Question: In patients with distal radial fractures, does external fixation give better results than conservative treatment?
Data sources: Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (September 2006); the Cochrane Central Register of Controlled Trials (2006, Issue 3); MEDLINE (1966 to September 2006); EMBASE/Excerpta Medica (1988 to September 2006); CINAHL (1982 to September 2006); Current Controlled Trials; the United Kingdom National Research Register; proceedings of orthopaedic meetings; hand-searching relevant journals; and reviewing reference lists of articles.
Study selection and assessment: Randomized controlled trials (RCTs) or quasi-RCTs that compared external fixation with conservative treatment (e.g., plaster cast immobilization) in adults with distal radial fractures. Trials comparing different methods of external fixation or comparing external fixation with other methods of surgical fixation were not included. Trials that included adults and children but did not provide separate data for adults were also excluded. Study quality was assessed with use of a rating scheme covering 11 aspects of trial validity.
Main outcome measures: Primary outcomes included patient functional assessment, return to work or activities of daily living, grip strength, pain, range of motion, complications, and cosmetic appearance.
Main results: 15 RCTs (n = 1022 patients; mean age range, 36 to 72 y) met the inclusion criteria. Methodological quality of the trials was generally poor, and substantial heterogeneity existed among trials due to variation in patient characteristics, interventions, methods and timing of outcome assessments, and selection of reported outcomes. All trials compared external fixation with plaster cast. Follow-up ranged from 4 months to 10 years. "Functional" scoring systems, which were mainly unvalidated and which often rated other outcomes such as radiographic deformity, were used in 13 RCTs. Results of these composite outcomes could be pooled in 9 RCTs for a rating of "not excellent" and in 11 RCTs for a rating of "fair or poor." With use of a fixed-effects model, external fixation was superior to plaster cast in both analyses (Table). Sensitivity analyses conducted in the review revealed, however, that these results were not robust. Two RCTs that evaluated activities of daily living showed no difference between groups at 1 and 7 years, respectively. One trial showed no difference between groups at 6 months in the proportion of patients who changed jobs because of their injury. One trial reported similar times to return to work or normal activities (70 vs 75 d). Two RCTs showed greater grip strength in the external fixation group at 1 year; at the time of final follow-up, no significant difference was observed between groups in 7 RCTs. Of 5 RCTs reporting pain outcomes, 1 showed reduced pain in the external fixation group whereas 4 RCTs showed no difference. Range of motion results were variable and inconclusive. Redisplacement generally occurred in the plaster cast group; this often resulted in secondary treatment (9 RCTs; relative risk 0.17, 95% CI 0.09 to 0.32). Pin-site infections were more common in the external fixation group (11 RCTs; relative risk 12.02, CI 5.07 to 28.49), as were iatrogenic nerve injuries. Data from 2 trials showed no difference between groups in cosmetic appearance. One trial reported that pin-track scars in the external fixation group were accepted by patients.
Conclusion: In patients with displaced distal radial fractures, weak evidence supports external fixation compared with conservative treatment. Although external fixation gives improved anatomical results, it is associated with an excess of mainly minor surgically related complications.
The mainstay of the management of stable distal radial fractures in adults remains plaster casts. External fixation is used for specific fracture types such as extra-articular or minimal articular fractures with metaphyseal instability or fractures with severe intra-articular displacement. There are 3 different types of external fixation (spanning, non-spanning, and augmented spanning), each of which has different reported results1. Other factors, such as age and initial fracture severity, are also likely to influence the outcome of these injuries2. Clearly, a review that makes use of studies comparing outcomes of a particular treatment type needs to take these factors into consideration.
Unfortunately, the heterogeneity of the studies in this meta-analysis by Handoll and colleagues makes any conclusion difficult. The authors have reviewed RCTs of different types of distal radial fractures, including severe intra-articular fractures and stable and unstable extra-articular fractures. The treatment interventions lack uniformity, with 1 paper even using pins in plaster, which would be considered a historical treatment by most experts. This lack of uniformity casts substantial doubt on the validity of the results; thus, the review falls short in assisting the practicing surgeon in his or her decision-making.
McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus non-bridging external fixation. J Bone Joint Surg Br.1998;80:665-9.80665
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Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes after surgical treatment of distal radius fractures. J Hand Surg [Am].2007;32:76-83.3276
2007
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