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Different methods of external fixation for treating 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: 23 JAN 2008

Assessed as up-to-date: 1 OCT 2007

DOI: 10.1002/14651858.CD006522.pub2


How to Cite

Handoll HHG, Huntley JS, Madhok R. Different methods of external fixation for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD006522. DOI: 10.1002/14651858.CD006522.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: 23 JAN 2008

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Characteristics of included studies [ordered by study ID]
Atroshi 2006

MethodsRandomised by sequentially opened numbered sealed opaque envelopes - based on computer-generated list
Assessor blinding: yes, for physical assessment (grip strength, ROM)
Intention-to-treat analysis: yes
Loss to follow up: 2 (at 1 year)


ParticipantsTeaching (?) hospital, Sweden
38 participants
Inclusion criteria: women 50 years or older, men 60 years or older, acute dorsally displaced distal radial fracture (20 or more degrees dorsal angulation or 5 mm or more radial shortening), extra-articular or intra-articular with at least 2 large articular fragments, informed consent
Exclusion criteria: articular step-off > 2 mm, ulnar fracture proximal to styloid, additional upper-limb fractures, nerve or tendon injuries, multiple injuries, high-energy trauma (such as fall from a height), previous fracture in injured radius, inflammatory joint disease, cerebrovascular disease or other severe illness, cognitive disorder or language problems hindering participation, drugs or alcohol abuse Classification: AO (A2, A3, C2, C3: extra-articular and intra-articular)
Sex: 31 female
Age: mean 71 years, range 55 - 86 years
Assigned: 19/19 [Ext-fix - non-bridge / Ext-fix - bridge]
Assessed: 18/18 (at 1 year)


InterventionsTiming of intervention: within 4 days from injury.
Regional or general anaesthesia; intraoperative fluoroscopy.
(1) Non-bridging external fixation: Hoffman II compact external fixator for 6 weeks. Two longitudinally parallel pins inserted via small incisions into radial shaft proximal to fracture. Two pins inserted into distal fragment: transverse incision in first 10 patients, 2 longitudinal incisions in next 9 patients. After drilling, two 3-mm pins inserted parallel to joint surface, fracture reduced using pins and pin clamp applied and fixator locked. Patients were instructed on early motion exercises for the wrist (see below).
(2) Bridging external fixation: Hoffman external fixator for 6 weeks. Via small incisions, 2 longitudinally parallel pins (3 mm) inserted into radial shaft proximal to fracture, and 2 into 2nd metacarpal. Closed reduction. Fixator locked.

All patients received antibiotics (Flucloxacillin) for 10 days. Patients were instructed on early motion exercises of fingers, wrist (non-bridging group only), elbow and shoulder. Patients referred to physiotherapy for ROM and strengthening exercises to restore normal hand and wrist function.


OutcomesLength of follow up: 1 year; also assessed at 2, 6, 10 and 26 weeks.
(1) Functional: disabilities of the arm, shoulder and hand (DASH) questionnaire (0: no disability to 100: most severe disability), SF-12 physical health score (norm = 50), mass grip strength, pain (VAS 0 to 10: worst pain), range of movement (flexion, extension, radial and ulnar deviation, pronation, supination).
(2) Clinical: patient satisfaction, complications: non-union (none), pin track infection, RSD (none), tendon rupture (none), numbness associated with median nerve, transient numbness radial sensory nerve, iatrogenic fracture, redisplacement.
(3) Anatomical: X-ray at 2 and 6 weeks and 1 year. Dorsal angulation, radial inclination, radial shortening (ulnar variance), redisplacement.


NotesAdditional information (on randomisation, surgeon experience and anaesthesia) and outcome data provided by trialist


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Hutchinson 1995

MethodsRandomised by odd or even medical record numbers but balanced in blocks of 4
Assessor blinding: not reported
Intention-to-treat analysis: likely at 1 year
Loss to follow up: 7 (at 1 year)


ParticipantsMulticentre trial in 6 university-affiliated hospitals, USA
89 participants with 90 fractures
Inclusion criteria: closed displaced unstable distal radial fractures (dorsal angulation > 20 degrees in Colles' type fractures; or extensive articular involvement or severe comminution, or both)
Exclusion criteria: need for internal fixation (not defined)
Classification: Frykman [86% 5-8]; also Colles', Smith's, Barton's (2 fractures), chauffeur's (1 fracture) and die punch. (Mainly or all intra-articular)
Sex: 68 female
Age: mean 65 years; range 14 - 93 years
Assigned: 44/46 (fractures) [Ext-fix / Ext-fix (POP)]
Assessed: 42/40 (at 1 year); 26/26 (out of 60 followed up at 2 years)


InterventionsTiming of intervention: not stated
Closed reduction under regional or general anaesthetic, usually overnight stay in hospital
(1) Fixator: AO small external fixator - 2 pins into radial shaft and 2 into 2nd metacarpal (at 45 degrees) - generally percutaneous insertion.
(2) Pins in plaster: 2 percutaneous pins - 1 threaded pin into radius proximal to fracture and 1 into the metacarpals in the plane of the palm - incorporated into forearm POP. Cast trimmed to allow thumb and metacarpophalangeal joint motion.

Fixator or pin removal 3 -12 weeks, mean 7.6 weeks.


OutcomesLength of follow up: 2 years; also assessed post reduction, 4 months and 1 year.
(1) Functional: subjective weakness, pain/discomfort & functional difficulty. Overall functional grades (Sarmiento 1975 modification of Gartland and Werley 1951). Mass grip strength, pain, range of movement (flexion, extension, radial and ulnar deviation, pronation, supination), finger motion, intrinsic and extrinsic tightness.
(2) Clinical: patient satisfaction, surgeon satisfaction. Complications: (major & minor), pin track infection, loss of reduction, radial neuritis, RSD or RSD symptoms, CTS (present before treatment), miscellaneous (skin breakdown, poor pin placement, aseptic pin loosening, pin related fracture, joint subluxation, tendon adhesion), arthritis (20 of 52 patients followed up at 2 years).
(3) Anatomical: X-ray at above times. Palmar (volar) angle, radial angle, radial length, articular incongruity, degenerative changes.


NotesAdditional information (method of randomisation) and data provided by trialist.
Surgery performed by residents under supervision.
Mixed fracture population


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Krishnan 2003

MethodsRandomised by closed envelopes
Assessor blinding: not reported, independent assessment of radiographs
Intention-to-treat analysis: likely but not known
Loss to follow up: not reported


ParticipantsTeaching hospital, Australia
60 participants
Inclusion criteria: intra-articular distal radial fractures including complex comminuted fractures, informed consent
Exclusion criteria: musculoskeletal or neurological disease, unable to follow routine pin track care, other associated fractures of the hand, wrist or forearm, previous fracture of same wrist
Classification: AO (A3.2, B2.1, C1.1, C1.2, C1.3, C2.1, C2.2, C2.3, C3.1, C3.2, C3.3: extra-articular (3 fractures) and intra-articular)
Sex: 41 female
Age: mean 56 years, range 18 - 83 years
Assigned: 30/30 [Ext-fix - non-bridge / Ext-fix - bridge]
Assessed: ?/? (at 1 year)


InterventionsTiming of intervention: not stated.
Closed reduction aided by 5 kg of horizontal finger-trap traction. Incision and open dissection to bone for pin placement.
(1) Non-bridging external fixation: dynamic non-bridging external fixator (Delta frame). Four 2.5 mm self-tapping pins placed in distal radial fragments in 2 horizontal planes: 2 into the dorso-radial aspect and 2 into the dorso-ulnar aspect. (Pins transfixed the fracture fragments and supported the articular surface; in cases of severe comminution and osteoporosis, these pins acted as subarticular supports.) A 4 mm threaded pin was inserted into the radial shaft approximately 6 cm proximal to the fracture. Frame assembled to produce a triangular shaped construct; not crossing the joint. Wrist mobilisation exercises started 2 weeks postoperatively.
(2) Bridging external fixation: Hoffman II Compact frame: 2 self-tapping pins into distal radial shaft proximal to the fracture, and 2 similar pins in the second metacarpal with one or two connecting rods between them. Wrist mobilisation exercises started after fixator removal after 6 weeks.

All patients received antibiotics (3 doses cephazolin: intra-operatively and post-operatively; then 1 week oral cephadine). Palmar plaster of Paris slab applied for one week. All external fixators removed at 6 weeks in outpatients. Patients were instructed on finger, elbow and shoulder mobilisation exercises. Physiotherapy prescribed for both groups.


OutcomesLength of follow up: 1 year; also assessed at 1,2,3,4,5,6, 12 and 26 weeks.
(1) Functional: scale of 17 activities of daily living scored as a percentage of full function, grip strength, pain (VAS 0 to 10: worst pain), range of movement (flexion, extension, radial and ulnar deviation, pronation, supination).
(2) Clinical: complications: total, pin track infection, neurological, fixation failure, RSD, EPL rupture, frozen shoulder, scar tethering, further surgery, redisplacement of fixator removal (none).
(3) Anatomical: X-ray at 1, 6, 12 and 26 weeks and 1 year. Dorsal angulation, radial length and angulation, radial step.


NotesOne person in the bridging group with a pin track infection needed incision and drainage, and early removal of the external fixator. She developed RSD and sustained a finger fracture during manipulation for stiffness of the metacarpophalangeal joints.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

McQueen 1996

MethodsRandomised by closed envelopes
Assessor blinding: not reported
Intention-to-treat analysis: likely
Loss to follow up: 6 (at 1 year)


ParticipantsTeaching hospital, UK
60 participants (in review comparison: see Notes)
Inclusion criteria: redisplaced unstable distal radial fracture (redisplaced to >10 degrees dorsal angulation or radial shortening > 3 mm)
Exclusion criteria: inadequate primary reduction, > 2 weeks from injury to recognised instability, displaced articular fragments requiring open reduction, previous malunion, mental incapacity
Classification: AO (A and C) (extra-articular and intra-articular)
Sex: 53 female
Age: mean 64 years, range 16 - 86 years (of 120 patients)
Assigned: 30/30 [Ext-fix with early mobilisation / Ext-fix]
Assessed: 26/28 (at 1 year)


InterventionsTiming of intervention: under 2 weeks from injury
(1) Dynamic fixation: closed reduction and Pennig external fixator. Two pins inserted into 2nd metacarpal and 2 into radial shaft using an open technique. Ball joint released at 3 weeks to allow wrist movement. Fixator removed after 6 weeks.
(2) Static fixation: as above (1) but ball joint of fixator remained locked for 6 weeks until fixator removal.

Physiotherapy prescribed on "purely clinical grounds". Patients did not receive physiotherapy when the fixator was in place.


OutcomesLength of follow up: 1 year; also assessed at 6 weeks, 3 and 6 months.
(1) Functional: activities of daily living (own scale), mass grip strength, other grips, pain (VAS 0 to 10: no data), range of movement (overall, flexion and extension).
(2) Clinical: complications: recurrent instability, malunion, pin track infection, RSD, CTS, dorsal medial neuropraxia (superficial radial nerve?), EPL rupture (none), carpal collapse.
(3) Anatomical: X-ray at all follow-up times. Dorsal angulation, radial shortening, carpal malalignment, malunion.


NotesTrial with 120 participants had 4 intervention groups. Excluded from this review are a) 30 participants receiving open reduction and bone graft held in place with a single Kirschner wire, and b) 30 participants receiving closed manipulation then forearm cast.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

McQueen 1998

MethodsRandomised by closed envelopes
Assessor blinding: not reported
Intention-to-treat analysis: likely
Loss to follow up: 4 (at 1 year)


ParticipantsTeaching hospital, UK
60 participants
Inclusion criteria: redisplaced unstable distal radial fracture (redisplaced to >10 degrees dorsal angulation within forearm cast), informed consent
Exclusion criteria: residual dorsal angulation after primary reduction, > 2 weeks from injury to recognised instability, displaced articular fracture, previous malunion, physically or mentally unable to perform functional evaluation, fracture with < 1 cm of intact volar cortex on the distal radial fragment
Classification: AO (A3.2, A3.3, C2.1: extra-articular and intra-articular)
Sex: 55 female
Age: mean 61 years, range 31 - 85 years
Assigned: 30/30 [Ext-fix - non-bridge / Ext-fix - bridge]
Assessed: 28/28 (at 1 year)


InterventionsTiming of intervention: under 2 weeks from injury
(1) Non-bridging external fixation: closed reduction and 2 pins inserted into distal fragment from dorsal to volar with a limited open technique and 2 into radial shaft. Fracture further reduced using pins as levers and Pennig external fixator completed. Fixator removed at 6 weeks.
(2) Bridging external fixation: closed reduction and Pennig external fixator for 6 weeks. Two pins inserted into 2nd metacarpal and 2 into radial shaft using an open technique. Ball joint locked.
Physiotherapy prescribed as "clinically indicated".


OutcomesLength of follow up: 1 year; also assessed post-operatively and at 6 weeks, and 3 and 6 months.
(1) Functional: mass grip strength, pain (VAS 0 to 10: worst pain), residual pain, pain site, range of movement (flexion, extension, pronation, supination).
(2) Clinical: complications: malunion, pin track infection, carpal collapse or malalignment, RSD, EPL rupture.
(3) Anatomical: X-ray at 6 weeks and 1 year. Dorsal angulation, radial shortening, carpal malalignment, malunion.


NotesSome discrepancies in the data (grip strength, complications, flexion) between abstract (McQueen 1997) and report. Also some discrepancies between text and tables in report: loss in radial length, and numbers with malunion (14) and those meeting definition of malunion: dorsal angulation >10 degrees (15).
Letter commenting on pin track infection and Kapandji pinning from Casteleyn 1999 prompted definition of pin track infection from McQueen.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Moroni 2001

MethodsRandomised using a computer generated list
Assessor blinding: not reported
Intention-to-treat analysis: likely but missing data points (1 patient?) in figure of torque results
Loss to follow up: not stated, maybe 1


ParticipantsHospital, Italy
20 participants
Inclusion criteria: extra-articular distal radial fracture A2 or A3 (AO classification), female with osteoporosis (bone mineral density < -2.5 T score), fracture from minor trauma, ability to communicate physical condition, informed consent
Exclusion criteria: age < 65 years; open fracture; secondary fracture to malignant tumour, bone or soft-tissue infection at fracture site, on chemotherapy treatment, multiple fractures, severe systemic disease
Classification: AO (A2, A3) (extra-articular)
Sex: all female
Age: mean 74.5 years
Assigned: 10/10 [hydroxyapatite pins / usual pins]
Assessed: 10?/10 (at 6 weeks)


InterventionsTiming of intervention: not stated
All had external fixation using a Pennig II wrist fixator: 2 pins in distal radius and 2 in 2nd metacarpal. Pins, all tapered 3.3-3 mm thread diameter, were inserted through small incisions and positioned using fluoroscopy and implanted after predrilling.
(1) Hydroxyapatite coated tapered pins
(2) Standard (uncoated) tapered pins
Ball joint of fixator was kept locked throughout. Pin sites were cleaned daily with saline solution. All patients had antibiotic prophylaxis (cephalosporin) for 2 days. Fixator removed without anaesthesia at 6 weeks post surgery.


OutcomesLength of follow up: 6 weeks.
(1) Functional: no information.
(2) Clinical: complications: pin track infection, pain during pin removal ( VAS scores (0 to 10: maximum pain), RSD.
(3) Anatomical: no information.
(4) Other: pin insertion and extraction torques.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Raskin 1993

MethodsMethod of randomisation not stated: "prospective random selection". However an external fixator was used for 5 people with highly comminuted fractures
Assessor blinding: not reported
Intention-to-treat analysis: no information
Loss to follow up: 0 (at 12+ months)


ParticipantsTeaching hospital, USA
60 participants
Inclusion criteria: closed unstable intra-articular distal radial fractures
Exclusion criteria: open fracture or concomitant injuries.
Classification: Melone (type IIA and IIB); AO type C; all had die-punch fragment of the medial complex; (all intra-articular)
Sex: not stated; male and female
Age: mean 45 years; range 18 - 73 years
Assigned: 30/30 [Ext-fix / Ext-fix (POP)]
Assessed: 30/30 (at 12+ months)


InterventionsTiming of intervention: 1 to 14 days from injury, mean 6 days.
Before operation, resolution of soft tissue swelling; use of protective wrist splint immobilisation with limb elevation; continuous active motion of fingers and thumb. Closed reduction in 14 participants with severe angular deformity before external fixation. Probably regional anaesthesia used for both groups.
(1) Fixator: unilateral external fixator including a ball joint - 2 threaded pins into radial shaft and 2 into 2nd metacarpal - inserted using limited open techniques and predrilling. Manipulation under traction and further reduction via percutaneous placement through the radial styloid fragment of a Kirschner wire. 5 people had open reduction. Fixator frame covered with sterile gauze at skin contact interface. Dressing changes 4 times in 8 weeks. Supplemental volar splint applied.
(2) Pins in plaster: 2 percutaneous Steinmann pins: 1 in radius proximal to fracture and 1 through 2nd and 3rd metacarpals. Percutaneous stab incisions and use of power drill. Manipulation under traction and probably through the use of supplementary Kirschner wires inserted obliquely from radial styloid fragment into radial shaft in most patients. Intraoperative fluoroscopy. Steinmann pins incorporated into forearm plaster cast.

Immediate post-operative elevation and active finger movements. Fixator or pins in cast removal at 8 weeks.


OutcomesLength of follow up: 12 to 60 months, mean 28 months; no indication of other follow-up times.
(1) Functional: overall functional grades (modified McBride, and Green and O'Brien), return to former activities of daily living, grip strength, range of movement (extension, flexion, pronation, supination). Finger stiffness.
(2) Clinical: patient satisfaction. Complications:
pin track infection, pin loosening, pin track inflammation (not infection), pin breakage (none), osteomyelitis (none), loss of reduction (remanipulated), persistent neuropathy (none), RSD (none), finger stiffness (none), secondary operations (none).
(3) Anatomical: X-ray. Lidstrom 1959 grades (dorsal angulation; radial shortening).


NotesAll 8 cases of pre-operative median nerve compression resolved with closed reduction.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Sommerkamp 1994

MethodsRandomised by odd or even chart number
Assessor blinding: not reported, independent assessment of X-rays at fixator removal
Intention-to-treat analysis: problems (14 omitted due to inadequate follow up or poor compliance to rehabilitation programme; baseline characteristics were not presented for these or for the 11 lost to follow up)
Loss to follow up: 11 lost and 14 excluded (at 1 year)


ParticipantsTeaching hospital, USA
73 participants with 75 fractures
Inclusion criteria: skeletally mature, unstable comminuted fractures of the distal radius. Either primary external fixation (dorsal angulation > 20 degrees or radial shortening > 10 mm or intra-articular, comminuted dorsal cortex or open, bilateral, polytrauma) or post-reduction (radial shortening 11-14 mm or persistent dorsal angulation) or secondary external fixation within 14 days from first reduction for failed anatomical restoration (radial shortening > 5 mm, loss volar tilt > 5 degrees)
Excluded: ipsilateral fracture of scaphoid, carpal fracture-dislocation or a more proximal upper limb injury, Smith's or Barton's fractures.
Classification: Frykman (I to VIII), extra-articular and intra-articular (mainly)
Sex: 26 female (of 48 analysed)
Age: of 48: mean 36 years, range 18 - 70 years
Assigned: 37/36 (38/37 fractures) [dynamic / static Ext-fix]
Assessed: 24/24 (25/25 fractures) (at 1 year)


InterventionsTiming of intervention: either after preliminary closed reduction (2 days) or within 14 days after an incomplete restoration of anatomical alignment.
Anaesthesia regional or general. Closed reduction under fluoroscopy.
(1) Dynamic fixation: closed reduction + dynamic Clyburn external fixator (hinged ball-joint design): 2 pins in 2nd metacarpal and 2 in radial shaft. Limited mobilisation (neutral to 30 degrees flexion) at around 2 weeks (actually 9 to 38 days; mean 23 days - often delayed until oedema resolved) and full mobilisation (extension and flexion) at around 4 weeks (actually 24 to 55 days; mean 34 days). Fixator removed 6-11 weeks (mean 10 weeks)
(2) Static fixation: closed reduction + static AO/ASIF external fixator (multiplanar): 2 pins in 2nd metacarpal and 2 in radial shaft. Fixator removed after 6-11 weeks (mean 9 weeks).
Additional procedures:
Adjunctive percutaneous pinning: 3/2 [dynamic / static Ext-fix]
Open reduction + bone graft: 0/1

Dressed pin sites. Post-operatively, patients were managed with active and active-assisted range of motion exercises of the fingers, thumb, elbow and shoulder; and instructed on twice-daily care of pin tracks. Bi-weekly assessments at the Hand Clinic.


OutcomesLength of follow up: 1 year (post fixator removal); also assessed at during fixator usage, and at fixator removal (10 weeks) and 1 and 6 months after that.
(1) Functional: overall score: activities of daily living including pain, disability, activity limitations (Sarmiento modified Gartland & Werley), grip strength, pinch strength, pain (VAS - no data), range of movement (flexion, extension, radial and ulnar deviation, pronation, supination).
(2) Clinical: complications: equipment failure (broken/unstable fixator), pin breakage, dysfunction of median nerve (due to injury), transient neuritis of superficial radial nerve, RSD, tendon rupture (none), iatrogenic fractures (none), osteomyelitis, intrinsic or extrinsic tightness, pin site problems (drainage or erythema in some cases resulting in fixator removal (3 versus 4), osteoarthritis, osteopenia (grade III: severe) on fixator removal.
(3) Anatomical: X-ray after application and after removal of fixator (10 weeks) and 1 year. Dorsal angulation, radial shortening, radial deviation, deformity (Lidstrom 1959). Angular incongruity.


NotesThere was considerable variation in treatment regimens within groups.
There were small discrepancies in the data between the full report and abstract - mainly could be rounding errors - the results of the full report are used in this review.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Werber 2003

MethodsRandomised via a "complete block design"
Assessor blinding: not reported, independent assessment of radiographs
Intention-to-treat analysis: likely but discrepancies in some patient characteristics and data between abstracts and full reports
Loss to follow up: probably none


ParticipantsTeaching hospital, Germany
50 participants
Inclusion criteria: unstable dorsally angulated distal radial fracture. Unstable = severe comminution, intra-articular extension, a large dorsal cortical comminution or defect, or reduction could not be maintained with a cast or a splint.
Exclusion criteria: stable, open, Smith's or diaphyseal fracture; bilateral or concomitant fractures; ligamentous wrist injury, pre-existing wrist deformity, previous surgical or non-surgical treatment
Classification: AO (ASIF) (A2.2, A3.1, A3.2, C2.1, C2.2, C2.3: extra-articular and intra-articular)
Sex: 35 female
Age: mean 58.5 years (all of employment age or above)
Assigned: 25/25 [5 pins / 4 pins]
Assessed: 25/25 (at 6 months)


InterventionsTiming of intervention within 10 days of injury.
All fractures manipulated under local anaesthesia within 4 hours of injury and a plaster cast applied. Standard 4 pin small AO (ASIF) fixators (linear) applied under general anaesthesia and fluoroscopy. Two partially threaded 3 mm pins into 2nd metacarpal and 2 partially threaded 4 mm pins into radial shaft. Closed reduction by traction using the distal pin. Intra-articular fractures reduced using a percutaneous Kirschner wire. Additional temporary wire inserted in some patients (12 versus 10) in distal fragment of radius to correct radial inclination.
(1) 5 pin external fixation: 5th pin (2.5 mm threaded Kirscher wire) used to fix the 'floating' distal fragment, then attached to fixator frame with a pin clamp. Pin removed after 7 weeks.
(2) 4 pin external fixation (standard external fixator)

Pin clamps on metacarpal pins loosened after 3 weeks. Fixators removed approximately 9 weeks post surgery. Physical therapy started first day after surgery. Patients advised no load bearing for at least 12 weeks. Physical therapy including range of motion exercises (fingers, wrist, elbow) continued for 8 weeks after fixator removal.


OutcomesLength of follow up: 6 months; also 1 day and 9 weeks (fixator removal. (Also post-operatively. "On a weekly basis.": abstracts)
(1) Functional: Lidstrom rating scheme (1: unimpaired wrist function to 4: poor result, including pain), grip strength, range of movement (flexion, extension, radial and ulnar deviation, pronation, supination).
(2) Clinical: treated persistent pain and swelling. Complications: pin site infection or drainage, temporary paraesthesias of thumb, index and long fingers (radial nerve?), RSD (none), tendon rupture (none), non-union (none), nerve compression syndrome (none), fixator failure (none).
(3) Anatomical: X-ray at 1 day and 9 weeks post-operatively and 6 months. Volar tilt ('normal': 10 degrees), "relative radial length" ('normal': 0 mm), (ulnar variance in abstracts), radial inclination ('normal': 30 degrees), articular step off.


NotesNumber of females was given as 37, the mean age as 64 years and the mean duration of fixation as 8.5 weeks in the 2 abstract reports. Follow up schedules and radiological results also differ.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Asche 1995Not a randomised comparison. May not even be a controlled trial.

Auge 2000Not a randomised comparison, nor a controlled trial.

Cardone 2006The randomised trial mentioned in a conference abstract is focused on biomechanical outcome and is yet to take place (March 2007).

Hutchinson 2000Randomised trial of intervention (predrilling or not for external fixator pins) within patients: the complex study design prevents the drawing of direct conclusions on clinical outcome.

Rawes 1995Quasi-randomised (based on dates of birth) trial of dynamic versus static fixation (for 6 weeks) only reported in a conference abstract. Insufficient information. No response from lead trialist. Reports disuse osteoporosis (1/16 versus 4/16 at 24 weeks), but no other data split by treatment group. (This was an included trial in the previous review: Handoll 2003a.)

Stoffelen 1999Randomised or, more likely, quasi-randomised trial that evaluated the use of wrist arthroscopy in 30 (?) people who had external fixation. Only reported in a conference abstract. Insufficient information. No response from lead trialist when approached regarding another study.

Stokes 1998Trial involving 20 people "randomly selected" (over a 10 year period) to non-bridging (of joint) versus bridging external fixation. Only reported in a conference abstract. Insufficient information. No response from lead trialist. (This was an included trial in the previous review: Handoll 2003a.)

Tortosa 1995Not a randomised comparison.

 
Comparison 1. External fixator versus pins and plaster external fixation

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

 1 Functional grading: fair (or poor)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Subjective assessment of function1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Some pain or discomfort present
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    2.2 Some functional difficulty
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

 3 Grip strength (% or normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

    4.2 Loss of reduction resulting in remanipulation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Loss of reduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.4 Pin track complications: infection or inflammation
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.5 Pin track infection: major
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.6 Reflex sympathetic dystropy or symptoms
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.7 Reflex sympathetic dystropy or symptoms: major
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.8 Radial neuritis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.9 Radial neuritis: persistent
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    4.11 Miscellaneous complications (skin breakdown, pin loosening, tendon adhesion etc)
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

 6 Anatomical grading: fair or poor1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 2. Non-bridging versus bridging external fixation

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

 1 DASH scores (0 to 100: most disability)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 SF-12 physical domain scores (0 onwards; higher better: population mean = 50)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Grip strength (kg)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Mass grip strength (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Residual pain2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Pain (VAS 0 to 100: worst)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 7 Range of motion (degrees)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

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

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

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

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

 8 Range of motion (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

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

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

 9 Complications3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

    9.2 Pin track infection
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.3 Redisplaced fracture resulting in re-reduction and pinning
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.4 Iatrogenic fracture
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.5 Transient numbness in radial sensory nerve
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.6 Neurological (not defined)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.7 Tendon rupture
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.8 Reflex sympathetic dystrophy
3Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.9 Frozen shoulder
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.10 Scar tethering
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    9.12 Other (non-specified)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

 11 Anatomical displacement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    11.1 Loss in radial length (radial shortening) (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

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

    12.1 Palmar or volar tilt (reverse to dorsal angulation) (degrees)
2Mean Difference (IV, Fixed, 95% CI)Not estimable

    12.2 Radial inclination (degrees)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

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

 13 Deformity (structural)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    13.1 Carpal malalignment
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    13.2 Malunion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 14 Length of surgery (minutes)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 3. Supplementary percutanous pinning of distal radial fracture fragment

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

 1 Functional gradings1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Not very good
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

 2 Grip strength (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Range of motion (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

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

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

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

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

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

    4.1 Fixation failure including early removal of fixator
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.2 Pin site problems
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Pin loosening
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.4 Persistent pain and swelling (resolved after medication)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.5 Osteomyelitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    4.7 Nerve compression syndrome
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.8 RSD
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 5 Ulnar plus variance1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 6 Length of surgery (minutes)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 4. Hydroxyapatite coated versus standard pins

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

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

    1.1 Pin track infection
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

 2 Torque for insertion and removal of pins (Nmm)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

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

 
Comparison 5. Dynamic versus static fixation

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

 1 Functional gradings1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

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

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

    1.3 Fair or poor: best case for dynamic fixation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.4 Fair or poor: worst case for dynamic fixation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 2 Mass grip strength (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Range of movement (% of normal side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

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

    3.2 Flexion/extension
1Mean Difference (IV, Fixed, 95% CI)Not estimable

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

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

    4.2 Loss of reduction prompting re-reduction
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.3 Pin track infection or complications
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    4.5 Osteomyelitis of radius
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.6 Pin loosening resulting in early fixator removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.7 Unstable or broken fixator
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    4.9 Carpal tunnel syndrome or dysfunction of median nerve
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.10 "Dorsal medial neuropraxia"
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    4.11 Transient neuritis of superficial radial nerve
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

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

    4.13 Moderate or severe osteopenia at fixator removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 5 Anatomical displacement1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Loss in radial length (radial shortening) (mm)
1Mean Difference (IV, Fixed, 95% CI)Not estimable

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

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

 7 Deformity (structural)2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    7.1 Carpal collapse
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    7.2 Malunion
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    7.3 Moderate or severe deformity (Lidstrom grades III & IV): at fixator removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    7.4 Articular incongruity (step off > 2mm): at fixator removal
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    7.5 Radiologically assessed osteoarthrosis (moderate or severe): at 1 year
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 
Table 1. Commonly used classification systems

Name (reference ID)Brief outlineComment

AO (Arbeitsgemeinschaft fur Osteosynthesefragen) (Muller 1991)This system is organised in order of increasing fracture severity. It 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.There is no assessment of the extent of fracture displacement.

Frykman
(Frykman 1967)
This system 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 (ulnar styloid) fracture. There are 8 types labelled I to VIII (1 to 8): the higher the number, the greater complexity of the fracture.There is no assessment of the extent or direction of fracture displacement, or of comminution.

Melone
(Melone 1993)
This system identifies 5 fracture types, based on 4 major fracture components: the radial shaft, the radial styloid, and the dorsal-medial and volar-medial fragments.This is for intra-articular fractures only.

Older
(Older 1965)
This system divides fractures into 4 types, labelled I to VI (1 to 4) of increasing severity. The types are defined according to extent of displacement (angulation and radial shortening) and comminution.There is no consideration of radio-ulnar joint involvement.

'Universal Classification' (Cooney 1993)This system divides fractures into 4 main types, labelled I to VI (1 to 4), distinguishing between extra-articular and intra-articular fractures and displaced and non-displaced fractures. Displaced fracture types II and IV are further subdivided based on 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).This does not distinguish between the radiocarpal and radio-ulnar joints. Additionally, there is a 'trial by treatment'.

 
Table 2. Definitions of key radiological parameters

ParameterDefinitionNormal value

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

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

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

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

 
Table 3. Methodological quality assessment scheme

ItemsGradesNotes

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

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

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

(4) Were important baseline characteristics reported and comparable?Y = good comparability of groups, or confounding adjusted for in analysis.
? = confounding small, mentioned but not adjusted for, or comparability reported in text without confirmatory data.
N = large potential for confounding, or not discussed.
Although many characteristics including hand dominance are important, the principal confounders are considered to be age, gender, type of fracture.

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

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

(7) Were care programmes, other than the trial options, identical?Y = care programmes clearly identical.
? = clear but trivial differences, or some evidence of comparability.
N = not mentioned or clear and important differences in care programmes.
Examples of clinically important differences in other interventions are: time of intervention, duration of intervention, anaesthetic used within broad categories, operator experience, difference in rehabilitation.

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

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

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

(11) Was the timing (e.g. duration of surveillance) clinically appropriate?Y = optimal. (> 1 year)
? = adequate. (6 months - 1 year)
N = not defined, not adequate. (< 6 months)

 
Table 4. Categories of effectiveness (definitions)

RankCategoryDefinition

1BeneficialInterventions for which effectiveness has been demonstrated by clear evidence from randomised controlled trials, and for which expectation of harms is small compared with the benefits.

2Likely to be beneficialInterventions for which effectiveness is less well established than for those listed under "beneficial".

3Trade off between benefits and harmsInterventions for which clinicians and patients should weigh up the beneficial and harmful effects according to individual circumstances and priorities.

4Unknown effectivenessInterventions for which there is currently insufficient data or data of inadequate quality.

5Unlikely to be beneficialInterventions for which lack of effectiveness is less well established than for those listed under "likely to be ineffective or harmful"

6Likely to be ineffective or harmfulInterventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence.

 
Table 5. Key characteristics of participants, fractures and interventions


Study IDParticipants (N, gender, age)Fracture type and classificationTiming/ common intervention/ durationInterventionControl

Atroshi 200638; 82% female; mean age 71 years.Acute dorsally displaced (> 20 degrees dorsal angulation or 5+ mm radial shortening). At least 2 large articular fragments if intra-articular. AO types A2, A 3 and C2, C3 (extra-articular and intra-articular).Within 4 days from injury. Closed reduction.
Open incisions for pin insertion. External fixation for 6 weeks.
Non-bridged fixation using /hoffman II compact external fixator. Two pins in radial shaft and 2 in distal fracture fragment. Instructions for early wrist exercises.Bridged (across wrist joint) fixation using Hoffman external fixator. Two pins in radial shaft and 2 in 2nd metacarpal. Fixator locked.

Hutchinson 199589; 76% female; mean age 65 years.Various fractures including Colles' (>20 degrees dorsal angulation). Frykman (mainly V to VIII), probably extra-articular as well as intra-articular.Timing not stated. Closed reduction and generally percutaneous insertion of pins.
Trans-articular fixation for 3 to 12 weeks (mean 7.6 weeks).
AO external fixator; 2 pins in radial shaft and 2 in 2nd metacarpal.Two pins in radial shaft and 1 in metacarpals in plane of palm. Pins incorporated into plaster.

Krishnan 200360; 68% female; mean age 56 years.Mainly intra-articular including complex and comminuted. AO types A3.2, B2.1, C1, C2, C3 (extra-articular and intra-articular).Timing not stated. Closed reduction.
Open incisions for pin insertion. External fixation for 6 weeks.
Non-bridged fixation using Delta frame external fixator. One pin in radial shaft and 4 in distal fracture fragments in 2 horizontal planes. Free wrist movement.Bridged (across wrist joint) fixation with Hoffman II Compact frame. Two pins in radial shaft and 2 in 2nd metacarpal.

McQueen 199660 of 120 in comparison; 88% female; mean age 64 years.Redisplaced (>10 degrees dorsal angulation / >3 mm radial shortening). AO types A and C (extra-articular and intra-articular).Within 2 weeks from injury. Closed reduction.
Open incisions for pin insertion. Trans-articular fixation. Pennig external fixator for 6 weeks.
Ball joint of fixator released for limited wrist motion at 3 weeks.Ball joint remained locked.

McQueen 199860; 92% female; mean age 61 years.Redisplaced (>10 degrees dorsal angulation). AO types A3.2, A 3.3 and C2.1 (extra-articular and intra-articular).Within 2 weeks from injury. Closed reduction.
Open incisions for pin insertion. Pennig external fixator for 6 weeks.
Non-bridged fixation. Two pins in radial shaft and 2 in distal fracture fragment. Free wrist movement.Bridged (across wrist joint) fixation. Two pins in radial shaft and 2 in 2nd metacarpal. Ball joint locked.

Moroni 200120; all females with osteoporosis; mean age 74.5 years.Extra-articular wrist fracture. AO types A2 and A3.Timing and reduction not stated. Trans-articular fixation: 2 pins in distal radius and 2 in 2nd metacarpal. Small incisions for pin insertion. Pennig II external fixator applied for 6 weeks.Hydroxyapatite coated tapered pins.Standard uncoated tapered pins.

Raskin 199360; % female unknown; mean age 45 years.Unstable intra-articular distal radial fractures. Melone IIA and IIB; AO type C.Within 2 weeks of injury (1-14 days). Closed reduction prior to surgery in 14 patients. Manipulation under traction for both operations and probably further reduction by supplementary percutaneous Kirschner wire(s) used to fix fracture in most patients. Open reduction in 5 patients. Trans-articular fixation for 8 weeks.Uniplaner external fixator; 2 threaded pins in radial shaft and 2 in 2nd metacarpal, inserted using limited open techniques.Percutaneous insertion of one Steinmann pin in radial shaft and 1 through 2nd and 3rd metacarpals. Pins incorporated into plaster.

Sommerkamp 199473; of 48: 54% female; mean age 36 years.Displaced (>20 degrees dorsal angulation / >10 mm radial shortening) or unstable intra-articular and comminuted fractures, or post-reduction (persistent radial shortening / dorsal angulation) or redisplaced (loss volar tilt >5 degrees/ >5 mm radial shortening). Frykman I to VIII (extra-articular and intra-articular).After primary closed reduction or within 2 weeks from injury. Closed reduction.
Trans-articular fixation for 6 to 11 weeks.
Dynamic Clyburn external fixator. Limited mobilisation around 2 weeks, full mobilisation
around 4 weeks.
Static AO/ASIF external fixator.

Werber 199950; 70% female; mean age 58.5 years.Unstable dorsally angulated fracture. AO types A2.2, A3.1, A3.2, and C2.1, C2.2, C2.3) (extra-articular and intra-articular).Fixation within 10 days of injury. Closed reduction; intra-articular fractures reduced using percutaneous wire.
Standard 4 pin small AO (ASIF) fixator for approximately 9 weeks.
Additional pin inserted percutaneously to fix the "floating" distal fracture fragment. Pin attached to fixator frame. Removed after 7 weeks.Standard fixator; distal fragment not fixed.

 
Table 6. Quality assessment results for individual trials (see Table 04 for scheme)

Study IDItems and gradesItems and gradesItems and gradesNotes

Study IDItem 1: Allocation concealment Item 2: Intention-to-treat analysis Item 3: Outcome assessor blinding Item 4: Comparable baseline characteristicsItem 5: Participant blinding Item 6: Treatment provider blinding Item 7: Identical care programmes Item 8: Clearly defined inclusion criteriaItem 9: Well defined outcome measures Item 10: Optimal outcome assessment Item 11: Optimal timing of follow up (> 1 year) In brackets: date of last follow up; % lost to last follow upComments and explanations for specific items

Atroshi 2006Y, Y, ?, YN, N, Y, YY, Y, ? (1 year; 5% at 1 year)Item 3: blinding for physical examination (grip strength, range of motion).

Hutchinson 1995N, ?, N, ?N, N, ?, YY, ?, Y (2 years; 8% at 1 year)Item 11: note that only 52/60 were followed up at 2 years; 13% lost to last follow up. Rest only followed up 1 year.

Krishnan 2003?, ?, N, ?N, N, ?, YY, ?, ? (1 year; ?%)Item 2: no report of drop-outs.
Item 4: small imbalances in numbers of males, age and hand dominance.

McQueen 1996?, Y, N, YN, N, ?, YY, ?, ? (1 year; 10%)

McQueen 1998Y, ?, N, YN, N, Y, YY, ?, ? (1 year; 7%)Item 2: some discrepancies in full trial report and between full report and one abstract.

Moroni 2001?, ?, N, YN, N, ?, YY, ?, N (6 weeks; 5%?)Item 2: loss to follow up not reported but missing data points on graph for 1 person.

Raskin 1993?, ?, N, NN, N, ?, ??, N, Y (12 to 60 months; 0%)Item 4: no information on gender, difference in mean ages, 5 more serious fractures in the external fixator group.
Item 10: variable length of follow up.

Sommerkamp 1994N, N, N, NN, N, ?, YY, ?, Y (12 months after fixator removal; 34%)Item 2: exclusions for non-compliance with rehabilitation regimen.
Item 4: data not provided for whole group.

Werber 2003?, ?, N, YN, N, Y, ?Y, ?, ? (6 months, 0%)Item 2: some discrepancies between full report and the two abstract reports.
Item 3: independent assessment of radiographs.

 
Table 7. Category of effectiveness for variants of external fixation

ComparisonCategoryJustificationQualifiersComments

External fixator versus pins and plaster external fixation4: Unknown effectivenessNot enough evidence: two small flawed (e.g. one was quasi-randomised; and one had imbalances in baseline characteristics) and very different (e.g. study populations, interventions and study performance including experience of participating surgeons) trials.(1) In one trial (Hutchinson 1995) there was a notable difference between the two groups in the types of complications: there were tendencies for more serious pin track infection and persistent nerve injury in the bridged uni-planar external fixator group, and for more pain or discomfort and loss of reduction in the pins and plaster group.Lower costs of pins and plaster mentioned but advantages of external fixators (unimpeded access to wounds, possibility of adjustment etc) also stressed.

Non-bridging versus bridging (over wrist joint) external fixation4: Unknown effectivenessNot enough evidence: three small heterogenous (e.g. interventions and study populations, especially types of fracture) trials with differing conclusions. The only one (Atroshi 2006) using a validated functional outcome measure (DASH) found no difference in functional outcome. McQueen 1998 found better grip strength, wrist flexion and anatomical outcome for non-bridging fixation. Krishnan 2003 found no difference in outcome except lower wrist flexion with non-bridging,(1) For both Atroshi 2006 and McQueen 1998, the distal fracture fragments needed to be sufficiently sized for placement of the distal pins.
(2) McQueen 1998 included redisplaced fractures only - the majority were extra-articular. Half of the fractures were extra-articular in Atroshi 2006 and the majority were complex intra-articular fractures in Krishnan 2003.
(2) McQueen 1998 was a single surgeon trial; the results are likely to differ in other situations, such as where the surgeons are less experienced.
Non-bridging enabling greater wrist mobility is attractive. But, while superior results were found for non-bridging fixation in 1 trial, this was not the case for the other two.

Supplementary percutaneous pinning versus external fixation alone: 5 pin versus 4 pin external fixation3: Trade off between benefits and harmsOne small trial found the fixing of the 'floating' distal fragment with a single pin, which was then attached to the fixator, gave superior functional and anatomical results. However, the operation took longer and the possibility of additional complications from the extra pin cannot be ruled out.(1) This is just one of a variety of possible techniques for supplementary pinning.
(2) The duration of immobilisation was 9 weeks; rather longer than usual.
(3) An additional pin was used to reduce intra-articular fractures.
(4) All operations were performed by one experienced surgeon: the results may not apply elsewhere.
There are some reservations about the reliability of the evidence from this trial. Additionally the methods of outcome assessment were not optimal.

Hydroxyapatite coated pins versus uncoated pins4: Unknown effectivenessNot enough evidence: one small trial that recorded few clinical outcomes.The clinical implications of the biomechanical finding that hydroxyapatite coating may help hold external fixator pins in osteoporotic bone during external fixation are not established in this trial.

Dynamic external fixation versus static external fixation.4: Unknown effectivenessNot enough evidence: two small and very different trials (e.g. study populations and interventions) evaluated early wrist mobilisation in different ways. One trial (Sommerkamp 1994) was quasi-randomised and had a large loss to follow up.(1) The five cases of unstable or broken dynamic fixator in Sommerkamp 1994 may reflect some unrelated deficiency in this device.As well as questions over the reliability of the evidence from Sommerkamp 1994, there are issues regarding the actual comparison. This was not simply early wrist mobilisation, which anyway occurred at various times, but also involved the use of two different fixators.