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External fixation versus conservative treatment for distal radial fractures in adults

  1. Helen HG Handoll1,*,
  2. James S Huntley2,
  3. Rajan Madhok3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 18 JUL 2007

Assessed as up-to-date: 16 MAY 2007

DOI: 10.1002/14651858.CD006194.pub2


How to Cite

Handoll HHG, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD006194. DOI: 10.1002/14651858.CD006194.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

    Royal Infirmary of Edinburgh, University Department of Orthopaedic Surgery, Edinburgh, 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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Abstract

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

Background

Fracture of the distal radius ('broken wrist') is a common clinical problem. It can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation.

Objectives

To evaluate the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults.

Search methods

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

Selection criteria

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared external fixation with conservative treatment.

Data collection and analysis

After independent study selection by all review authors, two authors independently assessed the included trials. Independent data extraction of new trials was performed by two authors. Pooling of data was undertaken where appropriate.

Main results

Fifteen heterogeneous trials, involving 1022 adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. While all trials compared external fixation versus plaster cast immobilisation, there was considerable variation especially in terms of patient characteristics and interventions. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment.

External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment: 7/356 versus 51/338 (data from 9 trials); relative risk 0.17, 95% confidence interval 0.09 to 0.32) and prevented late collapse and malunion compared with plaster cast immobilisation. There was insufficient evidence to confirm a superior overall functional or clinical result for the external fixation group. External fixation was associated with a high number of complications, such as pin-track infection, but many of these were minor. Probably, some complications could have been avoided using a different surgical technique for pin insertion. There was insufficient evidence to establish a difference between the two groups in serious complications such as reflex sympathetic dystropy: 25/384 versus 17/347 (data from 11 trials); relative risk 1.31, 95% confidence interval 0.74 to 2.32.

Authors' conclusions

There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.

 

Plain language summary

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

External fixation versus conservative treatment for distal radial fractures in adults

In older people, a 'broken wrist' (from a fracture at the lower end of one of the two forearm bones) can result from a fall onto an outstretched hand. Treatment usually involves reduction (putting the broken bone back into position) and immobilising the wrist in a plaster cast (conservative treatment). Surgery may be considered for more seriously displaced fractures. One type of surgery is external fixation, in which metal pins are driven into bone, generally via small skin incisions, on either side of the fracture. These pins are then fixed externally by incorporation into a plaster cast or securing into the frame of an external fixator. The external component holds the bony fragments in position while the bone heals. This review looked at the evidence from randomised controlled trials comparing external fixation with conservative treatment.

Fifteen trials, involving 1022 adults with potentially or evidently unstable fractures, were included. While all trials compared external fixation versus plaster cast immobilisation, there was considerable variation in their characteristics especially in terms of patient characteristics and the method of external fixation. Weak methodology, such as using inadequate methods of randomisation and outcome assessment, means that the possibility of serious bias can not be excluded.

The review found that external fixation reduced fracture redisplacement that prompted further treatment and generally improved final anatomical outcome. It appears to improve function too but this needs to be confirmed. The complications, such a pin tract infection, associated with external fixation were many but were generally minor. Serious complications occurred in both groups. The review concludes that there is some evidence to support the use of external fixation for these fractures.

 

摘要

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

背景

成人遠端橈骨骨折時使用外固定與保守性治療的比較

遠端橈骨骨折是常見的臨床問題,可以接受如腕部石膏固定的保守性治療,也可以採用開刀治療,而外固定是開刀治療中重要的方式。

目標

使用隨機對照試驗的方式來比較成人遠端橈骨骨折的外固定與保守性治療成效

搜尋策略

我們搜尋Cochrane Bone, Joint and Muscle Trauma Group Specialised Register(2006年9月)、 the Cochrane Central Register of Controlled Trials、MEDLINE、EMBASE,以及其他資料庫、研討會紀錄、文章參考資料。其中並沒有語言上的限制

選擇標準

比較成人遠端橈骨骨折的外固定與保守性治療的隨機或半隨機對照的臨床試驗

資料收集與分析

在多位寫作者各自挑選適合的文章後,再由兩位寫作者獨立評估篩選上述的文章,擷取各文章中的數據成為本篇文章中的資料。

主要結論

在十五篇不同的試驗中,包含了1022位有背側位移以及不穩定的遠端橈骨骨折成年人,這些試驗比較了外固定治療和石膏固定兩種方式,但其中還是存在試驗間的變異,尤其是針對病人的特性和治療的方式。未使用盲法試驗分配病人以及治療效果評估是這些試驗方法學上較為不足的地方。相對於石膏固定,外固定的治療方式較能維持已復位後的位置(復位後再移位並需要再次治療的比例:7/356和51/338),也能避免骨折處後期塌陷和骨折未癒合等治療失敗的結果,但關於功能上及臨床上的結果,這些試驗中並沒有充分的證據足以證明外固定有較佳的效果,另一方面,外固定治療有較多的併發症,例如入針處感染,但很多都是輕微的,而有些併發症或許可經由不同的鋼針入針技巧避免。有些較嚴重的併發症,如交感神經反射性骨營養不良(reflex sympathetic dystropy),在兩組治療方式中也沒有明顯證據支持何項治療發生機率較高

作者結論

目前已經有些證據支持使用外固定治療背向錯位的遠端橈骨骨折的成年人,雖然沒有足夠的證據支持外固定有較佳的功能恢復,這種治療方式可降低再錯位的機率,也可達到較佳的解剖學上結構,同時手術造成的併發症也較輕微

翻譯人

本摘要由臺灣大學附設醫院陳勇璋翻譯。

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

總結

老年人會因為跌倒時使用手臂支撐身體造成手腕骨骨折,治療此類骨折多半將骨折處復位然後打上石膏固定,較嚴重的錯位骨折則會考慮用手術治療,用鋼針經由皮膚小傷口固定於橈骨內外兩側的外固定方式是手術治療的方式之ㄧ,手腕再由石膏包覆固定或在鋼針上架上支架,這些石膏或支架等外固定部份支撐住骨折處直到骨癒合,這篇綜論性文章針對隨機分配的試驗比較手術外固定以及保守性治療的差異,其中15篇文章中共納入1022位不穩定的遠端橈骨骨折成年人,每篇文章皆是比較外固定和石膏固定的治療成效,但病人族群和手術固定方式不完全相同,但像是隨機分配和成效評估等是這篇文章方法學上較薄弱之處,可能造成嚴重的偏差。這篇文章發現外固定可以減少治療後再錯位的機會,因此在結構上有較佳的的效果,但功能上的效果則有待進一步的評估確認。外固定的併發症如鋼針入針處感染等較保守治療為多,但多半是輕微的併發症,而嚴重的併發症在兩組治療方式中皆有發生。因此這篇文章總結,有些證據支持使用外固定的方式治療此類的骨折。