Closed reduction methods for treating distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Displaced fractures are usually reduced using closed reduction methods, which are non-surgical and generally comprise traction and manipulation, and the resulting position stabilised by external means, typically plaster cast immobilisation.
OBJECTIVES: To examine the evidence for the relative effectiveness of different methods of closed reduction for displaced fractures of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (to July 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to July week 4 2002), EMBASE (1988 to 2002 week 31), CINAHL (1982 to June week 4 2002), the UK National Research Register (Issue 2, 2002) and reference lists of articles. We also handsearched the British Volume of the Journal of Bone and Joint Surgery supplements (1996 onwards), and abstracts of the American Orthopaedic Trauma Association annual meetings. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating different methods of closed reduction. We also included trials in which the use (or not) of anaesthesia could be classed as a co-intervention. DATA COLLECTION AND ANALYSIS: All trials judged as fitting the selection criteria by both reviewers were independently assessed by both reviewers for methodological quality. Data were extracted independently by one reviewer and checked by the other. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. No pooling was possible. MAIN
RESULTS: Three trials involving a total of 404, mainly female and older, patients with displaced fractures of the distal radius were included. These failed to assess functional outcome, and only one trial reported on complications. One trial found no statistically significant differences between mechanical reduction using finger trap traction and manual reduction in anatomical outcomes. 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 patients of the novel method group suffered more, yet not intolerable, pain 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 haematoma block (local anaesthesia). Less pain during the reduction procedure was recorded for the mechanical traction group. Both methods yielded similar radiological results. Fewer patients in the mechanical traction group had signs of neurological impairment, mainly finger numbness, at five weeks but this difference was not statistically significant by one year. REVIEWER'S
CONCLUSIONS: There was insufficient evidence from comparisons tested within randomised trials to establish the relative effectiveness of different methods of closed reduction used in the treatment of displaced fractures of the distal radius in adults. Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of reduction methods, is the way forward.