Treatment of distal radial fractures in adults
In this report, we have summarized the evidence on treatment and rehabilitation of distal radial fractures from the most recent available systematic reviews of high quality.
The most frequent type of fracture in Norway is the fracture of the distal radius, with an incidence of approximately 15,000 per year. Various treatment alternatives exist, but it remains uncertain which patients should be treated surgically, and which methods are best suited. As a result, there is a relatively large variation in practice in Norway. In this report, we have summarized the evidence on treatment and rehabilitation of distal radial fractures from the most recent available systematic reviews of high quality.
Main findings are as follows:
- There is not enough evidence to decide which method of reduction is best.
- There is some evidence to support the use of percutaneous pinning, however the best methods of percutaneous pinning are not established.
- There is some evidence to support the use of external fixation compared to plaster cast. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces the incidence of redisplacement, gives better anatomical results and most of the surgically-related complications are minor.
- There is insufficient evidence to determine the relative effects of the various methods of external fixation. Bone scaffolding (bone transplantation or use of bone substitutes) may improve anatomical outcome compared with plaster cast alone, but there is insufficient evidence to conclude on functional outcome or complications. The same applies for other comparisons between different bone scaffolding methods.
- There is some evidence that supports the use of rehabilitation interventions for patients with distal radius fractures. However, the evidence did not allow us to calculate the relative effect of different rehabilitation methods.
The evidence base for the management of distal radius fracture is limited. Further research should therefore be preceded by agreement on the priority questions for the management of these fractures, and to be addressed through large multi-centre trials.
The most frequent type of fracture in Norway is the fracture of the distal radius, with an incidence of approximately 15,000 per year. Plaster cast is the usual treatment for uncomplicated fractures, whereas more advanced techniques are often used for complicated fractures. However, it remains uncertain which patients should be treated surgically, and which methods are the most appropriate. In addition, it is still not established whether it is the type of fracture or possibly the age of the patient that should be decisive for what treatment to opt for. In addition, there is still uncertainty around which methods of reduction and rehabilitation are best suited. As a result, there is a relatively large variation in practice in Norway.
The Norwegian Orthopedic Association (NOA) has therefore gathered a working group to develop guidelines for treating distal radius fractures. To support this work, NOA have asked the Norwegian Knowledge Centre for the Health Services for support in performing a systematic review of the available literature on the effect of different treatments and rehabilitation interventions for the treatment of distal radius fractures.
This report summarizes results from systematic reviews on the treatment and rehabilitation of distal radius fractures.
We have performed a systematic literature search in October 2007 (updated in November 2008, November 2009 and November 2011) in The Cochrane Library, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE Cochrane), Health Technology Assessment (HTA) database, PreMEDLINE, MEDLINE and EMBASE, using a filter for systematic reviews. Inclusion criteria were that the reviews had to be systematic; the population included adults aged 18 or more with any types of fractures in the distal radius. Interventions to be included were conservative and operative treatments, all methods of reduction as well as all types of rehabilitation interventions. Quality assessments of the systematic reviews were done using a check-list adapted from the one developed by the Cochrane Collaboration described in the Cochrane Handbook for Systematic reviews of Interventions. Strength of evidence for each outcome was assessed using the GRADE method.
With a few exceptions, studies included in the systematic reviews summarized in this report, had few participants and few events. Therefore, we decided to describe results from studies that had significant results and/or had more than 100 participants.
Based the inclusion criteria and the quality assessment of the documentation available, we included six systematic reviews, which all were Cochrane Reviews.
Closed reduction methods
One systematic review published in 2003 (search 1966-2003, updated in 2005 but resulted in no additional included studies) dealt with closed reduction methods. It included three trials involving a total of 404 mainly female and older participants with displaced fractures of the distal radius. These trials failed to assess functional outcome, and only one trial reported on complications. One trial found no significant differences between mechanical reduction using finger trap traction and manual reduction in anatomical outcomes (both groups were under anaesthesia).
One trial compared a novel method of manual reduction where the non-anaesthetised patient actively provided counter-traction versus traditional manual reduction under intravenous regional anaesthesia. While participants of the novel method group suffered more, yet not intolerably, during the reduction procedure, the latter was shorter in duration. No differences in anatomical outcome were detected. The third study compared mechanical reduction involving a special device without anaesthesia versus manual reduction under local anaesthesia. Less pain during the reduction procedure was recorded for the mechanical traction group. Both methods yielded similar radiological results. Fewer participants of the mechanical traction group had signs of neurological impairment, mainly finger numbness, at five weeks, but this difference was not statistically significant after one year.
External fixation versus conservative treatment
One systematic review published in 2007 (search 1966-2006) included fifteen heterogeneous trials involving 1022 adults with dorsally displaced and potentially or evidently unstable distal radius fractures. While all trials compared external fixation versus plaster cast immobilization, there was considerable variation in terms of patient characteristics and interventions. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment) and prevented late collapse and malunion compared with plaster cast immobilization.
There was insufficient evidence to confirm a superior functional or clinical result for the external fixation group. External fixation was associated with a high number of complications, but many of these were minor. Probably, some complications could have been avoided using a different surgical technique for pin insertion. There was insufficient evidence to establish a difference between the two groups in serious complications such complex regional pain syndrom.
One systematic review published in 2007 (search 1966-2006) included thirteen trials involving 940 generally older adults with dorsally displaced and potentially or evidently unstable distal radius fractures. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. Factors affecting the applicability of trial evidence included inconsistent fracture classification, variations in outcome assessment and incomplete reporting.
Six heterogeneous trials compared percutaneous pinning with plaster cast immobilization. Across-fracture pinning used in five trials was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group compared with plaster cast. One trial found an excess of complications after Kapandji pinning. Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across-fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation which uses two wires introduced via the styloid process across the fracture). Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material. Two small trials compared plaster cast immobilization for one week versus for six weeks postoperatively. One trial found duration of immobilization after trans-styloid fixation did not have a significant effect on outcome. In the second trial, more complications occurred in the early mobilization group after Kapandji pinning.
Different methods of external fixation
One systematic review published in 2008 (search 1966-2007) included nine small trials involving 510 adults with potentially or evidently unstable distal radius fractures grouped into five comparisons. The interventional, clinical and methodological heterogeneity of trials precluded data pooling. Only one trial had secure allocation concealment.
Two trials comparing a bridging (over the wrist) external fixator versus pins and plaster external fixation found no significant differences in function or deformity. One trial found tendencies for more serious complications but less subsequent discomfort and deformity in the fixator group. Three trials compared non-bridging versus bridging fixation. Of the two trials testing uni-planar non-bridging fixation, one found no significant differences in functional or clinical outcomes; the other found that non-bridging fixation significantly improved grip strength, wrist flexion and anatomical outcome. The third trial found no significant findings in favour of multi-planar non-bridging fixation of complex intra-articular fractures. One trial using a bridging external fixator found that deploying extra pinning to fix the ’floating’ distal fragment gave superior functional and anatomical results. One trial found no evidence of differences in clinical outcomes for hydroxyapatite coated pins compared with standard uncoated pins. Two trials compared dynamic versus static external fixation. One trial found no significant effects from early dynamism of an external fixator. The poor quality of the other trial related to risks of bias due to for instance few participants undermines its findings of poorer functional and anatomical outcomes for dynamic fixation.
Bone grafts and bone substitutes
One systematic review published in 2008 (search 1966-2007) included ten heterogeneous trials involving 874 adults with generally unstable fractures grouped into six comparisons. No trial had proven allocation concealment.
Four trials (239 participants) found that implantation of autograft (one trial), use of Norian SRS - a bone substitute (two trials), and use of methylmethacrylate cement (one trial) improved anatomical outcomes compared with plaster cast alone, while two found that it improved function. Reported complications of bone scaffolding were transient discomfort resulting from extraosseous deposits of Norian SRS. One trial (323 participants) comparing bone substitute (Norian SRS) versus plaster cast or external fixation found no difference in functional or anatomical outcomes at one year. Statistically significant complications in the respective groups were extraosseous Norian SRS deposits and pin track infection. Three trials (180 participants) found that autograft (one trial), Norian SRS (one trial) and methylmethacrylate cement (one trial) gave no significant difference in functional outcomes, but some indication of better anatomical outcomes compared with external fixation. Most reported complications were associated with external fixation. Extraosseous deposits of Norian SRS occurred in one trial. One trial (93 participants with dorsal plate fixation) found that autografts slightly improved wrist function compared with allogenic bone material, but with an excess of donor site complications.
In one systematic review published in 2006 (search 1966-2005) included fifteen trials involving 746 mainly old female patients. Initial treatment was conservative, involving plaster cast immobilization, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised.
For interventions started during immobilization, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilization (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial).
Six Cochrane reviews of high methodological quality included in this review have assessed treatments and rehabilitation interventions following distal radial fractures. Interventions assessed cover closed reduction, conservative and operative methods, as well as rehabilitation techniques. The majority of the studies are small (20-100 patients) and often heterogeneous, and for some of the outcomes, the methods of measurement are different, which has made gathering effect estimates into meta-analysis impossible. This has resulted in weak level of evidence and reduced the possibility of drawing clear-cut conclusions. In some studies there is significant discrepancy between number of participants enrolled in the study and the actual number of patients that have been assessed for a particular outcome. This makes it difficult to interpret the findings.
There is little systematically gathered information regarding more recent methods used for treating distal radius fractures such as volar plating and volar angle-stable plates. Nevertheless, volar plate fixation has become a common method in treating complicated fractures. There is however a protocol for a Cochrane review entitled “Internal fixation and comparisons of different fixation methods for treating distal radial fractures in adults”. When finalized, results from this review probably will shed more light on the effect of these various operative methods.
There is not enough evidence to determine which method is best for reduction of the distal radius fracture in adults. There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius when compared with conservative treatment (plaster cast). Although there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor. There is however insufficient robust evidence to determine the relative effects of the different methods of external fixation. Some evidence supports the use of percutaneous pinning through less serious complications, but the higher rates of complications with Kapandji pinning and biodegradable materials cast some doubt on their general use. Nevertheless for dorsally dislocated fractures, across-fracture percutaneous pinning helps to maintain reduced positions. Bone scaffolding may improve anatomical outcome compared with plaster cast alone, but there is insufficient evidence to conclude on functional outcome and complications (as for the other comparisons that involve bone scaffolding). There is not enough evidence available to determine the best form of rehabilitation for patients with distal radius fractures.
Besides that pinning and stabilizing plaster cast or external fixation lead to better results for unstable distal radius fractures compared with conservative treatment, none of six Cochrane reports included in this review have discussed in depth implications of the results in terms of practice. One exception is that precaution should be taken when using Kapandji pinning or biodegradable materials due to risks of complications. The review that assesses rehabilitation interventions points to the fact that the lack of evidence does not mean that rehabilitation is not helpful for distal radius fractures, and further underlines that these fractures always should be followed up with general advices and instructions for mobilization exercises.
The evidence base for the management of distal radius fracture is limited. Further research should be preceded by agreement on the priority questions for the management of these fractures, and to be addressed through large multi-centre trials.