, generally within two to three weeks. Trials with a mixed population of adults and children were included provided the proportion of children was clearly small (< 5%); otherwise they would have been excluded unless separate data for adults could have been obtained.

 

Types of interventions

This includes the following comparisons.
(1) Surgical interventions involving percutaneous pinning by itself versus conservative interventions such as plaster cast immobilisation.
(2) Different methods of percutaneous pinning in the treatment of fractures of the distal radius. Thus comparisons evaluating:
(a) different types of devices used for pinning;
(b) use of different surgical techniques associated with percutaneous pinning, including type and extent of skin incision and measures to assist pin removal;
(c) type and duration of immobilisation after percutaneous pinning;
(d) type and timing of pin or wire removal.

Excluded were trials comparing percutaneous pinning with other methods of surgical fixation, such as external fixation, or trials evaluating the use of supplementary percutaneous pinning in addition to another method of surgical fixation. We also excluded trials on pin site maintenance or other measures to prevent wound infection (already covered in Temple 2004).

 

Types of outcome measures

Our primary outcome of choice is the number of people with an uncomplicated and speedy restoration of a pain-free fully-functioning wrist and arm with acceptable anatomic restoration and appearance. However, compatible with the general assessment and presentation of outcome within the orthopaedic literature, we reported outcome in the following four categories.

Primary outcomes
(1) Functional outcome and impairment

  • 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)
  • Return to previous occupation, including work, and activities of daily living
  • Grip strength
  • Pain
  • Range of movement (wrist and forearm 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)

(2) Clinical outcome

  • Residual soft tissue swelling
  • Early and late complications associated with distal radial fractures or their treatment, including reflex sympathetic dystrophy (RSD) and post traumatic osteoarthritis
  • Cosmetic appearance
  • Patient satisfaction with treatment or outcome

Secondary outcomes
(3) Anatomical outcome (anatomical restoration and residual deformity)
Radiological parameters include radial length or shortening and shift, dorsal angulation, radial inclination or angle, ulnar variance, and for intra-articular fractures: step off and gap deformity of the articular surface (Fernandez 1996; Kreder 1996a). Composite measures include malunion and total radiological deformity. Definitions of four of the most commonly reported radiological parameters are presented in  Table 1.

(4) Resource use
Hospital stay, number of outpatient attendances and other costs.

Timing of outcome assessment
Results were collected for the final follow-up time for which these were available. Where reported, interim trial results were also checked to see if a marked and important difference in the timing of recovery had occurred.

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2006, Issue 3) (see Appendix 1), MEDLINE (1966 to September week 1 2006), EMBASE (1988 to 2006 week 36), CINAHL (1982 to September week 2 2006). 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 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 September 2006) and the UK National Research Register at www.update-software.com/national/ (up to Issue 3, 2006) for ongoing and recently completed trials.

 

Searching other resources

We searched the reference list 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 2005: http://www.hwbf.org/ota/am/) and American Academy of Orthopaedic Surgeons annual meeting (2004 to 2006: http://www.aaos.org/education/anmeet/libscip.asp). We also included handsearch results from the final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003), and the British Orthopaedic Association Congress (2000, 2001, 2002 and 2003), and various issues of Orthopaedic Transactions and issues of Acta Orthopaedica Scandinavica Supplementum.

We 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 (www.amedeo.com).

 

Data collection and analysis

Selection of studies
All review authors independently assessed potentially eligible trials identified via the search for inclusion using a pre-piloted form. Any disagreement was resolved by discussion.

Data extraction and management
Two of the review authors (HH and MV) extracted trial details and data using a data extraction form. All disagreements were resolved by discussion. We contacted trialists of trials that were not reported in full journal publications for additional information and data. Contact with other trial authors was dictated by the vintage of the publication, a general impression of the expected gain, and anticipated or known difficulty in locating trial authors.

Results were collected for the final follow-up time for which these were available. We also recorded where clinically important differences had been reported at intermediate follow-up assessments but were no longer apparent at final follow up.

One author (HH) entered the data into RevMan.

Assessment of methodological quality
In this review, risk of bias is assessed in terms of methodological quality.

Two of the review authors (HH and MV) independently assessed the methodological quality of the included trials using a pre-piloted form. Any disagreement was resolved by discussion. Titles of journals, names of authors or supporting institutions were not masked at any stage. A modification of the quality assessment tool used in the previous 'umbrella' review (Handoll 2003a) was used. In this, each item was graded either 'Y', '?' or 'N', respectively indicating that the quality criteria were met for the item ("Yes"), or possibly or only partially met for the item ("Possible, partial"), or not met ("No"). The rating scheme covering 11 aspects of trial validity, plus brief notes of coding guidelines for selected items, is given in  Table 2.

Measures of treatment effect
Where available, quantitative data, both dichotomous and continuous, that are reported in individual trial reports for outcomes listed in the inclusion criteria are presented in the analyses. Relative risks and 95% confidence intervals are calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes.

Unit of analysis issues
No unit of analysis issues arose in this review.

Dealing with missing data
Where appropriate, we performed intention-to-treat analyses to include all patients randomised to the intervention groups. In our protocol for this review we indicated that we would where appropriate investigate the effect of missing data (drop outs and exclusions) by conducting best and worse case scenarios. So far, we have found no included dataset where this would have been appropriate. We were alert to the potential mislabelling or non identification of standard errors and standard deviations. There were no confidence interval data available to calculate missing standard deviations, and we did not assume values in order to present standard deviations in the analyses.

Assessment of heterogeneity
Heterogeneity was assessed by visual inspection of the forest plot (analysis) along with consideration of the test for heterogeneity and the I² statistic (Higgins 2003).

Assessment of reporting biases
There were insufficient data to assess publication bias; for example, by preparing a funnel plot.

Data synthesis (meta-analysis)
Where appropriate, results of comparable groups of trials were pooled. As stipulated in the protocol we used the fixed-effect model and 95% confidence intervals.

Subgroup analysis and investigation of heterogeneity
There were no data available to carry out our pre-specified subgroup analyses by age and gender and type of fracture (primarily, extra-articular versus intra-articular fractures). As stipulated beforehand, presentation in separate subgroups was performed where there was a fundamental difference in pinning method (such as transfixation versus Kapandji's intrafocal method). If, in a future update, we wish to test whether subgroups are statistically significantly different from one another, we plan to test the interaction using the technique outlined by Altman and Bland (Altman 2003).

Sensitivity analysis
There were no data available to carry out pre-specified sensitivity analyses examining various aspects of trial and review methodology, including the effects of missing data, study quality (specifically allocation concealment, outcome assessor blinding and reportage of surgical experience), and inclusion of trials only reported in abstracts.

Interpretation of the evidence
We have graded the findings of the treatment comparisons according to the six categories of effectiveness used by contributors to Clinical Evidence (BMJ 2006) (see  Table 3) to assist our interpretation of the evidence.

 

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. Index terms
 

Description of studies

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

Results of the search
The search for trials predated the development of this review, which is essentially a reworked update of part of a previously published review (Handoll 2003a) covering all surgical intervention for these fractures. We have not documented the numbers of references retrieved by electronic searches; updates of MEDLINE, EMBASE and CINAHL are now generated on a weekly basis. Of 24 potentially eligible studies put forward for study selection, 13 were included, five were excluded and six are in 'Studies awaiting assessment'.

Aside from the two most recently published trials (Azzopardi 2005; Strohm 2004), the other included trials were present in the review covering all surgical intervention for these fractures (Handoll 2003a). Azzopardi 2005 appeared as an ongoing trial in Handoll 2003a.

Included studies
Eleven of the 13 included studies were fully reported in medical journals. Trial reports of the other two trials (Korner 1999; Verhulst 1990) were only available as abstracts. Seven of the included trials were initially located by handsearching. The rest were located in the following ways: The Cochrane Bone, Joint and Muscle Trauma Group Specialist Register (2); EMBASE (1); and MEDLINE (3).

Details of the methods, participants, interventions and outcomes of individual trials are provided in the 'Characteristics of included studies' table.

Setting
The publication dates of the main reports of these trials span 16 years; Verhulst 1990 being the earliest. Aside from Lenoble 1995, which had two centres, the studies were all single centre studies, mainly conducted in teaching hospitals. They each took place in one of seven countries (Belgium (3), France (3), Germany (2), India (1), Morocco (1), Spain (1), UK (2)). Translations were obtained for the two trials in French (Fikry 1998; Milliez 1992).

Participants
The 13 included trials involved a total of 940 participants, most of whom were female and older adults. Two studies (Korner 1999; Verhulst 1990), both reported in abstract only, provided no information on gender or age of their study populations; although Verhulst 1990 referred to an "elderly" population. Nine studies had more female participants, ranging between 68% and 89% of their study populations. There were more male than female participants in Fikry 1998, and probably in Stoffelen 1998; however, the disparities in the data provided in the three papers reporting this trial meant that we could not establish this. The trial population of Fikry 1998 was also markedly younger (mean age 34 years) than the other studies, whose trial populations had mean ages ranging from 55 years (Allain 1999; Milliez 1992) to 71.5 years (Azzopardi 2005). The youngest (15 years) and oldest recorded (92 years) participants appeared in the same trial (Strohm 2004). It is clear that the vast majority of participants in the included trials were skeletally mature: five trials excluded children either by explicitly setting a lower age limit or stipulating that the participants should be adults or skeletally mature. Two trials (Azzopardi 2005; Rodriguez-Merchan 97) further restricted the trial population to more mature adults: above 60 and 45 years respectively. An upper age limit of 60 years was applied in Rodriguez-Merchan 97 and 80 years in Stoffelen 1998.

Fractures
A variety of descriptions was used to define the types of fracture in the included trials. Nonetheless, explicit reference to dorsally displaced or Colles' fractures was made in all trials except Casteleyn 1992, in which it was also clear that the fractures were dorsally displaced. Thus volar displaced fractures such as Barton's (Smith 1988) were not included. Trials often used descriptive terms such as displaced, unstable and comminuted, and referred to classification systems such as Frykman (Frykman 1967) or the AO system (Muller 1991). While Strohm 2004 included a few people with open fractures, it is likely that all the fractures in the other trials were closed, and certain in those trials (Allain 1999; Azzopardi 2005; Casteleyn 1992; Lenoble 1995; Milliez 1992) stipulating the exclusion of open fractures. Two trials (Azzopardi 2005; Rodriguez-Merchan 97) described radiological criteria for defining an unstable fracture, thus defining the extent of displacement required for trial entry. None of the trials testing definitive treatment explicitly included fractures that had redisplaced after a primary reduction. Of the 10 trials applying or reporting fracture type according to an established (not own) classification system, two trials grouped fractures according to more than one classification system. The Frykman system was used by seven trials, the AO system by four trials and Castaing system by one trial. Six trials (Allain 1999; Casteleyn 1992; Korner 1999; Lenoble 1995; Milliez 1992; Strohm 2004) explicitly included both extra-articular and intra-articular fractures, although the extent of intra-articular involvement was often limited; such as the exclusion of radiocarpal joint articular fractures in Casteleyn 1992, and of fractures with more than two articular fractures in Allain 1999 and Lenoble 1995. Three trials only included or involved extra-articular fractures (Azzopardi 2005; Gupta 1999; Stoffelen 1998), whereas two trials (Rodriguez-Merchan 97; Shankar 1992) included intra-articular fractures only. The involvement of the articular surface of the distal radius fracture was not clear in either Fikry 1998, where dislocated radiocarpal joint fractures were excluded, or Verhulst 1990, which only referred to Colles' type fractures.

Comparisons
The 13 included trials have been grouped according to the comparisons addressed by each trial. While most of the trials evaluated definitive treatment, two trials (Allain 1999; Milliez 1992) tested the duration of immobilisation after surgery.

Any method of percutaneous pinning versus conservative treatment involving plaster or brace use

Percutaneous pinning versus plaster cast immobilisation alone
Six trials (Azzopardi 2005; Gupta 1999; Rodriguez-Merchan 97; Shankar 1992; Stoffelen 1998; Verhulst 1990) involving 420 patients compared internal fixation involving percutaneous pinning with plaster cast immobilisation. A concise summary of the participants, fracture type, timing and details of the interventions for the six trials is given in  Table 4.

Each trial employed a different pinning technique or duration of immobilisation, or both. Various numbers of pins were used to transfix the distal radius fragment to the radial shaft in four trials (Azzopardi 2005: 2 pins; Gupta 1999: 2 pins; Rodriguez-Merchan 97: 3 pins; Verhulst 1990; 1 pin). In Shankar 1992, two pins were placed obliquely through the distal radial fragments across the inferior radio-ulnar joint and fixed in the ulna. Stoffelen 1998 used Kapandji's triple intrafocal technique, where three pins introduced at the fracture site and driven into the radial shaft support the fracture fragment. Stoffelen 1998 also differed from the other five trials in that there was a difference in the duration of plaster immobilisation between the two intervention groups (Kapandji's pinning group: 1 week; conservative treatment group: 6 weeks).

Any method of percutaneous pinning versus any other method of percutaneous pinning

Kapandji fixation versus trans-styloid fixation
One trial (Lenoble 1995) compared Kapandji fixation with two or three Kirschner wires followed by immediate mobilisation versus trans-styloid fixation with two Kirschner wires followed by plaster cast immobilisation for about 45 days in 120, mainly female (68% of those followed up) skeletally mature people (mean age: 57 years) with either an extra-articular or intra-articular dorsally displaced fracture.

Kapandji fixation versus Py's isoelastic pinning
Fikry 1998 compared Kapandji intrafocal pinning with three Kirschner wires versus with Py's isoelastic pinning, where two wires were inserted across the fracture and along the medullary canal, in 110 people. Both groups had immobilisation in a forearm cast for four weeks. The majority of the 88 participants with complete data at follow up were male (75%) with an average age of 34 years. All had dorsally displaced fractures, with or without displacement of the ulnar styloid. Though some involvement of the articular surface of the distal radius was possible in Fikry 1998, dislocated radiocarpal joint fractures were excluded.

Modified Kapandji fixation versus Willenegger fixation
In Strohm 2004, one patient group was treated with a modified Kapandji method, involving intrafocal pinning with two Kirschner wires combined with a third wire inserted via the radial styloid used to fix the fracture, followed by six weeks of immobilisation in a volar splint. Physiotherapy, with the volar splint removed, was started at three weeks. The other patient group received Willenegger pinning, where two wires introduced via the styloid process were inserted across the fracture, followed by immobilisation in a forearm cast for six weeks. The 100, mainly female (85%), participants with an average age of 65 years had Colles' type fractures, either extra- and intra-articular (AO types A2, A3 or C1).

Any technique or type of material or device used for percutaneous pinning versus any other technique or type of material or device at surgery or post-operatively

Biodegradable pins or wires versus metal pins or wires
Two trials (Casteleyn 1992; Korner 1999) evaluated the use of biodegradable pinning in 70 people with extra-articular and intra-articular fractures. None of the 30, mainly female (77%) and older (mean age 61 years), participants of Casteleyn 1992 had radiocarpal joint fractures. Few details of the study population were available for Korner 1999. Different pinning techniques were used in the two trials: Kapandji's intrafocal pinning with two wires was used in Casteleyn 1992, while two pins or Kirschner wires were inserted via the radial styloid and across the fracture (modified Willenegger method) in Korner 1999. There was no cast immobilisation in Casteleyn 1992; there was no mention of post-surgical care in Korner 1999.

Any type or duration of post-operative immobilisation versus any other type or duration of immobilisation including none

Duration of post-operative immobilisation after percutaneous pinning
The duration of immobilisation (plaster cast immobilisation for one week versus for six weeks) after surgery was tested by two trials (Allain 1999; Milliez 1992) in 120 people with extra-articular or intra-articular fractures. The participants were mainly female (74%) with a mean age of 55 years. Trans-styloid fixation with two Kirschner wires was used in Allain 1999. Kapandji intrafocal pinning with three Kirschner wires was used in Milliez 1992. In both trials, the early mobilisation group was advised against heavy work and lifting heavy loads but did not appear to receive any other specific instructions to those given after cast removal in both groups.

Any method or timing of pin or wire removal versus any other method or timing of pin or wire removal including no removal
There were no included trials for this topic.

Excluded studies
Five studies were excluded for reasons stated in the 'Characteristics of excluded studies' table. Four studies were found not to be randomised trials and one trial was abandoned.

Ongoing studies
There are no ongoing studies.

Studies awaiting assessment
Details of the six trials pending assessment are given below.

  • Gravier 2005: published abstract of trial comparing trans-styloid versus intrafocal pinning contains insufficient information for inclusion. Trial author has indicated that a full report has been submitted for publication.
  • Hargreaves 2004: published report of trial comparing buried versus protruding wires does not provide separate data for adults and has unit of analysis problems. Lead author has contacted his coauthor for details of the trial results but these have yet to appear.
  • Russe 2000: published abstract of the full study population for a multicentre trial comparing bioabsorbable versus metal wires provides insufficient information for inclusion. Translations from German now obtained for two of the four abstracts pertaining to the trial and a request for further information has been sent.
  • Shannon 2003: published abstract of trial evaluating new "spring loaded" technique provides insufficient information for inclusion. No response obtained yet from authors.
  • Snow 2006: registered trial, completed in 2004, comparing plaster cast immobilisation in dorsi versus palmar (volar) flexion after percutaneous K-wire fixation. Pre-publication report received after completion of the first version of the review. Trial selected for inclusion in the next version of the review.
  • Waheed 2004: published abstract of trial comparing buried versus protruding wires provides insufficient information for inclusion. No response obtained yet from authors.

 

Risk of bias in included studies

The quality of trial methodology based on trial reports was disappointing. Inevitably, much of the quality assessment related to trial reporting and both trials (Korner 1999; Verhulst 1990) reported only in conference abstracts failed to satisfy most of the 11 quality criteria ( Table 2). The results, together with some notes on specific aspects, of the quality assessment for the individual trials are shown in  Table 5. Information specific to the first three items of the quality assessment is given in the methods section of the 'Characteristics of included studies' table. A summary of the results for individual items of quality assessment is given below.

Allocation concealment (item 1)
Only one trial (Rodriguez-Merchan 97), which used blinded consecutively numbered envelopes, was considered to have satisfied the criteria for secure allocation concealment (item 1). Of those trials using inadequate methods or providing no information on which to judge this item, two gave some details of their method of randomisation (Azzopardi 2005: coin toss; Casteleyn 1992: use of sealed cards), whereas six trials provided no information (Fikry 1998; Korner 1999; Lenoble 1995; Shankar 1992; Strohm 2004; Verhulst 1990). Blinded randomisation was, however, claimed by Strohm 2004. The remaining trials used quasi-randomised methods based on admission sequence or alternation (Gupta 1999; Milliez 1992; Stoffelen 1998), or patient chart numbers (Allain 1999).

Intention-to-treat analysis (item 2)
Clear statements of participant flow with evidence of intention-to-treat analysis were available for three trials (Allain 1999; Casteleyn 1992; Gupta 1999). There were serious problems in four trials. In two of these (Fikry 1998; Lenoble 1995), both with a high loss (20%) to follow up, baseline data were not provided for the whole study population. In both Stoffelen 1998 and Verhulst 1990, there was no explanation on the imbalances in the numbers randomised into the two groups, and no information on loss to follow up.

Blinding of outcome assessors (item 3)
This was only confirmed in Allain 1999 where all participants were independently reviewed by a physician who was not involved in their treatment and who was unaware of the duration of post-operative immobilisation. Total blinding of outcome assessment is impractical for trials testing surgical interventions but it is possible for some outcomes and more so at longer term follow-up.

Comparability of baseline characteristics (item 4)
Two trials (Azzopardi 2005; Casteleyn 1992) provided sufficient information indicating the similarity in the baseline characteristics of gender, age and type of fracture. Potentially important imbalances between treatment groups in participant characteristics were found in Allain 1999 (age and activity) and Stoffelen 1998 (gender and high-energy injuries).

Blinding of patients and treatment providers (items 5 and 6)
These are unlikely in these studies and none was claimed.

Care programme comparability (item 7)
Comparability of care programmes comprising interventions (such as type of anaesthesia, timing of the interventions, comparability of the experience of the health professionals applying the interventions (operator bias), and rehabilitation) other than the trial interventions proved hard to confirm. However, it was considered highly likely in three trials (Allain 1999; Azzopardi 2005; Casteleyn 1992). Distinctive differences between the two groups where an intervention other than the trial intervention was used exclusively in one group can change the actual comparison under test. For instance, in Strohm 2004, physiotherapy was provided after three weeks of immobilisation to the modified Kapandji pinning group only.

Description of inclusion criteria (item 8)
Most of the included trials provided sufficient trial inclusion and exclusion criteria to define the study population. This item was rated 'N' ("not defined") where no details of the type of fractures were available ("Colles'" was not considered enough).

Definition of outcome measures and quality of outcome measurement (items 9 and 10)
The definition of outcome measurement was clear enough to give a good idea of what was recorded in 10 of the 11 trials written up as full reports. Only Azzopardi 2005 was rated as having 'optimal' quality outcome measurement, which included use of a validated patient assessed quality of life instrument and active follow-up. Of note, but not rated, was the grading or scoring of overall functional outcome according to scoring systems in several trials. These systems, which often included anatomical and clinical outcomes, included modifications of other scoring systems such as that of Gartland and Werley (Gartland 1951). Also, noted but not rated, were instances where adjustments were made for hand dominance. The variety of schemes used and other outcome measures reported by the trials is evident from inspection of the 'Characteristics of included studies' table.

Length of follow up (item 11)
Follow up ranged from three months (Milliez 1992) to two years (Lenoble 1995; Verhulst 1990), but was of variable duration in Fikry 1998, Korner 1999 and Strohm 2004.

 

Effects of interventions

Any method of percutaneous pinning versus conservative treatment involving plaster or brace use

Percutaneous pinning versus plaster cast immobilisation alone
Percutaneous pinning was compared with plaster immobilisation in six trials (Azzopardi 2005; Gupta 1999; Rodriguez-Merchan 97; Shankar 1992; Stoffelen 1998; Verhulst 1990). Five trials applied across-fracture pinning whereas Stoffelen 1998 used Kapandji's triple intrafocal technique with early mobilisation and is thus considered separately for most outcomes (functional and anatomical) in the following.

The functional scoring systems used by three of the trials (Gupta 1999; Rodriguez-Merchan 97; Shankar 1992), all derived from Gartland and Werley's scheme (Gartland 1951), also rated deformity and various complications. Consistently (test for heterogeneity: I² = 0%) superior functional grades were obtained in the pinning group in three of the fracture fixation trials (Gupta 1999; Rodriguez-Merchan 97; Shankar 1992): see Analysis 01.01 Functional grading: not excellent (Pins through fracture). 29/68 versus 54/67; relative risk (RR) 0.53, 95% confidence interval (CI) 0.39 to 0.71; also Analysis 01.02 Functional grading: fair or poor (Pins through fracture). 8/68 versus 25/67; RR 0.31, 95% CI 0.15 to 0.64). Azzopardi 2005 found no significant differences between the two groups in the physical or mental score domains of the Short-Form 36 at four months (see Analysis 01.03) nor in either unilateral (reported P = 0.43) or bilateral (reported P = 0.74) activities of daily living scores at one year. Two people, both in the conservative treatment group, out of 11 former labourers in Rodriguez-Merchan 97 did not return to their former work (see Analysis 01.04). The failure to state the numbers of participants in the two treatment groups at one-year follow up meant that the results of individual functional outcomes for Azzopardi 2005 could not be presented in the Analyses. Results for individual functional outcomes were often incomplete for the other four trials. Grip strength, presented as a percentage of the grip strength of the unaffected arm, was greater in the pinning group in both Azzopardi 2005 (77% versus 72%; reported P = 0.54) and Rodriguez-Merchan 97 (85% versus 65%; P not reported) and demonstrably significantly better in the pinning group in Shankar 1992 (see Analysis 01.05 Under half grip strength at 6 months. 0/23 versus 11/22; RR 0.04, 95% CI 0.00 to 0.67). There were no statistically significant differences between the two groups in pain scores at one year (0.7 versus 1.2 on a 0 (no pain) to 10 (worst pain) point scale; reported P = 0.16) in Azzopardi 2005 or in the numbers of participants with occasional pain at long-term follow up in Rodriguez-Merchan 97 (see Analysis 01.06. 2/20 versus 4/20; RR 0.50, 95% CI 0.10 to 2.43). Azzopardi 2005 reported no statistically significant differences between the two groups in the components of wrist movement at one year except for ulnar deviation (93% versus 76% of normal; reported P = 0.009). All components of wrist movement were significantly better in the pinning group in Gupta 1999 (see Analysis 01.07). The overall range of wrist motion was reported to be better in the pinning group in Rodriguez-Merchan 97 (80% versus 60% of normal), as were the components of wrist movement in Shankar 1992 (statistical significant differences were reported for extension and ulnar deviation). Verhulst 1990 reported that the range of motion along the three axes showed no statistically significant differences between the two groups.

The difference in the mean functional scores (pain, functional status, range of motion and grip strength were rated) of the two groups of Stoffelen 1998 was not significant, and similar numbers in the two groups had a satisfactory outcome (see Analysis 01.02). Although eight of the conservative treatment group achieved an excellent grade, none did in the pinning group (see Analysis 01.01 Functional grading: not excellent (Pins supporting fracture). 48/48 versus 42/50; RR 1.19, 95% CI 1.05 to 1.34), the spread of the functional scores shown in a graph in the trial report seems to indicate that little should be made of this. Stoffelen 1998 also found no significant differences between the two treatment groups in grip strength or finger movements at final follow up.

Complications suffered by the participants of all six trials are presented in Analysis 01.08. Null events have also been entered when reported. Redisplacement requiring secondary treatment only occurred in the conservative treatment group (0/115 versus 22/154; RR 0.09, 95% CI 0.02 to 0.37). Complications associated with the pins (K-wires) and pin insertion were few and generally minor in consequence except for the removal of K-wires after a pin-track infection in Azzopardi 2005 and the K-wire migration in Gupta 1999 that caused a redisplacement of the fracture. There was no report of tendon rupture or injury. Complications relating to the median nerve, such as carpal tunnel syndrome, were more common, but not statistically significantly so, in the conservative treatment group (3/161 versus 11/202; RR 0.53, 95% CI 0.19 to 1.46). All six cases of superficial radial nerve injury, one of which persisted, occurred in the pinning group in Stoffelen 1998; these may have resulted from injuries caused by the radially-sited pin. The incidence of RSD was similar in the two groups. There was a high incidence of short-term RSD in Stoffelen 1998; this persisted in twice as many participants of the pinning group (4/48 versus 2/50). There was one case of shoulder hand syndrome in Shankar 1992. Slightly more patients (21/48 versus 29/50) in the conservative treatment group had diminished finger function at six weeks in Stoffelen 1998.

Anatomical results were better in the pinning group compared with the plaster group in all five fracture fixation trials. Redisplacement requiring secondary treatment (reduction or reduction and K-wire fixation) occurred only in conservatively treated fractures in four trials (see Analysis 01.08 Complications). The sole redisplacement in the pinning group was caused by K-wire (pin) migration in Gupta 1999. Healing of all fractures was confirmed in Gupta 1999 and Shankar 1992 and is likely in the other trials. There was a greater incidence of wrist deformity, depicted by angulated malunion, articular incongruity or an articular step in excess of two millimetres, in the conservative treatment group in Rodriguez-Merchan 97 (see Analysis 01.09). Significantly more people in the conservative treatment group had prominence of the ulnar styloid, stated as indicating radial collapse, in Shankar 1992 (see Analysis 01.09. 0/23 versus 12/22; RR 0.04, 95% CI 0.00 to 0.61). Verhulst 1990 reported that a quarter of pinning group participants had cosmetic deformity of the wrist compared with over a half of those treated conservatively. Moreover the gross appearance of the wrist was worse in participants of the conservative treatment group. Significantly better overall anatomical grades were achieved by the pinning group in Gupta 1999 (see Analysis 01.10). Losses in radial angulation, radial length and dorsal angulation from the reduced position were reported as being significantly greater in the conservative treatment group in Gupta 1999, Shankar 1992 and Verhulst 1990. Complete data for anatomical measures were only available for five-weeks follow up in Azzopardi 2005 and at final follow up for Gupta 1999 show better values for the pinning group in dorsal and radial angulation, and radial length (see Analysis 01.11).

In contrast, Stoffelen 1998 did not report superior anatomical results for the Kapandji's pinning group. Whilst radial shift (lateral) was less in the pinning group (mean values: 0.5 mm versus 1.5 mm), radial shortening was greater (mean values: 2 mm versus < 1 mm). Stoffelen 1998 claimed that these differences were statistically significant. Stoffelen 1998 made no specific mention of the apparently greater, though indicated as not statistically different, difference in dorsal angulation between the two groups.

Any method of percutaneous pinning versus any other method of percutaneous pinning

Kapandji fixation versus trans-styloid fixation
In Lenoble 1995, Kapandji fixation followed by immediate mobilisation was compared with trans-styloid fixation followed by around six weeks of plaster cast immobilisation in 120 people. Neither baseline data nor results were provided for three participants who died, 15 who were lost to follow up and six with missing data. Standard deviations were not provided for functional and anatomical outcomes presented as continuous outcomes.

Lenoble 1995 reported there was no statistically significant difference between the two groups in either grip or pinch strength, both presented as a percentage of the uninjured wrist (one-year results: mean grip strength 84% versus 83%; mean pinch strength 89% versus 87%). More participants of the Kapandji group were reported to suffer pain but the difference between the groups in the mean visual analogue scale values was not statistically significant (two-year results: 7.6 versus 6.9 on a 0 (no pain) to 100 (unbearable pain) point scale). Wrist mobility was reported to be significantly better in the Kapandji group up until the removal of the K-wires at six to eight weeks (all values as percentage of uninjured arm, flexion: 59% versus 46%; extension: 58% versus 44%; radial deviation: 60% versus 38%; ulnar deviation: 61% versus 52%; pronation: 80% versus 62%; supination: 76% versus 64%) but not subsequently. Lenoble 1995 considered that better early range of motion results for the Kapandji group related to the early mobilisation of this group and occurred at the cost of increased pain.

There were more complications in the Kapandji group (see Analysis 02.01). In particular, there were more Kapandji group participants with persistent symptoms related to the superficial radial nerve (8/54 versus 3/42; RR 2.07, 95% CI 0.59 to 7.34), and an identical result for bone-scan confirmed RSD. Lenoble 1995 suggested that the radial nerve complications were related to Kirschner wire removal; these are closer to the sensory branches of the radial nerve in Kapandji pinning. The redisplaced fracture in the trans-styloid fixation group was treated with an external fixator. There were no cases of tendon or vascular injury or median nerve dysfunction. All four cases of pin-track infection were superficial.

Similar long-term results for anatomical outcomes in the two groups were evident from graphs presented in the trial report. The mean ulnar variance, which was positive in both groups, was approximately one millimetre greater in the Kapandji group; the increase in ulnar variance from the reduction position was said to be statistically more significant in this group. One of the six over-reduced (by 15 degrees in the anterior direction) fractures in the Kapandji group developed a more extreme anterior tilt whilst the two over-reduced fractures in the trans-styloid group did not worsen. The four cases of DISI (dorsal intercalated segment instability) and seven cases of VISI (volar intercalated segment instability) were reported as being "evenly" distributed through the two groups.

Kapandji fixation versus Py's isoelastic pinning
Fikry 1998 compared Kapandji intrafocal pinning with Py's isoelastic pinning in 110 people but presented results only for the 88 participants who were available at 27 months follow up.

Function, rated with the Jakim scoring system (Jakim 1991), was presented in two categories; subjective (pain and function) and objective (mobility, grip strength and deformity). The results for subjective function were almost the same for the two groups (see Analysis 03.01) but the difference in the objective results was statistically significant (see Analysis 03.02), as was the difference in the combined function and radiological results (see Analysis 03.03). A superior result was claimed for the Py's pinning group but the mean values for the objective and overall scores presented in Table III of the trial report show the converse (see Analyses 03.02 and 03.03). Thus, two set of values have been presented in the four analyses showing mean Jakim scores: the first set of values are those in the report; in the second set the results for the two groups are reversed, based on the assumption that the rows in the Table were presented in the reverse order. Though slightly fewer Py's pinning patients had an unsatisfactory outcome according to the grading of the overall outcome into four categories (excellent, good, fair, poor), the difference between the two groups did not reach statistical significance (see Analysis 03.04, overall outcome grades: not excellent 20/42 versus 16/46; RR 1.37, 95% CI 0.82 to 2.27; and overall outcome grades: fair or poor 7/42 versus 6/46; RR 1.28, 95% CI 0.47 to 3.50).

Kapandji intrafocal pinning was associated with significantly more complications (see Analysis 03.05). Fikry 1998 suggested that the excess of secondary fracture displacements (7/42 versus 2/46; RR 3.83, 95% CI 0.84 to 17.44) and wire displacements (6/42 versus 0/46; RR 14.21, 95% CI 0.82 to 244.80) in the Kapandji group was linked to posterior comminution of the original fracture. The iatrogenic fracture in the Py's pinning group was successfully treated by a plate; Fikry 1998 suggested that a missed epiphyseal fracture generated a weakness that resulted in the shearing of the epiphyseal fragment when the posterior pin was inserted. Similar numbers of participants suffered tendon rupture or RSD; all participants with ruptured tendons had successful secondary tendon transfer, and all those with RSD required prolonged rehabilitation.

Anatomical results including dorsal and radial angulation, radial length, articulation of the radio-ulnar joint, incongruity ("step-off") and signs of arthritis were scored according to Jakim's scoring system (Jakim 1991). A superior result was claimed for the Py's pinning group but again the mean values for the radiological section presented in the report show the converse (see Analysis 03.06). As noted above, more secondary displacement of fractures occurred in the Kapandji group.

Modified Kapandji fixation versus Willenegger fixation
In Strohm 2004, intrafocal pinning with two Kirschner wires and fracture fixation with a third wire was compared with Willenegger pinning in 100 participants. While both groups had wrist immobilisation for six weeks, a volar splint was used in the first group and a forearm cast in the second. Moreover, the modified Kapandji group started physiotherapy after three weeks.

Strohm 2004 reported that the modified Kapandji group had significantly higher modified Martini scores (this composite score included pain, subjective assessment, strength, work and sports, wrist and forearm mobility, radiological results and complications) at a median of 10 months follow up: 34 versus 28 on a scale 0 (worst) to 38 (best); reported P < 0.005). There were no significant differences between the two groups in the numbers of people with complications (see Analysis 04.01). Two participants of the Willenegger group had an undefined "conversion procedure". Both cases of RSD resolved after treatment; and both cases of carpal tunnel syndrome were operated on. Strohm 2004 reported there was no significant difference between the two groups in operating times but that imaging time was significantly less in the modified Kapandji group (89.5 versus 156 seconds; reported P < 0.004).

Any technique or type of material or device used for percutaneous pinning versus any other technique or type of material or device at surgery or post-operatively

Biodegradable pins or wires versus metal pins or wires
Two trials (Casteleyn 1992; Korner 1999) compared biodegradable pins with Kirschner wires in 70 people. Casteleyn 1992 used Kapandji's intrafocal pinning with two wires whereas two pins or wires were inserted across the fracture, via the radial styloid, in Korner 1999. Despite the differences in the pinning techniques, the results for the two trials are presented together in the analyses but no pooling has been performed. (The possibility that the subcutaneous protrusion of the ends of the pins in the Kapandji pinning technique could increase the specific complications of biodegradable implants was raised in Casteleyn 1992; this could also have applied to Korner 1999.)

Functional recovery in the Kirschner wire group was reported to have been quicker in Casteleyn 1992 although the eventual difference between the two groups (based on a five point scale) was reported as not being statistically significant, and no participant had any restriction in activities of daily living. The range of motion was satisfactory in both groups; again there was no statistically significant difference between them (see Analysis 05.01). Korner 1999 did not report whether the greater loss in range of motion in the biodegradable pinning group was statistically significant: mean loss compared to contralateral wrist: 30 versus 20 degrees (extension/flexion); 35 versus 30 degrees (pronation/supination).

In both trials there was an excess of complications in the biodegradable pinning group (see Analysis 05.02). Difficulties during pin insertion in Korner 1999 (8/19 versus 0/21; RR 18.70, 95% CI 1.15 to 303.59) contributed to the longer duration of the operation in the biodegradable pinning group (mean duration: 40.5 versus 23.5 minutes). Secondary surgery was performed for the two tendon ruptures (Kirschner wiring group) and for one of the two cases of carpal tunnel syndrome; both of the latter were attributed to swelling brought on by the biodegradable rod. Painful scars, sinus formation and severe osteolytic reactions (9/15 versus 0/21; RR 19.00, 95% CI 1.20 to 299.63) were also related to the degradation and resorption of the biodegradable material in Casteleyn 1992. One of the people with a sinus showed a non-specific foreign-body reaction with abundant giant cells. Most of the severe osteolytic reactions were most obvious around three to six months post-operatively, but had resolved or regressed by one year. Casteleyn 1992 pointed out that the main putative advantage of biodegradable implants, namely that they do not need to be removed, was offset by the "management cost and inconvenience of the late inflammatory reactions".

Final anatomical results were considered satisfactory in both groups in Casteleyn 1992, who found no statistically significant differences between the two groups (see Analysis 05.03). One person in the biodegradable pinning group in Korner 1999 had a secondary displacement requiring revision (see Analysis 05.02).

Any type or duration of post-operative immobilisation versus any other type or duration of immobilisation including none

Duration of post-operative immobilisation after percutaneous pinning
Two trials (Allain 1999; Milliez 1992) compared plaster cast immobilisation for one week versus six weeks after surgery in 120 people. Given the different methods of percutaneous pinning (trans-styloid fixation in Allain 1999 and Kapandji intrafocal pinning in Milliez 1992) and clear heterogeneity in the results of the few comparable outcomes (all complications) with data, pooled results are not presented for this comparison.

Overall, there was little difference between the two treatment groups in functional outcome in either trial. Allain 1999 reported there were no significant differences between the two groups in the mean duration of sick leave (7 weeks) for the 39 trial participants who worked, in the numbers (14) with functional discomfort during domestic chores, or in the numbers of "sportsmen" with residual discomfort (3 of 22). One participant, who had RSD, of the six weeks group was the only one of 19 people in Milliez 1992 who had not returned to work by three months. At final follow up (1 year: Allain 1999; 3 months: Milliez 1992), differences in grip strength, which was greater in the early mobilisation group in both trials (Allain 1999: 25 kg versus 21 kg; Milliez 1992: 55% versus 44% of normal side), were reported not to be statistically significant. Allain 1999 reported there was no significant difference between the two groups in the mean pain scores (13 versus 12.5 (15 = no pain)) or use of analgesics. Though, as calculated from percentages in the trial report, fewer people in the early mobilisation groups had pain at follow up in Milliez 1992 (see Analysis 06.01; 4/27 versus 10/30; RR 0.44, 95% CI 0.16 to 1.25); the difference between the two groups was not statistically significant. All the mean values for the six parameters for range of movement in Allain 1999 were greater in the early mobilisation group but only the difference in the ulnar deviation was reported as being statistically significant (39 versus 37 degrees; reported P = 0.03). There were no statistically significant differences in flexion (74% versus 77% of normal side) or extension (72% versus 74% of normal side) in Milliez 1992, although the results were marginally better in the group immobilised for six weeks.

None of the differences between the two treatment groups in the reported clinical outcomes were statistically significant for either trial. Analysis 06.02 presents the numbers of participants with various complications. These were fewer overall with similar numbers in the two groups in Allain 1999. Surgery was necessary for the person of the six weeks group who had ruptures of two tendons, and an anterior approach to wire removal was required for a displaced wire in another person in the same group. Three of the four cases of persistent radial nerve paraesthesia or hypoaesthesia appeared only after Kirschner wire removal. In Milliez 1992, all the complications occurred in the early group with the exception of one case of RSD, referred to above. One of the five wire displacements in the early mobilisation group in Milliez 1992 was associated with a tendon rupture, one resulted from poor technique (wiring was done by "junior" operators) and two from osteoporotic bone. In Milliez 1992, the wrists of three people with "treatment failure", one due to the need for tendon repair and two due to the risk of secondary displacement, were immobilised. There was no significant difference between the two treatment groups of in Allain 1999 in the numbers of people who were disappointed with their outcome (see Analysis 06.03: 3/30 versus 1/30; RR 3.00, 95% CI 0.33 to 27.23).

Similar radiological results in the two treatment groups were reported by both trials. As it is likely that the unusually small "standard deviations" provided in Allain 1999 were standard errors, the results for dorsal and radial angulation and radial length with standard deviations calculated from the supposed standard errors are shown in Analysis 06.04. These results are compatible with the claim of no statistical significance. The three radiological parameters listed in Milliez 1992 are defined in the 'Characteristics of included studies' table. However, the results at three months seem to be for dorsal angulation (volar tilt: 6.9 versus 6.5 degrees), radial inclination (21.4 versus 21.3 degrees) and ulnar variance (1.4 mm versus 1.1 mm).

Allain 1999 concluded that additional immobilisation was not necessary after trans-styloid fixation, whereas Milliez 1992 concluded that early mobilisation after Kapandji intrafocal fixation should only be used in patients with good quality bone stock who would comply with the instructions after surgery.

 

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. Index terms

This review of one of the most common surgical interventions for one of the most common fractures has only 13 trials, involving a total of 940 participants, and evaluates six comparisons, with data pooling for one comparison. There is either no or limited evidence to inform the many choices for percutaneous pinning; this variation is illustrated by the questions addressed by and the interventions used in the included trials, as well as those for the six trials in 'Studies awaiting assessment'.

Limitations of the review methods
As this review abided by the criteria and methods set out in a published protocol, we have restricted our comments to two issues. The first is whether trials have been missed or inappropriately excluded in our search and selection processes. The second concerns decisions concerning pooling and subgroup analysis.

Our search was comprehensive and built on searches carried out over many years prior to the separate development of this review (Handoll 2003a). It has included the handsearch of conference proceedings and checks for ongoing trials. An inclusive and benefit-of-doubt approach during trial searches has been maintained throughout by the lead author (HH). Additionally, trial authors of unpublished trials have been sent requests for information and trial reports. While it is possible that we have missed some potentially eligible trials, it is questionable whether these would have ultimately been included if they had remained unpublished and substantially under-reported. We guarded against study selection bias by the independent selection of eligible trials by all three review authors.

We restricted pooling to one comparison. As stated beforehand, we treated Kapandji intrafocal pinning as a distinctly separate method of pinning to across-fracture methods. The decision not to pool data from trials of these two different pinning approaches is supported by the clear and statistically significant differences in effect (e.g. see Analysis 01.02. Test for interaction: two tail Z-test = 0.02). Though the five across-fracture trials were heterogeneous, such as in the type of fracture, the pooled results for the few available outcomes were statistically homogeneous. It was not possible to conduct subgroup analyses to explore other trial characteristics or sensitivity analyses, including those to explore the effects of the high loss to follow up in some trials.

Limitations of the review evidence
Overall, the available evidence is limited in scope and quantity, and is of uncertain validity. There is a potential for chance findings from these 13 small trials and, in addition, any apparent comparability of results of interventions tested within some trials should not be interpreted as evidence of no effect or no difference. Systematic bias, in the form of selection, performance, exclusion or assessment bias, or a combination of these could not be ruled out for any trial. Incomplete reporting of methods and results was a major problem in many of these trials, and especially Korner 1999 and Verhulst 1990 which were available in conference abstracts only. Another limitation was the inadequate assessment of outcome, particularly of function and in the long-term. Non-validated outcome measures, such as those based on the Gartland and Werley scoring system (Gartland 1951), that combine aspects of function, pain, deformity and complications are particularly crude indicators of outcome. Considerable caution is needed when interpreting these, and more so when the scores have been categorised. Many trials predated the development of validated 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). These help to standardise functional assessment in a meaningful way and assist interpretation (Amadio 2001).

Applicability of the review evidence
Generalising the findings of the included trials, should these be valid, is hampered by inadequate reporting of study details, such as the type and severity of the fracture, and bone quality. The variety of fracture classification systems, with associated issues of reliability and validity further complicates this area (Jupiter 1997). For example, the two fracture classifications used by trials in this review (the AO and Frykman) place different emphases on various fracture patterns and anatomical components. Studies have revealed unsatisfactory interobserver reliability and intraobserver reproducibility for both classification systems (Andersen 1996; Kreder 1996b), and neither was useful for predicting clinical outcome (Flinkkila 1998). Two trials in this review stipulated criteria for anatomical displacement of the fracture for trial entry. However, Kreder 1996a found quite broad margins of error ("tolerance limits") for anatomical measurements in general. This with other factors, such as variations in anatomical reference points, again hinders treatment comparison.

Fracture instability was the inherent or explicit criterion for many of the included trials, but it is not established how best to predict this. A recent study of 4024 patients concluded that patient age, metaphyseal comminution of the fracture and ulnar variance were the most important factors in predicting instability of distal radial fractures (MacKenney 2006).

Comparisons
A summary of the conclusions of effectiveness drawn from the findings of each comparison is provided in  Table 6. Here, the effectiveness of each intervention relative to the 'control' intervention in each comparison is graded according to the categories of effectiveness (1: Beneficial; 2: Likely to be beneficial; 3: Trade off between benefits and harms; 4: Unknown effectiveness; 5: Unlikely to be beneficial; 6: Likely to be ineffective or harmful) described in  Table 3. Some notes in justification of the grading, some qualifying statements and other comments are also provided.

Any method of percutaneous pinning versus conservative treatment involving plaster or brace use

Percutaneous pinning versus plaster cast immobilisation alone
The six trials for this comparison were heterogeneous in terms of patient and fracture characteristics, pinning techniques and aftercare (see  Table 4). As specified in the protocol, the results of Stoffelen 1998, which used the Kapandji pinning technique, for functional and anatomical outcomes were presented separately.

The better anatomical result, both in maintaining the reduced fracture position and in final anatomy, found in the across-fracture pinning group is likely to be valid. The extent of improvement varied. The two trials (Rodriguez-Merchan 97; Shankar 1992) with potentially the most unstable fractures (all participants had comminuted intra-articular fractures) had higher proportions of conservatively-treated participants with redisplacements requiring secondary treatment and deformity. Azzopardi 2005 found the improvement in radiological parameters to be "marginal". Superior functional results were found in the pinning group in three trials but these are partly based on non-validated scoring systems that also rated deformity, and small numbers of participants. Neither Azzopardi 2005 nor Verhulst 1990 found significantly improved functional outcome in their "elderly" populations. Complications of pinning were generally minor. In all, there is some evidence to suggest superior results of percutaneous pinning to stabilise fracture fragments compared with conservative treatment. However, the available evidence is insufficient to address questions such as those regarding the fracture pattern and the type of pinning.

Stoffelen 1998 was compromised by poor methodology and inconsistent reporting in the three trial reports. Kapandji pinning with early mobilisation (one week of plaster immobilisation) for dorsally displaced extra-articular fractures was not associated with better anatomical or functional results to plaster cast immobilisation for six weeks, three weeks of which involved an above-elbow cast. There was a high rate of complications, in particular of RSD and finger stiffness, in Stoffelen 1998; of note were the six cases of radial nerve injury from pin placement. The available evidence from this trial is insufficient to show the effectiveness of the Kapandji approach.

Any method of percutaneous pinning versus any other method of percutaneous pinning

Kapandji fixation versus trans-styloid fixation
One trial (Lenoble 1995) compared two or three-pin Kapandji pinning with two-pin trans-styloid fixation in dorsally displaced fractures. These were stated to be the two most commonly used methods in France for such fractures. Final anatomical and functional results were similar in both groups, though better early mobility but more pain occurred in the Kapandji pinning group reflecting their earlier mobilisation. The exclusion of 20% of participants from the analyses, already small numbers and other methodological shortcomings weakens the validity of the trial's results. However the higher, while not statistically significantly so, numbers with superficial radial nerve symptoms in the Kapandji pinning group is plausibly related to the pin placement of this method.

Kapandji fixation versus Py's isoelastic pinning
Contradictory anatomical and functional results, based on an unvalidated scoring scheme were reported in the only trial comparing these two methods (Fikry 1998) for dorsally displaced fractures. There was insufficient evidence to draw any conclusions of difference between the two groups. However, the suggestion in Fikry 1998 that the higher numbers of complications, specifically fracture and wire displacement, in the three-pin Kapandji pinning group were associated with fractures with dorsal comminution seems pertinent to the use of this method. Others have also advised the restriction of the Kapandji pinning to non-comminuted fractures (Fernandez 1999) as well as noting the further refinements of the method such as the use of "arum" pins which may improve results and lessen tendon-related complications (Fernandez 1999; Rayhack 1993).

Modified Kapandji fixation versus Willenegger fixation
The modified Kapandji method used in Strohm 2004 is essentially a combination of fracture fixation and intrafocal pinning. The comparison in Strohm 2004 should not be viewed as simply testing two approaches for pinning because of other differences such as the additional physiotherapy starting after three weeks in the modified Kapandji group. The serious methodological flaws, in particular the use of an unvalidated and composite scoring scheme, variable follow up times and exclusion of 19% of participants from the analyses, of Strohm 2004 mean that the promising results for the "Kapandji" method should not be taken as proven. The smaller mean duration of radiographic exposure for the modified Kapandji group is curious given that it seems the more complicated of the two pinning procedures.

Any technique or type of material or device used for percutaneous pinning versus any other technique or type of material or device at surgery or post-operatively

Biodegradable pins or wires versus metal pins or wires
The use of biodegradable pins was tested in two small trials (Casteleyn 1992; Korner 1999) using two very different pinning techniques. There was insufficient evidence to detect a difference in anatomical and functional outcome between the two groups. What were evident, however, were the extra demands at surgery of insertion of biodegradable pins, and the significant excess of complications associated with biodegradable material. Thus the recommendation, expressed by both studies, not to use biodegradable pins for these fractures (in adults) seems justified. This conclusion may be moderated should evidence become available for a trial, involving 115 participants, currently in 'Studies awaiting assessment'.

Any type or duration of post-operative immobilisation versus any other type or duration of immobilisation including none

Duration of post-operative immobilisation after percutaneous pinning
The two small quasi-randomised trials (Allain 1999; Milliez 1992) evaluating duration of immobilisation after percutaneous pinning used very different pinning techniques. Thus it is likely that the findings of one trial may not apply to the other. No statistically significant differences between one and six weeks plaster cast immobilisation in functional, clinical or radiological results were found in either trial; except for a clinically irrelevant difference of in ulnar deviation in Allain 1999. However, more complications occurred in the early mobilisation group after Kapandji pinning in Milliez 1992. As Allain 1999 acknowledged, the small numbers involved are not enough to conclude that one week immobilisation, reducing the inconvenience and problems through disuse associated with prolonged immobilisation, was sufficient after trans-styloid fixation for certain fracture patterns. Early mobilisation is put forward as a key advantage of Kapandji fixation (Kapandji 1988) and often applied. Whilst the excess of complications in the early mobilisation group in Milliez 1992 is of concern, there is not enough good quality evidence to determine whether this aspect of the Kapandji method is appropriate.

Any method or timing of pin or wire removal versus any other method or timing of pin or wire removal including no removal
At present there are no included trials for this topic.

 

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. Index terms

 

Implications for practice

Only a few and provisional conclusions relating to clinical management can be drawn from the available randomised trials.

For dorsally displaced fractures, across-fracture percutaneous pinning helps to maintain reduced positions and thereby reduce deformity and malunion compared with plaster cast immobilisation alone. There is limited evidence that its use improves function. Complications are usually minor and, to some extent, avoidable. However, uncertainty remains about the indications for percutaneous pinning, the best technique to employ, and the extent and duration of immobilisation. Kapandji pinning, involving the support rather than fixation of the distal fracture fragment, appears to be associated with a less favourable outcome, particularly an excess of probable iatrogenic complications. More recent refinements of this technique have yet to be evaluated. There was some evidence of an excess of complications which, coupled with the extra demands at surgery, are likely to outweigh the putative advantages - avoidance of metal wire extraction and the associated risk of damage - of biodegradable pins.

 
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, further research is called for (Handoll 2003a). However, rather than embark on yet more small single centre trials, particularly those with inadequate methodology that are unlikely to provide the good quality generalisable evidence required, the identification of the priority questions for the management of these fractures is required (Handoll 2003d). The updating of the evidence summaries for other surgical interventions of these fractures is likely to inform this process.

 

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. Index terms

We thank Lesley Gillespie for her help with the search strategy. We thank the following for helpful comments at the editorial and external review of the protocol: Bill Gillespie, Lesley Gillespie, Peter Herbison, Jesse Jupiter and Janet Wale. We thank Lindsey Shaw for her help during editorial processing of the protocol. We thank the following for helpful comments at the editorial and external review of the review: Bill Gillespie, Jesse Jupiter, Vicki Livingstone and Janet Wale. We thank Joanne Elliott and Lindsey Shaw for their help during editorial processing of the review.

We thank Sonia Stewart for her help with translation. We are very grateful to those trialists, in particular Rakesh Gupta, who provided clarification and further information on their trials.

 

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. Index terms
Download statistical data

 
Comparison 1. Percutaneous pinning versus plaster cast

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

 1 Functional grading: not excellent4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Pins through fracture
3135Risk Ratio (M-H, Fixed, 95% CI)0.53 [0.39, 0.71]

    1.2 Pins supporting fracture
198Risk Ratio (M-H, Fixed, 95% CI)1.19 [1.05, 1.35]

 2 Functional grading: fair or poor4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Pins through fracture
3135Risk Ratio (M-H, Fixed, 95% CI)0.31 [0.15, 0.64]

    2.2 Pins supporting fracture
198Risk Ratio (M-H, Fixed, 95% CI)0.96 [0.49, 1.89]

 3 Short Form 361Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Physical score at 4 months (0: worst to 100: best health)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.2 Mental score at 4 months (0: worst to 100: best health)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 4 Non return to work (labourers)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Under half grip strength at 6 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Pain (occasional)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Range of movement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

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

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

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

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

 8 Complications6Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    8.1 Redisplacement
150Risk Ratio (M-H, Fixed, 95% CI)3.0 [0.13, 70.30]

    8.2 Redisplacement resulting in secondary treatment (reduction or reduction and K-wire fixation)
4269Risk Ratio (M-H, Fixed, 95% CI)0.09 [0.02, 0.37]

    8.3 K-wire migration
2180Risk Ratio (M-H, Fixed, 95% CI)8.68 [1.19, 63.23]

    8.4 K-wire extrusion
150Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    8.5 K-wire removal due to metal sensitivity
145Risk Ratio (M-H, Fixed, 95% CI)2.88 [0.12, 67.03]

    8.6 Pin track infection
4189Risk Ratio (M-H, Fixed, 95% CI)3.62 [0.61, 21.32]

    8.7 Stab wound infection
1130Risk Ratio (M-H, Fixed, 95% CI)13.09 [0.69, 247.92]

    8.8 Joint infection/osteomyelitis
140Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    8.9 Tendon injury/rupture
294Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    8.10 Median nerve compression/neuropathy/contusion /CTS
5363Risk Ratio (M-H, Fixed, 95% CI)0.53 [0.19, 1.46]

    8.11 Superfical radial nerve injury
2152Risk Ratio (M-H, Fixed, 95% CI)13.53 [0.78, 233.82]

    8.12 Reflex sympathetic dystrophy/Sudeck's atrophy
3188Risk Ratio (M-H, Fixed, 95% CI)0.84 [0.45, 1.59]

    8.13 Persistent reflex sympathetic dystrophy
198Risk Ratio (M-H, Fixed, 95% CI)2.08 [0.40, 10.85]

    8.14 Shoulder hand syndrome
295Risk Ratio (M-H, Fixed, 95% CI)0.32 [0.01, 7.45]

    8.15 Diminished finger function (at 6 weeks)
198Risk Ratio (M-H, Fixed, 95% CI)0.75 [0.51, 1.12]

 9 Deformity (clinical and radiological)2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    9.1 Angulated malunion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.2 Articular incongruity
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.3 Articular step off > 2 mm
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.4 Residual deformity - prominence of ulnar styloid
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

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

    10.2 Fair or poor
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 11 Anatomical measurements2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    11.1 Dorsal angulation (degrees)
2Mean Difference (IV, Fixed, 95% CI)Not estimable

    11.2 Radial angulation (degrees)
2Mean Difference (IV, Fixed, 95% CI)Not estimable

    11.3 Radial length (mm)
2Mean Difference (IV, Fixed, 95% CI)Not estimable

    11.4 Ulnar variance (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 
Comparison 2. Kapandji intrafocal pinning (2 or 3 wires) versus trans-styloid fixation (2 wires)

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

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

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

    1.2 Superficial pin-track infection
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    1.4 Superficial radial nerve - symptoms
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.5 Median nerve dysfunction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.6 Confirmed reflex sympathetic dystrophy (bone scan)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 3. Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires)

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

 1 Subjective results: pain and function (normal = 30 points)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 In paper
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    1.2 Reversed results
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 2 Objective results: mobility, grip strength, deformity (normal = 30 points)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 In paper
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    2.2 Reversed results
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 3 Overall results: radiological, subjective and objective (normal = 100 points)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 In paper
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    3.2 Reversed results
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 4 Overall outcome grades1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

    4.2 Fair or poor
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    5.1 Secondary displacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    5.2 Fracture caused by pinning
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    5.3 Wire displacement
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    5.4 Superficial infection
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

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

 6 Radiological results (normal = 40 points)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 In paper
1Mean Difference (IV, Fixed, 95% CI)Not estimable

    6.2 Reversed results
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 
Comparison 4. Modified Kapandji pinning (3 wires) versus Willenegger pinning (2 wires)

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

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

    1.1 "Conversion procedure" (secondary treatment)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

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

    1.4 Carpal tunnel syndrome
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

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

    1.7 Signs of swelling
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Comparison 5. Biodegradeable pins versus Kirschner wires

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

 1 Range of movement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

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

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

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

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

 2 Complications2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Operational difficulties in pin or wire insertion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Secondary displacement requiring revision
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.3 Superficial wound infection
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    2.5 Carpal tunnel syndrome
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    2.7 Secondary surgery
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.8 Painful scars
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.9 Sinus formation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.10 Severe osteolytic reactions
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.11 Arthrosis (radiological signs)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Anatomical measurements1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

    3.3 Radio-ulnar index (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

 
Comparison 6. Early (after 1 week cast immobilisation) versus later (after 6 weeks) mobilisation post surgery

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

 1 Pain: usually or during effort (rounded data derived from percentages)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Complications2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Displaced wires or pins
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Treatment failure (change of treatment)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.3 Superficial pin-track infection
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.4 Tendon rupture
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.5 Persistent radial nerve paraesthesia or hypoaesthesia
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.6 Reflex sympathetic dystrophy
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Patient dissatisfaction with outcome1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Anatomical measurements (at 1 year): standard errors conversion1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Dorsal angulation - volar tilt (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

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

    4.3 Radial length (mm)
1Mean Difference (IV, 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. 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.
4. or/1-3

 

Appendix 3. Search strategies for CINAHL and EMBASE (OVID-WEB)


CINAHLEMBASE

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
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



 

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. Index terms

Last assessed as up-to-date: 15 May 2007.


DateEventDescription

25 July 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. Index terms

Protocol first published: Issue 3, 2006
Review first published: Issue 3, 2007

 

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. Index terms

This review was initiated by Helen Handoll (HH) who prepared the first draft of the protocol. This was critically reviewed by the other two authors, Rajan Madhok (RM) and Manesh Vaghela (MV). HH searched for trials and contacted trial authors. All three authors performed study selection. HH and MV reviewed the included trials. HH completed the first draft of the review in RevMan. All versions were scrutinised by the other two authors. Helen Handoll is the guarantor 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. 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. Index terms
 

Internal sources

  • University of Teesside, Middlesbrough, UK.
  • North Tees and Hartlepool NHS Trust, UK.
  • University of Manchester, Manchester, UK.

 

External sources

  • No sources of support supplied

* 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. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
Allain 1999 {published data only}
  • Allain J, Le Guilloux P, Le Mouel S, Goutallier D. Trans-styloid fixation of fractures of the distal radius. A prospective randomized comparison between 6- and 1-week postoperative immobilization in 60 fractures. Acta Orthopaedica Scandinavica 1999;70(2):119-23.
Azzopardi 2005 {published and unpublished data}
  • Azzopardi T. personal communication May 24 2006.
  • Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: A prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. Journal of Bone and Joint Surgery - British Volume 2005;87(6):837-40.
  • Ehrendorfer S. Management of distal radius fracture. In: The National Research Register, Issue 2, 2000. Oxford: Update Software.
Casteleyn 1992 {published data only}
  • Casteleyn PP, Handelberg F, Haentjens P. Biodegradable rod fixation of wrist fractures [Abstract]. Orthopaedic Transactions 1993;17(4):1036.
  • Casteleyn PP, Handelberg F, Haentjens P. Biodegradable rods versus Kirschner wire fixation of wrist fractures. A randomised trial. Journal of Bone and Joint Surgery - British Volume 1992;74(6):858-61.
  • Casteleyn PP, Handelberg F, Haentjens P, Opdecam P. Biodegradable rod fixation of wrist fractures [Abstract]. Journal of Bone and Joint Surgery - British Volume 1993;75 Suppl 2:196.
Fikry 1998 {published data only}
  • Fikry T, Fadili M, Harfoui A, Dkhissi M, Zryouil B. Metaphysis fracture of the distal radius: Kapandji's or Py's pinning? [Fractures metaphysaires du radius distal: embrochage de Kapandji ou de Py?]. Annales de Chirurgie de la Main et du Membre Superieur 1998;17(1):31-40. [MEDLINE: 20396977]
Gupta 1999 {published and unpublished data}
  • Gupta R. personal communication April 4 2006.
  • Gupta R, Raheja A, Modi U. Colles' fracture: management by percutaneous crossed-pin fixation versus plaster of Paris cast immobilization. Orthopedics 1999;22(7):680-2.
Korner 1999 {published data only}
  • Korner J, Verheyden P, Nocker C, Josten C. The use of biodegradable pins in the operative treatment of distal radial fractures [Abstract]. Final program of the 21st Triennial World Congress SICOT 99; 1999 Apr 18; Sydney. Sydney: SICOT, 1999; Vol. Final Program:239.
Lenoble 1995 {published data only}
  • Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations. Journal of Bone and Joint Surgery - British Volume 1995;77(4):562-7.
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.
Rodriguez-Merchan 97 {published data only}
  • Rodriguez-Merchan EC. Plaster cast versus percutaneous pin fixation for comminuted fractures of the distal radius in patients between 46 and 65 years of age. Journal of Orthopaedic Trauma 1997;11(3):212-7.
Shankar 1992 {published data only}
  • Shankar NS, Craxford AD. Comminuted Colles' fractures: a prospective trial of management. Journal of the Royal College of Surgeons of Edinburgh 1992;37(3):199-202.
Stoffelen 1998 {published data only}
  • Stoffelen DV, Broos PL. Closed reduction versus Kapandji-pinning for extra-articular distal radial fractures. Journal of Hand Surgery - British Volume 1999;24(1):89-91.
  • Stoffelen DV, Broos PL. Kapandji pinning or closed reduction for extra-articular distal radius fractures. Journal of Trauma 1998;45(4):753-7.
  • Stoffelen DVC, Broos PL. Conservative treatment versus Kapandji-pinning for extra-articular distal radius fractures. Osteosynthese International 1999;7 Suppl 1:87-93.
Strohm 2004 {published data only}
  • Strohm PC, Muller CA, Boll T, Pfister U. Two procedures for Kirschner wire osteosynthesis of distal radial fractures: a randomized trial. Journal of Bone and Joint Surgery - American Volume 2004;86(12):2621-8.
Verhulst 1990 {published data only}
  • Verhulst D, Pimontel P, Puylaert D, Gijs T, Bogehams J. Single Kirschner wire fixation of Colles' fractures [Abstract]. Orthopaedic Transactions 1990;14(3):654.

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. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
Biedermann 2001 {published and unpublished data}
  • Biedermann M. personal communication July 25 2002.
  • Biedermann M, Gerber BE. Minimal invasive stabilisation of distal radius fractures with an 1 K-wire technique [Abstract]. Journal of Bone and Joint Surgery - British Volume 2001;83 Suppl 2:258.
Delattre 1994 {published data only}
  • Delattre O, Saillant G, Lemoine J, Benazet JP, Roy-Camille R. Reduction and osteosynthesis with pin fixation of wrist fractures. A comparative study between Kapandji's and Py's techniques [Reduction et synthese par brochage des fractures du poignet. Etude comparative entre la technique de Kapandji et la technique de Py]. Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur 1994;80(2):94-107.
  • Delattre O, Saillant G, Lemoine J, Benazet JP, Roy-Camille R. Reduction and pin fixation for fractures of the distal radius: A comparative study between the Kapandji and Py techniques [Abstract]. Orthopaedic Transactions 1996;20(2):492.
  • Delattre O, Saillant G, Lemoine J, Benazet JP, Roy-Camille R. Reduction and pinning of wrist fractures: Comparative study of the Kapandji and Py techniques [Abstract]. Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur 1996;82(7):672.
Galli 2002 {published data only}
  • Galli S, De Filippo G, Bonaspetti G, Zarattini G, Pazzaglia UE. Long arm cast versus percutaneous pinning in the treatment of distal radial fractures [Abstract]. Journal of Hand Surgery - British Volume 2002;27 Suppl 1:6-7.
Harper 2000 {published and unpublished data}
  • Harper WM. personal communication October 2001.
  • Harper WM. A randomised prospective trial comparing MUA and POP with K wire fixation in Colles fractures. In: The National Research Register, Issue 2, 2000. Oxford: Update Software.
Seifert 1998 {published data only}
  • Seifert J, Muller C, Schauwecker HH. Studying minimally invasive osteosynthesis methods for distal radius fractures. Intra-focal vs. conventional wire osteosynthesis [Untersuchungen zu minimalinvasiven Osteosyntheseverfahren bei distalen Radiusfrakturen. Intrafokale versus konventionelle Bohrdrahtosteosynthese.]. Unfallchirurgie 1998;24(1):18-24.

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. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
Gravier 2005 {published data only}
  • Argenson JN. personal communication July 4 2006.
  • Gravier R, Flecher X, Parratte S, Rapaie P, Argenson JN. Trans-styloid and intrafocal pinning of Pouteau-Colles fractures: advantage in terms of postoperative stability compared with simple intrafocal pinning [abstract]. Journal of Bone and Joint Surgery - British Volume 2005;87 Suppl 2:130.
Hargreaves 2004 {published and unpublished data}
  • Hargreaves D. personal communication March 20 2006.
  • Hargreaves DG, Drew SJ, Eckersley R. Kirchner wire pin tract infection rates: A randomized controlled trial between percutaneous and buried wires. Journal of Hand Surgery - British Volume 2004;29(4):374-6.
Russe 2000 {published and unpublished data}
  • David A. personal communication August 16 2006.
  • David A, Muller D, Eitenmuller J, Muhr G. One-year results of the osteosythesis of distal radius fractures with resorbable pins [Abstract] [Einjahresergebnisse der osteosynthese distaler radiusfrakturen mit resorbierbaren stiften]. Hefte zur Zeitschrift der Unfallchirurg 1998;265:203-6.
  • Muller D, David A, Pommer A, Muhr G. Osteosynthesis of typical radius fracture with new resorbable polyactide pins [Abstract] [Osteosynthese der radiusfraktur loco typico mit neuen resorbierbaren polyactidstiften]. Hefte zur Zeitschrift der Unfallchirurg 1997;268:567-8.
  • Russe K, Heyde VDD, David A. The osteosynthetic management of distal lower arm fractures - Comparison of bioresorbable material and Kirschner wire [Abstract] [Die osteosynthetische versorgung der distalen unterarmfrakturen - Vergleich von bioresorbierbarem material und Kirschner draht]. Hefte zur Zeitschrift der Unfallchirurg 2000;275:305-6.
  • Russe K, Pommer A, Heyde VDD, David A. The bioresorbable osteosynthesis of distal radius fractures [Abstract] [Die bioresorbierbare osteosynthese der distalen radiusfraktur]. Hefte zur Zeitschrift der Unfallchirurg 2000;282:122-3.
Shannon 2003 {published data only}
  • Shannon FJ, Thornes B, Awan N, Burke T. Fractures of the distal radius treated with 'spring loaded' wiring technique. A randomised prospective study [Abstract]. Journal of Bone and Joint Surgery - British Volume 2003;85 Suppl 2:137.
Snow 2006 {unpublished data only}
  • Fahmy N. Function vs position of the wrist following distal radial fracture. In: The National Research Register, Issue 3, 2000. Oxford: Update Software.
  • Johnson D. personal communication October 2 2006.
  • Snow M, Kelly M, Jeyam M, Fahmy N. Function versus position: A randomised controlled trial of interfocal Kirschner wiring of unstable distal radial fractures. European Journal of Trauma in press.
Waheed 2004 {published data only}
  • Waheed K, Mulhall K, Mwaura B, Kaar K. Percutaneous wire fixation of distal radial fractures: is it preferable to bury the wires? [Abstract]. Journal of Bone and Joint Surgery - British Volume 2004;86 Suppl 2:125-6.

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. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
Altissimi 1986
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Altman 2003
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Andersen 1996
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Atkins 1989
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BMJ 2006
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Cooney 1980
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Fernandez 1996
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Flinkkila 1998
  • Flinkkila T, Raatikainen T, Hamalainen M. AO and Frykman's classifications of Colles' fracture. No prognostic value in 652 patients evaluated after 5 years. Acta Orthopaedica Scandinavica 1998;69(1):77-81.
Frykman 1967
  • Frykman G. Fractures of the distal radius including sequelae - shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthopaedica Scandinavica Supplementum 1967;108:3-153.
Gartland 1951
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Handoll 2003a
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Handoll 2003b
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Handoll 2003c
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Kapandji 1988
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Knirk 1986
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MacDermid 2000
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MacKenney 2006
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