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 are presented together in the currently available review (Handoll 2003a). Following publication of the five reviews, Handoll 2003a will be converted to 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", occur in both children and adults. They are usually defined as occurring in the distal radius within three centimetres of the radiocarpal joint, where the lower end of the radius articulates 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, and between 60 to 94 years of age, females predominate. Before 40 years, the incidence is higher in men (Singer 1998). 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 osteoporosis. It has been estimated that, at 50 years of age, a white woman in 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 lifetime risk 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. It is estimated that around 20% of patients (mainly older people) require hospital admission (Cummings 1985; O'Neill 2001). This figure includes all people receiving surgery.
Surgeons have classified fractures by anatomical configuration and 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 appearance (commonly referred to as a 'dinner fork deformity') - reflecting 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 fracture patterns, which may be important determinants of outcome, and therefore the way in which the injury is treated. For example, the fracture through the distal radius may be extra-articular (leaving the articular or joint surface of the radius intact) or intra-articular (the articular surface is disrupted). Numerous classifications have been devised to define and group different fracture patterns (Chitnavis 1999). Brief descriptions of five commonly cited classification systems are presented in Table 1 (Cooney 1993; Frykman 1967; Melone 1993; Muller 1991; Older 1965).
Description of the intervention: external fixation
In the last century, most distal radial fractures in adults were treated conservatively, by reduction of the fracture if displaced, and stabilisation in a plaster cast or other external brace. The results of such treatment, particularly in older people with bones weakened by osteoporosis, are not consistently satisfactory (Handoll 2003b). This has resulted in attempts to develop other strategies involving surgery aimed at more accurate reduction and more reliable stabilisation.
One such strategy is external fixation (Capo 2006; Fernandez 1999; Pennig 1996). Typically this is a closed, minimally invasive method in which, in contrast to open surgery, the fractured bone is not exposed to direct view. Metal pins or screws are driven into bone, generally via small incisions in the skin and after drilling, on either side of the fracture. These pins are then fixed externally, such as by incorporation into a plaster cast or the frame of an external fixator. The external component stabilises or 'fixes' the reduced fracture. Fracture reduction (the alignment of the bony fragments) is generally achieved by closed means, often in the process of applying external fixation. Reduction may be assisted by the application of a percutaneously (through the skin) inserted wire as a 'joy stick' to move the bony fragments back into place. There is considerable variety in the techniques (such as for pin insertion and placement) and devices used for external fixation. Some devices are 'non-bridging' (of the wrist joint) in that the distal pins are placed in the distal radial fragment leaving the radiocarpal joint free to move. In 'bridging fixators', the distal pins are placed in one or more metacarpal bones. Some fixators are linear or uniplanar, whereas others are multiplanar. In addition, some bridging fixators have an articulation (e.g. a ball joint) that allows limited wrist movement. The duration and extent of immobilisation with external fixation also vary.
In some cases, external fixation may be augmented by additional methods of fracture fixation. In this review, we will include only trials using supplementary percutaneous pinning. This involves extra pins or wires being inserted through the skin and used to fix or support distal radial fragments.
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 (dynamic instability resulting from malaligned bones in the midcarpal joint (within the wrist) that is associated with pain, decreased grip strength and clicking) 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), pin track infection, soft tissue injury including tendon rupture, and additional fractures from external fixation. Complex regional pain syndrome type 1, still referred to as reflex sympathetic dystrophy (RSD), algodystrophy, Sudeck's atrophy and shoulder-hand syndrome (Fernandez 1996), is a major complication (Atkins 2004) requiring many months of physiotherapy to alleviate symptoms (pain and tenderness, impairment of joint mobility, swelling, dystrophy, vasomotor instability) in serious cases. The etiology and pathology of RSD are often unclear.
Why it is important to do this review?
External fixation is one of the main methods for surgical fixation of distal radial fractures. The key question of whether it produces superior results to conservative treatment is addressed in another review (Handoll 2007). Meanwhile, this review examines what is the best method of external fixation. The answers to both these questions are likely to depend on fracture configuration and bone quality.
We aimed to evaluate the evidence from randomised controlled trials comparing the relative effects (benefits and harms) of different methods of external fixation for fractures of the distal radius in skeletally mature people. Studies evaluating augmented external fixation where supplementary percutaneous (through the skin) pinning was used to fix or support distal radial fragments were also included.
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.
Our plan to study the outcomes in different age groups and for different fracture types, especially whether they are extra-articular or intra-articular, was thwarted by the lack of data and variation in the trial characteristics.
Criteria for considering studies for this review
Types of studies
We considered all 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 comparing different methods of external fixation for treating distal radial fractures in adults.
Types of participants
Patients of either sex with a fracture of the distal radius, who had completed skeletal growth were included. External fixation may be used as primary treatment or else secondary treatment after the failure of initial conservative management, generally within two to three weeks. Augmented external fixation in the form of supplementary percutaneous pinning was also included. Trials with a mixed population of adults and children were included, provided the proportion of children was clearly small (< 5%). Otherwise these would have been excluded unless separate data for adults were obtained. We considered it unlikely that we would find trials comparing different methods of external fixation with conservative treatment for fracture patterns such as the Barton's fractures (Smith 1988) that are inherently unstable and generally considered not to be amenable to external fixation. Nonetheless, a trial (Hutchinson 1995) with two Barton's fractures among 90 unstable fractures was included. Given the small number of Barton's fractures and the large variety of fracture types in this trial we did not seek separate subgroup data for different fracture types.
Types of interventions
Randomised comparisons of different methods of external fixation, including augmentation with supplementary percutaneous pinning, for treating fractures of the distal radius in adults. This includes comparisons of:
- primary methods (external fixator versus pins and plaster external fixation; and non-bridged versus bridged (over wrist joint) external fixation);
- augmented external fixation involving supplementary percutaneous pinning versus external fixation alone;
- different subsidiary components of surgical technique (different methods of reduction of the fracture fragments; different methods of pin insertion; use and type of imaging modalities (e.g. X-ray fluoroscopy) for monitoring the reduction and operation; different types of supplementary percutaneous pinning);
- different types of fixation devices (different types and coatings of external fixator pins; uniplanar versus multiplanar external fixators; recycled versus new external fixators);
- different types or duration of post-operative immobilisation (including dynamic versus static external fixation).
We excluded trials comparing external fixation with conservative treatment (see Handoll 2007) or with other methods of surgical fixation, such as percutaneous pinning. We also excluded trials evaluating the use of supplementary methods, such as bone grafts and substitutes, other than percutaneous pinning, to external fixation. These comparisons will be covered in other reviews, including one covering the use of bone grafts and substitutes. 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 report outcome in the following four categories.
(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
- 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
(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 2.
(4) Resource use
- Hospital stay, number of outpatient attendances, physiotherapy and other costs.
Comparison specific outcomes
For some comparisons, such as those of different techniques used for external fixation, outcomes other than those listed above may be relevant and reported. Such outcomes, namely length of surgery, were presented in the analyses.
Timing of outcome assessment
Results were usually collected for the final follow-up time for which these are available. However, we also planned to note interim results where a marked and important difference in the timing of recovery had occurred.
Search methods for identification of studies
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2007, Issue 2) (see Appendix 1), MEDLINE (1996 to June week 1 2007) , EMBASE (1988 to 2007 week 22), CINAHL (1982 to June week 1 2007). No language restrictions were applied.
Similar search strategies were used for EMBASE (OVID-WEB) and CINAHL (OVID-WEB) (see Appendix 2).
We also searched Current Controlled Trials at www.controlled-trials.com (accessed June 2007) and the UK National Research Register at www.update-software.com/national/ (up to Issue 2, 2007) for ongoing and recently completed trials.
Searching other resources
We searched reference lists of articles. We also included the findings from handsearches of the British Volume of the Journal of Bone and Joint Surgery supplements (1996 onwards) and abstracts of the American Society for Surgery of the Hand annual meetings (2000 to 2006: www.assh.org/), the American Orthopaedic Trauma Association annual meetings (1996 to 2006: www.hwbf.org/ota/am/) and American Academy of Orthopaedic Surgeons annual meeting (2004 to 2007: www.aaos.org/wordhtml/libscip.htm). We also included handsearch results from the final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003), EFFORT (2007) and the British Orthopaedic Association Congress (2000, 2001, 2002, 2003, 2005 and 2006), and various issues of Orthopaedic Transactions and of Acta Orthopaedica Scandinavica Supplementum.
We also scrutinised weekly downloads of "Fracture" articles in new issues of 15 journals (Acta Orthop Scand; Am J Orthop; Arch Orthop Trauma Surg; Clin J Sport Med; Clin Orthop; Foot Ankle Int; Injury; J Am Acad Orthop Surg; J Arthroplasty; J Bone Joint Surg Am; J Bone Joint Surg Br; J Foot Ankle Surg; J Orthop Trauma; J Trauma; Orthopedics) from AMEDEO (www.amedeo.com).
Data collection and analysis
Selection of studies
All review authors independently assessed potentially eligible trials for inclusion using a pre-piloted form. Any disagreement was resolved by discussion.
Data extraction and management
Using a data extraction form, two of the review authors (HH and JH) independently extracted trial details and data for new trials, and one author (HH) repeated data extraction of trials already included in Handoll 2003a and checked for consistency with her previous data extraction. HH entered the data into RevMan. Any disagreements were resolved by discussion. When appropriate, extraction of results from graphs in trial reports was performed where data were not provided in the text or tables. We contacted trialists of trials not reported in full journal publications for additional information or 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 noted instances where clinically important differences had been reported at intermediate follow-up assessments.
Assessment of methodological quality
In this review, risk of bias is implicitly assessed in terms of methodological quality
Two of the review authors (HH and JH) independently assessed methodological quality of the newly included trials using a pre-piloted form. One author (HH) repeated her assessment of the trials already included in Handoll 2003a. All disagreements were 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 current 'umbrella' review was used. Instead of scores, each item was graded based on whether the quality criterion was met: 'Y' (met), '?' (possibly or only partially met) or 'N' (not met). The rating scheme covering 11 aspects of trial validity plus brief notes of coding guidelines for selected items are given in Table 3.
Measures of treatment effect
Where available, quantitative data, both dichotomous and continuous, for the outcome measures listed above (see 'Types of outcome measures') are presented in the analyses. Relative risks and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals were calculated for continuous outcomes.
Unit of analysis issues
The unit of randomisation in these trials is usually the individual patient. Exceptionally, as in the case of trials including people with bilateral fractures, data for trials may be presented for fractures or limbs rather than individual patients. This occurred to a very limited extent for two trials in this review: Hutchinson 1995 (one person with bilateral fractures: unidentified group) and Sommerkamp 1994 (one person with bilateral fractures in each group). Although appropriate corrections for unit of analysis and randomisation discrepancies were not made in these two trials, we present data for these trials because the disparity between the units of analysis and randomisation is small.
Dealing with missing data
Where possible, we performed intention-to-treat analyses to include all people randomised to the intervention groups. To a very limited extent, we have investigated the effect of drop outs and exclusions by conducting best and worst scenario analyses. We were alert to the potential mislabelling or non identification of standard errors for standard deviations. Unless missing standard deviations could be derived from confidence interval data, we did not assume values in order to present these in the analyses.
Assessment of heterogeneity
Had pooling been feasible, heterogeneity would have been 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)
Given the clinical heterogeneity in the trials grouped in the same comparisons, we decided against pooling of the very few common outcomes. If we had pooled data, we planned to initially use the fixed-effect model and 95% confidence intervals. Then, especially where there was unexplained heterogeneity, we would have considered using the random-effects model.
Subgroup analysis and investigation of heterogeneity
There were no data available to carry out our pre-specified subgroup analyses by age, gender and type of fracture (primarily, extra-articular versus intra-articular fractures). Presentation in separate subgroups was also considered where there was a fundamental difference in the timing of external fixation (primary treatment versus after the failure of initial conservative management). Again there were no data available. To test whether subgroups were statistically significantly different from one another, we proposed to test the interaction using the technique outlined by Altman and Bland (Altman 2003).
There were no data available to carry out our pre-specified sensitivity analyses examining various aspects of trial and review methodology, including the study quality (specifically allocation concealment, outcome assessor blinding and reportage of surgical experience), and inclusion of trials only reported in abstracts (all were full reports).
Interpretation of the evidence
We graded the findings of the treatment comparisons according to the six categories of effectiveness used by contributors to Clinical Evidence (BMJ 2006) (see Table 4) to assist our interpretation.
Description of studies
Results of the search
The search for trials predated the development of this review, which is essentially an 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 21 potentially eligible studies put forward for study selection, nine were included, eight were excluded and four remain in 'Studies awaiting assessment'.
Seven of the included trials were previously included in Handoll 2003a; this includes Werber 2003, whose study ID has been changed to reflect the identification of a full report. The two other trials (Atroshi 2006; Krishnan 2003) are new inclusions. Krishnan 2003 was pending assessment in Handoll 2003a.
All of the included studies were fully reported in English language medical journals. Five 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 (1); EMBASE (1); and MEDLINE (2).
Details of the methods, participants, interventions and outcome measures of individual trials are provided in 'Characteristics of included studies'.
The publication dates of the main reports of these trials span 13 years; Raskin 1993 being the earliest. Aside from Hutchinson 1995, which had six centres, the studies were single centre trials, mainly conducted in teaching hospitals. They each took place in one of six countries (Australia (1), Germany (1), Italy (1), Sweden (1), UK (2), USA (3)).
The nine included trials involved a total of 510 participants. One trial (Raskin 1993) provided no information on the gender composition of their study population. For the rest, the percentage of females ranged from 54% (Sommerkamp 1994) to 100% (Moroni 2001). The mean ages of the trial populations ranged from 36 years (Sommerkamp 1994) to 74.5 years (Moroni 2001). It is clear that the vast majority of participants in the included trials were skeletally mature: this was explicit in Sommerkamp 1994. Two trials restricted the trial population to more mature adults: Atroshi 2006 (women 50 years or over; men 60 years or over) and Moroni 2001 (aged 65 years or over). The youngest (14 years) and oldest (93 years) participants both belonged to Hutchinson 1995. All participants of Werber 2003 were of working age or retired.
All participants of McQueen 1996 and McQueen 1998 and some of Sommerkamp 1994 had fractures that had redisplaced by two weeks, whereas the other trials involved primary treatment of people with acute fractures. Some fractures in Sommerkamp 1994 were open fractures but it is likely that most of the fractures in the other trials were closed; this was explicit in Hutchinson 1995, Moroni 2001, Raskin 1993 and Werber 2003. The majority of fractures were dorsally displaced; this was mandatory in four trials (Atroshi 2006; McQueen 1996; McQueen 1998; Werber 2003). Seven trials included both extra-articular and intra-articular fractures, the exceptions being Moroni 2001 (extra-articular fractures only) and Raskin 1993 (intra-articular fractures only). The trial inclusion criteria of Krishnan 2003 stipulated intra-articular fractures, but in fact three of the 60 participants had extra-articular fractures. There were two Barton fractures in the broad spectrum of 90 fractures included in Hutchinson 1995. In contrast, the study population of Raskin 1993 was much narrower and all 60 participants had a die punch fracture (this is an impacted displaced fracture of the lunate facet of the distal radial radiocarpal joint surface). Seven trials classified their fractures according to the AO system (Muller 1991), and the other two trials (Hutchinson 1995; Sommerkamp 1994) used the Frykman system (Frykman 1967). Raskin 1993 also applied the classification system devised by the second author of this trial report (Melone 1993). Four trials (Krishnan 2003; Moroni 2001; Raskin 1993; Werber 2003) provided no criteria of the extent of the displacement required for trial entry. Both Atroshi 2006 and McQueen 1998 indicated the need for sufficiently sized dorsal fragment(s) for insertion of the distal pins of the non-bridging fixators used in these two trials.
The nine included trials have been grouped according to the main comparison addressed by each trial. A concise summary of the trial participants, fracture types, timing and details of the interventions is given in Table 5. Some indications of major differences in the trials grouped under the same comparison are highlighted below.
External fixator versus pins and plaster external fixation
Two trials (Hutchinson 1995; Raskin 1993), involving 89 and 60 participants respectively, compared a bridging external fixator with pins and plaster external fixation. Among the known differences between the two trials were the older and more varied population of Hutchinson 1995 (mean age 65 years compared with 45 years in Raskin 1993) and the different pinning configurations in the pins and plaster group (see Table 5).
Non-bridging versus bridging external fixation
Three trials (Atroshi 2006; Krishnan 2003; McQueen 1998), involving 38, 60 and 60 participants respectively, compared a non-bridging with a bridging external fixator. In contrast to Atroshi 2006 and Krishnan 2003, McQueen 1998 only included redisplaced fractures. In the non-bridging groups of Atroshi 2006 and McQueen 1998, the two pins inserted into the distal fracture fragment(s) acted primarily as 'anchors'. In Krishnan 2003, which used the 'Delta frame' external fixator, the four pins inserted into the distal fracture fragments either transfixed the fracture fragments or, in severely comminuted fractures, functioned as subarticular supports.
Augmented external fixation involving supplementary percutaneous pinning versus external fixation alone
One trial (Werber 2003) involving 50 participants examined the use of an additional pin, inserted percutaneously, to fix the 'floating' distal fragment. The pin was then attached to fixator frame.
Different subsidiary components of surgical technique
There were no trials in this category.
Different types of fixation devices
Hydroxyapatite coated pins versus standard uncoated pins
One trial (Moroni 2001) involving 50 female participants with osteoporosis compared external fixation using hydroxyapatite coated tapered pins versus standard uncoated tapered pins.
Different types or duration of post-operative immobilisation
Dynamic versus static external fixation
Two trials (McQueen 1996; Sommerkamp 1994), involving 60 and 73 participants respectively, compared dynamic versus static external fixation. All fractures were redisplaced in McQueen 1996, whereas only some (proportion unknown) were in Sommerkamp 1994. The same fixator was used in both groups in McQueen 1996 but different fixators were used in Sommerkamp 1994. The timing and extent of dynamism of the fixator also varied between the two trials (see Table 5).
Eight studies were excluded for reasons stated in 'Characteristics of excluded studies'. Three studies were found not to be randomised trials and one will be a biomechanical study. There was insufficient information on three other trials (Rawes 1995; Stoffelen 1999; Stokes 1998) published only as conference abstracts. Both Rawes 1995 and Stokes 1998 appeared as included trials in Handoll 2003a. The complex study design of Hutchinson 2000 prevented the direct conclusions on clinical outcome.
No ongoing studies were identified.
Studies awaiting assessment
Details of the four trials pending assessment are given below.
Basdekis 2005: published abstracts of trial comparing fluoroscopic versus arthroscopic reduction of intra-articular fractures in 40 people given external fixation provide insufficient information for inclusion. No response obtained yet from authors.
Hove 2005: published abstract of trial, which compared a dynamic external fixator designed by the authors versus a traditional static external fixator in 70 people with distal radial fractures, provides insufficient information for inclusion. No response obtained yet from authors.
McQueen 2006: trial registered as ongoing in the National Trials Register (UK) has yet to begin (March 2007). If the trial, which includes a comparison of external fixation with percutaneous pinning versus non-bridging external fixation, takes place it is likely to be a single-centre trial.
Tornetta 2005: two published abstracts of a trial examining the reuse of external fixation components in a mixed fracture population provide insufficient information for inclusion. Trial author has indicated that a full report has been submitted for publication. Separate data for distal radial fractures (48 recruited) will be required before inclusion.
Risk of bias in included studies
The quality of trial methodology, judged using the 11 quality criteria listed in Table 3, is somewhat disappointing. Associated with this is a high potential for the key systematic biases (selection, performance, assessment and attrition) leading to questions about internal validity, and issues of clinical relevance and applicability or external validity. These will be considered further in the 'Discussion'. The results, together with some notes on specific aspects, of the quality assessment for the individual trials are shown in Table 6. Information specific to the first three items of the quality assessment is given in the methods sections of 'Characteristics of included studies'. A summary of the results for individual items of quality assessment is given below.
Allocation concealment (item 1)
Only one trial (Atroshi 2006), which used sequentially-opened numbered sealed and opaque envelopes, was considered to have satisfied the criteria for secure allocation concealment. It was unclear whether allocation was concealed prior to randomisation in six trials. Three of these used closed envelopes (Krishnan 2003; McQueen 1996; McQueen 1998), one used a computer generated list (Moroni 2001), and two trials provided no direct information (Raskin 1993; Werber 2003). The two remaining trials (Hutchinson 1995; Sommerkamp 1994) used quasi-randomised methods based on record or chart numbers.
Intention-to-treat analysis (item 2)
Clear statements of participant flow with evidence of intention-to-treat analysis, together with consistent reporting, were available for Atroshi 2006 and McQueen 1996. Sommerkamp 1994 had an 'N' rating because of the exclusion from the analyses of trial participants for non-compliance with rehabilitation.
Blinding of outcome assessors (item 3)
Atroshi 2006 reported blinded physical assessment and, while not rated, three trials (Krishnan 2003; Sommerkamp 1994; Werber 2003) referred to independent assessors of radiographs. Total blinding of outcome assessment is impractical for trials testing surgical interventions but, as shown by Atroshi 2006, it is possible for some outcomes and more so at longer-term follow up.
Comparability of baseline characteristics (item 4)
Five trials (Atroshi 2006; McQueen 1996; McQueen 1998; Moroni 2001; Werber 2003) provided sufficient information indicating the similarity in the baseline characteristics of gender, age and type of fracture. Potentially important imbalances in age and fracture severity between the two treatment groups of Raskin 1993, and a lack of baseline characteristics for Sommerkamp 1994 were reasons for an 'N' rating for these two trials.
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)
We found it difficult to confirm comparability of care programmes, including surgical experience, other than the trial interventions. Nonetheless, we judged it highly likely in three trials (Atroshi 2006; McQueen 1998; Werber 2003).
Definition and quality of outcome measurement (items 9 and 10)
Outcome measurement was sufficiently well described in all of the included trials except Raskin 1993. Raskin 1993 was also considered to have inadequate outcome measurement, which included follow up of variable duration. Only Atroshi 2006 was rated as having 'optimal' quality outcome measurement, which included use of validated patient assessed quality of life instruments and active follow up. Of note is the grading or scoring of overall functional outcome according to non-validated 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). The variety of schemes used and other outcome measures reported by the trials is evident from inspection of 'Characteristics of included studies'.
Length of follow up (item 11)
Follow up ranged from six weeks (Moroni 2001) to a maximum of five years (Raskin 1993). Follow up of variable duration, particularly at times where participants are at different stages of recovery, may be a potential cause of bias such as in Raskin 1993 (12 to 60 months).
Loss to follow up (not rated)
Loss to follow up was substantial in Sommerkamp 1994, where a third of participants were missing from the final analyses. While the loss to follow up at one year was modest (8%) in Hutchinson 1995, only 58% of the original study population were followed up at two years. For some of the trials appearing to have no losses, it may be the case that these were not reported.
Effects of interventions
External fixator versus pins and plaster external fixation
Two trials (Hutchinson 1995; Raskin 1993), involving 89 and 60 participants respectively, compared a bridging external fixator with pins and plaster external fixation. The characteristics of the external fixators and the pinning configurations in the pins and plaster group differed between the two trials (see Table 5). There was no pooling of the two outcomes (both complications) reported by both trials.
Both trials found no statistically significant differences in functional outcome. All participants of Raskin 1993 returned to their former activities of daily living. Assessed using a functional grading scheme that included radiographical results, similar numbers of participants in the two groups of Raskin 1993 had only 'fair' functional grades (see Analysis 01.01: 5/30 versus 4/30; relative risk (RR) 1.25, 95% confidence interval (CI) 0.37 to 4.21). While people in the external fixator group of Hutchinson 1995 tended to experience less pain or discomfort at one year (see Analysis 01.02: 6/42 versus 12/40; RR 0.48, 95% CI 0.20 to 1.15), equal numbers of people in each group experienced functional difficulty (3 versus 3) and weakness (26 versus 26). Hutchinson 1995 reported that there were no statistically significant differences between the two groups in the findings for mass grip strength (see Analysis 01.03), range of motion for wrist and fingers, or finger stiffness (tightness). Similarly, Raskin 1993 reported that there were no statistically significant differences in the various measures of functional impairment: grip strength relative to normal side (80% versus 85%); flexion/extension (122º versus 126º); and pronation/supination (156º versus 150º).
Complications, graded as minor (resolved, short term) and major (serious consequences, persistent) in Hutchinson 1995, for both trials are presented in Analysis 01.04. The overall numbers of participants of Hutchinson 1995 with "major" complications were similar in both groups (12/44 versus 10/46). However, eight of the 10 "major" complications were loss of reduction in the pins and plaster, whereas the four pin track infections with serious sequelae and four cases of persistent radial neuritis were found in the external fixator group. Significantly more people in the external fixator group of Hutchinson 1995 suffered pin track complications (11/44 versus 2/46; RR 5.75, 95% CI 1.35 to 24.48) and radial neuritis (8/44 versus 1/46; RR 8.36, 95% CI 1.09 to 64.15). There were similar numbers of participants in the two groups with carpal tunnel syndrome, which Hutchinson 1995 considered to be a complication of the injury rather than treatment. Two other major complications were a new radial fracture after removal of the pins and plaster in the pins in plaster group, and a tendon adhesion with a pin in the external fixator group, requiring tenolysis. There were few complications in Raskin 1993 and all resolved. The eight cases of median nerve compression in Raskin 1993 were resolved by closed reduction before external fixation. There was no significant difference in the numbers of participants who were dissatisfied with their outcome in Hutchinson 1995 (see Analysis 01.05: 7/42 versus 9/40; RR 0.74, 95% CI 0.30 to 1.80).
Fewer participants, but not statistically significantly so, of the external fixator group in Hutchinson 1995 had a major loss in reduction (see Analysis 01.04 Loss of reduction: 2/44 versus 8/46; RR 0.26, 95% CI 0.06 to 1.16). All resulted in subjectively assessed wrist deformity. Pin loosening, without infection, and pin fracture caused the loss of reduction in four participants of the pins in plaster group; the other six cases were stated as having resulted from incomplete reduction before fixation. Hutchinson 1995 reported no significant differences between the two groups in volar tilt, radial angle or radial length at one-year follow up. One loss of reduction requiring remanipulation occurred in the external fixator group in Raskin 1993. Just three participants of Raskin 1993 had an unsatisfactory anatomical grading (see Analysis 01.06) and no statistically significant difference was reported in the radiographic comparison of the two groups. Out of 52 participants followed up at two years in Hutchinson 1995, 20 had signs of early degenerative arthritis of which four had significant joint disease; separate data for the two groups were not available.
Hutchinson 1995 estimated the initial material cost in the US for an external fixator was around 20 times higher than pins and plaster ($775 versus $38).
Non-bridging versus bridging external fixation
Three trials (Atroshi 2006; Krishnan 2003; McQueen 1998), involving 38, 60 and 60 participants respectively, compared non-bridging with bridging external fixation. As described above and summarised in Table 5, there was marked variation in the trial populations and interventions of these three trials. Data for the few outcome measures in common were not pooled.
Atroshi 2006 found no significant differences between the two groups at any follow-up time in the DASH (Disabilities of the Arm, Shoulder and Hand) scores (see Analysis 02.01: mean difference (MD) 4.00, 95% CI -2.66 to 10.66) and SF-12 physical domain scores (see Analysis 02.02: MD 1.00, 95% CI -4.64 to 6.64). By 12 weeks, both groups in Krishnan 2003 achieved almost top scores for a 17-task activities of daily living scoring tool (no data reported). While grip strength results in Atroshi 2006 tended to favour the non-bridged group at all three follow-up times, the differences between the two groups did not reach statistical significance (see Analysis 02.03: MD 5.00 kg, 95% -2.05 to 12.05 kg). There was no significant difference between the two groups of Krishnan 2003 (% of uninjured side, medians: 45% versus 43%). The extreme range data (0% to 180%) for grip strength in Krishnan 2003 was not explained; in particular, how at least two participants had no grip strength. However, the non-bridging fixator group in McQueen 1998 had statistically significantly better grip strength (see Analysis 02.04). None of trials found differences between the two groups in numbers of participants with residual pain (see Analysis 02.05) or in pain scores: Atroshi 2006 (see Analysis 02.06); Krishnan 2003 (medians at 26 weeks: 0 versus 0); McQueen 1998 (VAS: 1.2 versus 1.3, (10 is worst pain)). Atroshi 2006 found very similar values for range of motion measures in the two groups (see Analysis 02.07). Flexion was reported as statistically significantly lower in the non-bridging group of Krishnan 2003 (medians: 50º versus 60º) but significantly higher in McQueen 1998 (see Analysis 02.08). Of note is the extreme upper range values of 100º for flexion in Krishnan 2003.
None of the differences between the two groups of any of the three trials in the numbers of people with individual complications were statistically significant (see Analysis 02.09). All pin-track infections in Atroshi 2006 resolved with antibiotics. The two iatrogenic fractures in the bridging group of this trial were respectively: a) a fracture of the second metacarpal that occurred after fixator removal; and b) an inconsequential proximal pin-site fracture detected after a subsequent fall. There were discrepancies in the reporting of the complications between text and table in Krishnan 2003; and some complications were not defined. One person with pin track infection of each group required hospital admission. The person in the bridging group, who required surgery and early removal of their fixator, also incurred a metacarpal fracture (during manipulation under anaesthesia for finger stiffness) and developed reflex sympathetic dystrophy (RSD). The other people requiring further "surgery" in Krishnan 2003 were two non-bridging group participants (one had open reduction and internal fixation; the other had manipulations for finger stiffness) and one bridging group participant (distal ulna resection for persistent distal radio-ulnar joint pain). There was no mention of the treatment received by the three people of the non-bridging group who had an extensor pollicis longus rupture. There was a discrepancy in the numbers with serious complications (5 compared with 4) reported in the trial report of McQueen 1998 and an earlier abstract (published 1997). However, the numbers of serious complications in the two groups were probably similar or the same. McQueen 1998 stated that neither of the tendon ruptures was related to the pins and that there were no cases of pin loosening. Two participants, both in the non-bridging fixation group, were dissatisfied with their outcome in Atroshi 2006 (see Analysis 02.10).
Fracture redisplacement resulting in a further operation occurred in one person of the bridging group in Atroshi 2006. Two people in each group had fixation failure in Krishnan 2003 (see Analysis 02.09). All fractures were reported as healed in Atroshi 2006 who reported non-bridging fixation was better at maintaining radial length, as shown by the statistically significantly lower ulnar variance for this group (see Analysis 02.12). Atroshi 2006 found no significant differences in volar tilt or radial inclination, and reported that no fracture had an articular step-off exceeding one millimetre. Krishnan 2003 reported no significant differences between the two groups in radiological measurements: palmar tilt (medians: 6.5º versus 7º), radial inclination (medians: 18.5º versus 22º), radial length (medians: 7.5 versus 8 mm), or radial step (medians: 0 versus 0 mm). In contrast, McQueen 1998 reported that the better reduction achieved in the non-bridging fixator group persisted at one year and a superior anatomical result was obtained for this group (see Analyses 02.11, 02.12 and 02.13). Notably, there were no cases of malunion in the non-bridging group compared with 14 in the bridging group (see Analysis 02.13: RR 0.03, 95% CI 0.00 to 0.55).
In Atroshi 2006, surgery took 10 minutes longer in the non-bridging group (see Analysis 02.14).
Augmented external fixation involving supplementary percutaneous pinning versus external fixation alone
One trial (Werber 2003) evaluated the effect of pinning the distal fragment in 50 people with unstable dorsally-displaced distal radial fractures treated by external fixation. The report of this trial in Handoll 2003a was based on two conference abstracts, which presented radiological findings only. No explanation has been received from the trial authors for the discrepancies between the abstract and full reports of the trial in the participant characteristics. In the following, only the data on ulnar plus variance are obtained from an abstract report.
Based on a functional assessment scheme including some consideration of symptomatic deformity (Lidstrom 1959), significantly more people in the extra-pin group had a 'very good' functional grading at six months; in other words, a lower proportion of people treated with supplementary percutaneous pinning had a 'not very good' grading (see Analysis 03.01: 7/25 versus 19/25; RR 0.37, 95% CI 0.19 to 0.72). Additionally fewer people in the extra pin group had only a fair or poor grading (see Analysis 03.01: 1/25 versus 4/25; RR 0.25, 95% CI 0.03 to 2.08). This is reflected in the findings in favour of the extra-pin group for grip strength (see Analysis 03.02) and range of motion (see Analysis 03.03). There were few complications (see Analysis 03.04). Six people in each group had pain and swelling necessitating medication averaging two months each person. There was no statistically significant difference between the two groups in the incidence of pin site problems (just one was an infection). One person (intervention group unknown) had temporary paraesthesias of thumb, index and long fingers that subsided after the removal of a metacarpal pin.
All fractures healed. Anatomical outcome was reported to be statistically significantly superior in the extra-pin group (e.g. volar tilt (normal = 10º): 6º versus -2º, reported P < 0.001). Post reduction radial shortening, which occurred in both groups, resulted in significantly fewer participants with an ulnar plus variance in the extra pin group (see Analysis 03.05: 3/25 versus 18/23; RR 0.15, 95% CI 0.05 to 0.45). Articular step-off was less than one millimetre for all participants.
Consistent with the additional procedure, the surgery took 10 minutes longer in the supplementary pinning group (see Analysis 03.06).
Hydroxyapatite coated pins versus standard uncoated pins
No functional or anatomical results were reported by Moroni 2001, which compared hydroxyapatite coated tapered pins versus standard (uncoated) tapered pins in 20 older women with osteoporosis who had extra-articular fractures treated with external fixation. There were two low grade pin track infections, requiring only local treatment, in the standard pin group (see Analysis 04.01). One participant of each group had RSD. All fractures healed and no additional cast or orthosis was required after fixator removal. Moroni 2001 found significantly greater torque (force) was required to remove pins coated with hydroxyapatite (see Analysis 04.02). This was interpreted as reflecting an enhancement of the bone-pin interface, with implications for management of patients with osteoporotic bone. The mean and standard deviation visual analogue scores for pain during pin removal were the same in both groups.
Dynamic versus static external fixation
Two trials (McQueen 1996; Sommerkamp 1994) evaluated early mobilisation of the wrist during external fixation. All 60 participants of McQueen 1996 and some participants of Sommerkamp 1994 had redisplaced fractures. The key differences in the interventions of the two trials are shown in Table 5. Sommerkamp 1994 presented outcome data for only 48 people (50 fractures) of the 73 people (75 fractures) recruited into the trial. Given the potential bias resulting from this large loss to follow up (34%), we have not conducted sensitivity analyses to examine the small disparity between the units of analysis and randomisation in Sommerkamp 1994. There was no pooling of the few outcomes (all complications) reported by both trials.
McQueen 1996 reported there were no statistically significant differences between the two groups in the ability to perform activities of daily living. Based on a scoring scheme (modified Gartland 1951) that included some anatomical measures and complications, Sommerkamp 1994 found a statistically non-significant tendency to better functional grades in the static fixator group (see Analysis 05.01. e.g. Fair or poor: 6/25 versus 2/25; RR 3.00, 95% CI 0.67 to 13.46). However, the large loss to follow up renders this unreliable: Analysis 05.01 also shows a best-case (for dynamic fixation) and then a worst-case analysis for this outcome. The result strongly favours dynamic fixation when it is assumed that all participants lost to follow up or excluded in this group had a good or better result compared with none of those lost or excluded from the static fixation group. Conversely, the result strongly favours static fixation. There were no significant differences between the two groups in grip strength for either McQueen 1996 (see Analysis 05.02) or, as reported, in Sommerkamp 1994 (mean grip strength expressed as percentage of uninjured wrist: 72% versus 78%). McQueen 1996 also found no significant differences between the two groups in range of motion (see Analysis 05.03), whereas in Sommerkamp 1994 the higher values for flexion (52.4º versus 59.4º) and radial deviation (14.8º versus 21.3º) in the static fixator group were reported to be statistically significant (P < 0.05).
Complications are presented in Analysis 05.04: null events have been entered when reported. None of the differences between the two groups in any complication was statistically significant in either trial. Of note, however, are the five cases of unstable or broken dynamic fixator in Sommerkamp 1994.
Any slight differences in radiological measurements and measures of wrist deformity between the two intervention groups in McQueen 1996 did not reach statistical significance (see Analyses 05.05, 05.06 and 05.07). Seven in each group had recurrent instability (see Analysis 05.04). In Sommerkamp 1994, the mean loss in radial length at the time of fixator removal (around 10 weeks) was reported to be significantly more in the dynamic fixation group (4 mm versus 1 mm). There was no difference at this time for dorsal angulation (means: 8º versus 6º). There were no statistically significant differences between the two groups of Sommerkamp 1994 in the numbers of people with moderate or severe radiological deformity (Lidstrom 1959) or with residual articular incongruity (> 2 mm) at fixator removal (see Analysis 05.07). Radiological signs of moderate osteoarthrosis were present in three people in Sommerkamp 1994 (see Analysis 05.07).
Our review (Handoll 2007) comparing external fixation with conservative treatment found some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. This evidence was firmer for a superior anatomical outcome after external fixation but insufficient to confirm a superior overall functional or clinical result. While external fixation was associated with a high number of complications, many of these were minor and there was not enough evidence to prove or disprove a difference in more serious complications between external fixation and conservative treatment. The methods of external fixation examined in Handoll 2007 varied considerably and point to the many choices available. The current review attempts to categorise these choices and then to identify and examine the evidence available to inform such choices. Only a limited number of these choices were addressed by randomised controlled trials.
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 about pooling.
Our search was comprehensive and built on searches carried out over many years (Handoll 2003a) prior to the development of our review. 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. It is possible that we have missed some potentially eligible trials but, if so, these may still not be suitable for inclusion, particularly if unpublished and inadequately reported. We guarded against study selection bias by the independent selection of eligible trials by all three review authors.
We decided against pooling for any of the multiple trial comparisons because of the evident heterogeneity in the study populations and interventions. Moreover, there were few outcomes in common and these were usually complications. The latter were usually poorly defined and their severity is likely to differ between trials (McKay 2001).
Limitations of the review evidence
Overall, the available evidence is limited in scope and quantity, and is of uncertain validity. The usual reservations of the reliability of evidence from small and underpowered trials apply. Especially, we were careful to avoid miss-interpreting inconclusive evidence as 'evidence of no effect'. 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. However, this was much less a concern with Atroshi 2006, which was the only trial with clearly concealed treatment allocation. 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, especially when the scores have been reduced into categories such as excellent, good, fair or poor. 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). Again, Atroshi 2006 proved an exception. Questions also arise on the reliability of measures of grip strength and range of motion. A particular aspect, as related above, is the puzzling extreme values of relative grip strength and of flexion in Werber 2003.
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).
Surgical intervention is generally complex, with a myriad of techniques and devices available, and variation too in the overall care programmes. While, as shown in this review, trials may have aspects in common such as comparing an external fixator with pins and plaster fixation, the ways they achieve this may be very different. Should there be sufficient evidence to inform the choice inherent in such a comparison, it is only the basic question that is addressed. There remains the issue of the best way to achieve this (i.e. what fixator?).
Another aspect of surgery is surgical expertise. Results from trials involving single experienced operators, as in McQueen 1998, need to be confirmed in other situations, particularly those where the operators are, by and large, less experienced (Kapandji 1988).
A summary of the conclusions of effectiveness drawn from the findings of each comparison is provided in Table 7. Here, the effectiveness of each intervention relative to the 'control' intervention in each comparison is graded according to the categories of effectiveness described in Table 4. A concise summary of the participants and interventions for the nine trials is provided in Table 5.
Implications for practice
There is insufficient robust evidence to determine the relative effects of the different methods of external fixation evaluated in this review: external fixator compared with pins and plaster external fixation; non-bridged compared with bridged (over wrist joint) external fixation; augmented external fixation involving supplementary percutaneous pinning compared with external fixation alone; hydroxyapatite coated compared with standard uncoated external fixator pins; or dynamic compared with static external fixation.
Implications for research
The evidence base for the management of distal radius fracture in adults is limited. Further research should be preceded by agreement on the priority questions for the management of these fractures, and be addressed through large multi-centre trials (Handoll 2003c).
We thank Lesley Gillespie for her help with the search strategy. We thank the following for helpful comments and input at the editorial and external review of the protocol: Bill Gillespie, Peter Herbison, Jesse Jupiter and Janet Wale. We thank the following for helpful comments and input at the editorial and external review of the review: Frank Burke, William Cooney, Bill Gillespie, Vicki Livingstone and Janet Wale. We thank Joanne Elliott and Lindsey Elstub for their help during editorial processing.
Data and analyses
- Top of page
- Authors' conclusions
- Data and analyses
- What's new
- Contributions of authors
- Declarations of interest
- Sources of support
- Index terms
Appendix 1. Search strategy for The Cochrane Library (Wiley InterScience)
#1 MeSH descriptor Radius Fractures explode all trees in MeSH products
#2 MeSH descriptor Wrist Injuries explode all trees in MeSH products
#3 (#1 OR #2)
#4 ((distal near radius) or (distal near radial)) in Title, Abstract or Keywords in all products
#5 (colles or smith or smiths) in Title, Abstract or Keywords in all products
#6 wrist* in Title, Abstract or Keywords in all products
#7 (#4 OR #5 OR #6)
#8 fractur* in Title, Abstract or Keywords in all products
#9 (#7 AND #8)
#10 (#3 OR #9)
Appendix 2. Search strategy for MEDLINE (OVID-WEB)
1. exp Radius Fractures/
2. Wrist Injuries/
3. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).ti,ab.
Appendix 3. Search strategies for CINAHL and EMBASE (OVID-WEB)
Last assessed as up-to-date: 1 October 2007.
Protocol first published: Issue 2, 2007
Review first published: Issue 1, 2008
Contributions of authors
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, Jim Huntley (JH) and Rajan Madhok (RM). HH searched for trials and contacted trial authors. All three authors performed study selection. HH and JH reviewed those trials that had not been included in a previous review covering all surgical interventions. HH repeated her review of the other included trials that had been quality assessed previously by HH and RM. 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
Sources of support
- University of Teesside, Middlesbrough, UK.
- University of Manchester, Manchester, UK.
- No sources of support supplied
Some of the wording in each of several sections of this review (in particular: Synopsis, Background, Methods, Discussion and Implications) is taken either entirely or in only a slightly modified form from related reviews on Percutaneous pinning for distal radial fractures in adults and External fixation versus conservative treatment for distal radial fractures in adults. This has been done to make the review self-contained and to ensure consistency between related reviews without requiring unnecessary cross-referrence by readers.
Medical Subject Headings (MeSH)
MeSH check words
Adult; Female; Humans; Male
* Indicates the major publication for the study