Review

Abstract

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 included. Trials that included adults and children but did 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 robust. Two RCTs that evaluated activities of daily living showed no difference between groups at I 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.