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External fixation versus conservative treatment for distal radial fractures in adults (Review

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Handoll HHG, Huntley JS, Madhok R

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2008, Issue 4 http://www.thecochranelibrary.com

External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 External fixation versus plaster cast, Outcome 1 Functional grading: not excellent. . . Analysis 1.2. Comparison 1 External fixation versus plaster cast, Outcome 2 Functional grading: not excellent. Worst and best case scenarios sensitivity analyses. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.3. Comparison 1 External fixation versus plaster cast, Outcome 3 Functional grading: fair or poor. . . . Analysis 1.4. Comparison 1 External fixation versus plaster cast, Outcome 4 Subjective and objective functional evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.5. Comparison 1 External fixation versus plaster cast, Outcome 5 Upper extremity function part of Musculoskeletal Function Assessment tool (0 to 100: maximum disability). . . . . . . . . . . . . Analysis 1.6. Comparison 1 External fixation versus plaster cast, Outcome 6 Difficulties in activities of daily living. . Analysis 1.7. Comparison 1 External fixation versus plaster cast, Outcome 7 Job change because of injury. . . . . Analysis 1.8. Comparison 1 External fixation versus plaster cast, Outcome 8 Mass grip strength (% of normal side). . Analysis 1.9. Comparison 1 External fixation versus plaster cast, Outcome 9 Grip, chuck and pinch strengths (injured normal side): units not given. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.10. Comparison 1 External fixation versus plaster cast, Outcome 10 Maximal voluntary contraction: injured uninjured side (Newtons). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.11. Comparison 1 External fixation versus plaster cast, Outcome 11 Persistent pain (1 year & 7 years). . . Analysis 1.12. Comparison 1 External fixation versus plaster cast, Outcome 12 Pain (6 months). . . . . . . . Analysis 1.13. Comparison 1 External fixation versus plaster cast, Outcome 13 Range of movement at 1 year (% of normal side). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.14. Comparison 1 External fixation versus plaster cast, Outcome 14 Range of movement at 2 years (injured normal side). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.15. Comparison 1 External fixation versus plaster cast, Outcome 15 Range of movement at 1 year. . . . Analysis 1.16. Comparison 1 External fixation versus plaster cast, Outcome 16 Range of movement at 7 years. . . . Analysis 1.17. Comparison 1 External fixation versus plaster cast, Outcome 17 Complications. . . . . . . . . Analysis 1.18. Comparison 1 External fixation versus plaster cast, Outcome 18 Reflex sympathetic dystrophy - exploratory analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.19. Comparison 1 External fixation versus plaster cast, Outcome 19 Cosmetic deformity. . . . . . . Analysis 1.20. Comparison 1 External fixation versus plaster cast, Outcome 20 Patient dissatisfied with wrist. . . . Analysis 1.21. Comparison 1 External fixation versus plaster cast, Outcome 21 Anatomical grading: not excellent. . Analysis 1.22. Comparison 1 External fixation versus plaster cast, Outcome 22 Anatomical grading: fair or poor. . . Analysis 1.23. Comparison 1 External fixation versus plaster cast, Outcome 23 Anatomical displacement. . . . . Analysis 1.24. Comparison 1 External fixation versus plaster cast, Outcome 24 Anatomical measurements. . . . . Analysis 1.25. Comparison 1 External fixation versus plaster cast, Outcome 25 Structural deformity. . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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[Intervention Review]

External fixation versus conservative treatment for distal radial fractures in adults
Helen HG Handoll1 , James S Huntley2 , Rajan Madhok3
1 Centre

for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, Middlesborough, UK. 2 University Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK. 3 Cochrane Bone, Joint and Muscle Trauma Group, University of Manchester, Manchester, UK

Contact address: 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. Editorial group: Cochrane Bone, Joint and Muscle Trauma Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008. Review content assessed as up-to-date: 16 May 2007. Citation: Handoll HHG, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD006194. DOI: 10.1002/14651858.CD006194.pub2. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Fracture of the distal radius (’broken wrist’) is a common clinical problem. It can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation. Objectives To evaluate the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied. Selection criteria Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared external fixation with conservative treatment. Data collection and analysis After independent study selection by all review authors, two authors independently assessed the included trials. Independent data extraction of new trials was performed by two authors. Pooling of data was undertaken where appropriate. Main results Fifteen heterogeneous trials, involving 1022 adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. While all trials compared external fixation versus plaster cast immobilisation, there was considerable variation especially in
External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1

Ltd. means that the possibility of serious bias can not be excluded. in which metal pins are driven into bone. were included. 95% confidence interval 0. It appears to improve function too but this needs to be confirmed. in whom they are one of the most common fractures. Published by John Wiley & Sons. There was insufficient evidence to establish a difference between the two groups in serious complications such as reflex sympathetic dystropy: 25/384 versus 17/347 (data from 11 trials). the overlying skin remaining intact. Serious complications occurred in both groups. relative risk 1. external fixation reduces redisplacement. relative risk 0. The majority are closed injuries. such as pin-track infection.74 to 2. a ’broken wrist’ (from a fracture at the lower end of one of the two forearm bones) can result from a fall onto an outstretched hand. Handoll 2003a will be converted to an ’umbrella’ review summarising the evidence for surgical treatment for these fractures. some complications could have been avoided using a different surgical technique for pin insertion. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. there was considerable variation in their characteristics especially in terms of patient characteristics and the method of external fixation.17. associated with external fixation were many but were generally minor. 95% confidence interval 0. such a pin tract infection. Probably. Singer 1998. The review concludes that there is some evidence to support the use of external fixation for these fractures. Weak methodology. . Description of the condition: distal radial fracture in adults Fractures of the distal radius. Treatment usually involves reduction (putting the broken bone back into position) and immobilising the wrist in a plaster cast (conservative treatment). generally via small skin incisions.terms of patient characteristics and interventions. BACKGROUND Note: This is one of five reviews that will cover all surgical interventions for treating distal radial fractures in adults. but many of these were minor. Though there is insufficient evidence to confirm a better functional outcome. Surgery may be considered for more seriously displaced fractures. PLAIN LANGUAGE SUMMARY External fixation versus conservative treatment for distal radial fractures in adults In older people. They are usually defined as occurring in the distal radius within three centimetres of the radiocarpal joint. One type of surgery is external fixation. gives improved anatomical results and most of the excess surgically-related complications are minor. In women. predominantly in white and older populations in the developed world (Sahlin 1990. The complications. where the lower end of the radius interfaces with two (the lunate and the scaphoid) of the eight bones forming the carpus (the wrist).32. These pins are then fixed externally by incorporation into a plaster cast or securing into the frame of an external fixator. Fifteen trials. Authors’ conclusions There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. are common in both children and adults.32) and prevented late collapse and malunion compared with plaster cast immobilisation. such as using inadequate methods of randomisation and outcome assessment. Each review will provide updated evidence for one of the several surgical categories that are presented together in the currently available review (Handoll 2003a). Following publication of the five reviews. In this review. While all trials compared external fixation versus plaster cast immobilisation. often referred to as “wrist fractures”. Van Staa 2001). we consider the treatment of distal radial fracture in adults only. The review found that external fixation reduced fracture redisplacement that prompted further treatment and generally improved final anatomical outcome. the 2 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. involving 1022 adults with potentially or evidently unstable fractures. This review looked at the evidence from randomised controlled trials comparing external fixation with conservative treatment.31. There was insufficient evidence to confirm a superior overall functional or clinical result for the external fixation group. External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment: 7/356 versus 51/338 (data from 9 trials).09 to 0. The external component holds the bony fragments in position while the bone heals. External fixation was associated with a high number of complications. on either side of the fracture.

It has been estimated that. Cooney 1993 proposed a ’Universal Classification’ based on fracture displacement. the term “Colles’ fracture” is still used for a fracture in which there is an obvious and typical clinical deformity (commonly referred to as a ’dinner fork deformity’) . Metal pins or screws are driven into bone. such as a traffic accident. some bridging fixators have an articulation (e. The results of such treatment. particularly in older people with bones weakened by osteoporosis.000 in men and 37/10. The duration and extent of immobilisation with external fixation also vary. to help in their management. Pennig 1996). In this review. and therefore the way in which treatment is conducted. Ltd. starting at around 40 years. a ball joint) that allows limited wrist movement. the fractured bone ends are not exposed to direct view. such as by incorporation into a plaster cast or securing into an external fixator frame. dorsal angulation. Complications Complications from this injury are diverse and frequent (Altissimi 1986. Classification Surgeons have classified fractures by anatomical configuration and fracture pattern. Another commonly used system is the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) system (Muller 1991) which divides the fractures into three major groups: group A (extra-articular). Description of the intervention: external fixation In the last century. This involves extra pins or wires being inserted through the skin and used to fix or support distal radial fragments. Other classifica- tion systems have attempted to link fracture type more directly with fracture management. Typically this is a closed. minimally invasive method where. The introduction of X-rays and other imaging methods made it clear that the characteristic deformity may be associated with a range of different fracture patterns. This has resulted in attempts to develop other strategies involving surgery aimed at more accurate reduction and more reliable stabilisation. the fracture through the distal radius may be extra-articular (leaving the articular surface of the radius intact) or intra-articular (the articular surface is disrupted. . Reduction may be assisted by the application of a percutaneously (through the skin) inserted wire as a ’joy stick’ to move the bony fragments back into place. O’Neill 2001). the incidence is higher in men (Singer 1998). sometimes in a complex manner). In some cases. Some devices are ’non-bridging’ (of the wrist joint) in that the distal pins are placed in the distal radial fragment. group B (simple/partial intra-articular). Some fixators are linear or uniplanar. Published by John Wiley & Sons. These three groups are then subdivided.g. The external component stabilises or ’fixes’ the reduced fracture. Atkins 1989. articular involvement. at 50 years of age. such as falling from standing height. In contrast.9% for men. This figure includes all people receiving surgery. tendons and nerves. yielding 27 different fracture types. a white woman in the USA or Northern Europe has a 15% lifetime risk of a distal radius fracture whereas a man has a lifetime risk of just over two per cent (Cummings 1985). Distal radial fractures are usually treated on an outpatient basis. resulting from osteoporosis. Fracture reduction or alignment of the bony fragments is generally achieved by closed means. This reflects the greater fragility of the bone.6% for women versus 2. In ’bridging fixators’. by reduction of the fracture when displaced. often in the process of applying external fixation. For example. Late complications include mid3 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. especially females. the fragments will remain so). In addition. which may be important determinants of outcome. and stabilisation in a plaster cast or other external brace. with median nerve dysfunction being the most common complication (Belsole 1993). once reduced.000 in women (O’Neill 2001). Numerous classifications have been devised to define and group different fracture patterns (Chitnavis 1999). dorsal comminution (fragmentation). external fixation may be augmented by additional methods of fracture fixation. we include only trials using supplementary percutaneous pinning. generally via small incisions of the skin and after drilling. Simple classifications were based on clinical appearance and often named after those who described them. in contrast to open surgery. One such strategy is external fixation (Capo 2006. These pins are then fixed externally. are not consistently satisfactory (Handoll 2003b). between 60 to 94 years of age. For instance. reducibility (whether the fracture can be reduced. Before this age. Young adults usually sustain this injury as a result of high-energy trauma. and the presence or absence of an associated distal ulnar (ulnar styloid) fracture ( Frykman 1967).dorsal displacement. It is estimated that around 20% of patients (mainly older people) require hospital admission (Cummings 1985.incidence of these fractures increases with age. Cooney 1980). that is whether the bone fragments can be put back in place) and stability (whether. As well as concomitant injuries to soft tissues. and radial shortening. the fracture more often results from low-energy or moderate trauma. females predominate. One of the most commonly used is that of Frykman which distinguishes between extra-articular fractures and intra-articular fractures of the radiocarpal and radio-ulnar joints. Fernandez 1999. A recent multi-centre study in the United Kingdom of patients aged 35 years and above with Colles’ fracture (see below) reported an annual incidence of 9/10. In the distal radius. the distal pins are placed in one or more metacarpal bones. fracture displacement can further compromise blood vessels. More recent estimates (Van Staa 2001) of lifetime risk of radius or ulna fracture at 50 years of age are similar: 16. on either side of the fracture. There is considerable variety in the techniques (such as for pin insertion and placement) and devices used for external fixation. In older adults. and group C (complex/complete intra-articular). most distal radial fractures in adults were treated conservatively. whereas others are multiplanar. Some are associated with the injury itself.

We considered it unlikely that we would find trials comparing external fixation with conservative treatment for rarer fracture patterns such as the Barton’s fractures (Smith 1988) that are inherently unstable and generally considered not to be amenable to conservative or external fixation. Ltd. External fixation may be considered as primary treatment or take place after the failure of initial conservative management. particularly in terms of function. which may be due to faulty application of plaster casts (Gartland 1951). including techniques and devices. such as bone grafts and substitutes. Nonetheless. and separate subgroup data sought for mixed fracture populations. otherwise they would have been excluded unless separate data for adults were obtained. Primary outcomes (1) Functional outcome and impairment 4 METHODS Criteria for considering studies for this review External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. such as percutaneous pinning. swelling. . but also referred to as algodystrophy. especially whether they are extra-articular or intra-articular. impairment of joint mobility. including one covering the use of bone grafts and substitutes. Augmented external fixation in the form of supplementary percutaneous pinning was also included. We excluded trials comparing different methods. OBJECTIVES We aimed to evaluate the evidence from randomised controlled trials for the use of external fixation for fractures of the distal radius in skeletally mature people. compatible with the general assessment and presentation of outcome within the orthopaedic literature. pin track infection. dystrophy. Why it is important to do this review External fixation is one of the main methods for surgical fixation of distal radial fractures. vasomotor instability) in serious cases. was thwarted by the variation in the trial characteristics. The issue of what is the best method of external fixation will be addressed in a separate review (Handoll 2007). pain and discomfort. Our plan to study the outcomes in different age groups and for different fracture types. other than percutaneous pinning. generally within two to three weeks. and other measures of function and impairment. by date of birth. Types of participants Included were patients of either sex who have completed skeletal growth. trials with these types of fractures would have been considered for inclusion. or trials evaluating the use of supplementary methods. Types of interventions Randomised comparisons of surgical interventions involving external fixation by itself or with supplementary percutaneous pinning versus conservative interventions such as plaster cast immobilisation. Trials with a mixed population of adults and children were included provided the proportion of children was clearly small (< 5%). to external fixation compared with conservative treatment.g. the incidence of complications. with a fracture of the distal radius.carpal instability and post-traumatic arthritis which can occur several months or years after injury (Knirk 1986. A key question is whether it produces superior results. Taleisnik 1984). The pathology of RSD remains unclear. and additional fractures. we report outcome in the following four categories. Types of outcome measures Our primary outcome of choice would be the number of people with an uncomplicated and speedy restoration of a pain-free fullyfunctioning wrist and arm with acceptable anatomic restoration and appearance. These comparisons will be covered in other reviews. often termed reflex sympathetic dystrophy (RSD). or trials comparing external fixation with other methods of surgical fixation. soft tissue injury including tendon rupture. of external fixation. Complex regional pain syndrome type 1. alternation) controlled clinical trial comparing external fixation with conservative methods for treating distal radial fractures in adults was considered. to conservative treatment. Published by John Wiley & Sons. We compared the relative effects (benefits and harms) of any method of external fixation versus conservative treatment involving plaster or brace use in adults with these injuries. However. anatomical deformity and use of resources. Types of studies Any randomised or quasi-randomised (method of allocating participants to a treatment which is not strictly random e. Also considered was augmented external fixation where supplementary percutaneous (through the skin) pinning was used to fix or support distal radial fragments. hospital record number. if found. The answer to this question is likely to depend particularly on fracture configuration and bone quality. Complications can also result from treatment interventions and include residual finger stiffness. Sudeck’s atrophy and sometimes shoulder-hand syndrome ( Fernandez 1996) is a major complication (Atkins 2003) requiring many months of physiotherapy to alleviate symptoms (pain and tenderness. We considered these effects primarily in terms of patient-assessed functional outcome and satisfaction.

dorsal angulation. . Radial length Distance between a) a line drawn at the tip Approximately 11-12 mm. radial inclination or angle. Side view of wrist. and pronation (ability to turn the hand so that the palm faces downwards) and supination (palm faces upwards) (2) Clinical outcome • Residual soft tissue swelling • Early and late complications associated with distal radial fractures or their treatment. Shoulder. and activities of daily living • Grip strength • Pain • Range of movement (wrist and forearm mobility): range of movement for the wrist is described in terms of six parameters: flexion (ability to bend the wrist downwards) and extension (or upwards). and for intra-articular fractures: step off and gap deformity of the articular surface (Fernandez 1996. including reflex sympathetic dystrophy (RSD) and post traumatic osteoarthritis • Cosmetic appearance • Patient satisfaction with treatment Secondary outcomes (3) Anatomical outcome (anatomical restoration and residual deformity) • Radiological parameters include radial length or shortening and shift. Published by John Wiley & Sons. Definitions of four of the most commonly reported radiological parameters are presented in Table 1. Definitions of key radiological parameters Parameter Definition Normal value Dorsal angulation (dorsal or volar or pal. volar cortical rims of the radius and b) the line drawn perpendicular to the longitudinal axis of the radius.Angle between a) the line which connects Palmar or volar tilt: approximately 11-12 mar tilt) the most distal points of the dorsal and degrees. Kreder 1996a). Table 1. radial deviation (ability to bend the wrist sideways on the thumb side) and ulnar deviation (on the little finger side). of the radial styloid process. Ltd. ulnar variance.• Patient functional assessment instruments such as Short Form-36 (SF-36). Composite measures include malunion and total radiological deformity. including work. the Disability of the Arm. and Hand questionnaire (DASH) and the Patient-Rated Wrist Evaluation (PRWE) (MacDermid 2000) • Return to previous occupation. 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 5 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.

Frontal view. CINAHL (1982 to September week 2 2006). J Arthroplasty.amedeo. Search methods for identification of studies Electronic searches We searched the Cochrane Bone.update-software. the American Orthopaedic Trauma Association annual meetings (1996 to 2005: http:// www. number of outpatient attendances and other costs.hwbf. the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2006. Injury.com). Timing of outcome assessment Results were usually collected for the final follow-up time for which these are available. J Trauma. J Orthop Trauma.org/ education/anmeet/libscip. nate facet of the distal radius and b) a line parallel to the articular surface of the ulnar head. Arch Orthop Trauma Surg. However.g. Published by John Wiley & Sons.com (accessed September 2006) and the UK National Research Register at www.assh. Ltd. J Foot Ankle Surg. We also scrutinised weekly downloads of “Fracture” articles in new issues of 17 journals (Acta Orthop Scand. Emerg Med Clin North Am. 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. 2001.aaos. Foot Ankle Int. Issue 3) (see Appendix 1). We also included handsearch results from the final programmes of SICOT (1996 & 1999) and SICOT/SIROT (2003).org/). we also noted interim results where a marked and important difference in the timing of recovery had occurred. Clin J Sport Med. Radial angle or radial inclination Angle between a) the line drawn from the Approximately 22-23 degrees. 6 . Searching other resources We searched the reference list of articles. Frontal view. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.org/ota/am/) and American Academy of Orthopaedic Surgeons annual meeting (2004 to 2006: http://www.neutral variance.asp). No language restrictions were applied. We also searched Current Controlled Trials at www. and the British Orthopaedic Association Congress (2000.com/national/ (up to Issue 3. MEDLINE (1966 to September week 1 2006). J Bone Joint Surg Br.controlledtrials. Vertical distance between a) a line drawn Usually negative variance (e. Am J Orthop. Clin Orthop. 2006) for ongoing and recently completed trials. 2002 and 2003).Table 1. J Bone Joint Surg Am. J Accid Emerg Med. Ulnar variance (4) Resource use • Hospital stay. -1 mm) or parallel to the proximal surface of the lu. and various issues of Orthopaedic Transactions and Acta Orthopaedica Scandinavica Supplementum. EMBASE (1988 to 2006 week 36). Joint and Muscle Trauma Group Specialised Register (September 2006). We also included the findings from handsearches of the British Volume of the Journal of Bone and Joint Surgery supplements (1996 onwards) and abstracts of the American Society for Surgery of the Hand annual meetings (2000 to 2006: www. Similar search strategies were used for EMBASE (OVID-WEB) and CINAHL (OVID-WEB) (see Appendix 3). Orthopedics) from AMEDEO (www. J Am Acad Orthop Surg. Definitions of key radiological parameters (Continued) head. In MEDLINE (OVID-WEB) the search strategy was combined with all three sections of the optimal MEDLINE search strategy for randomised trials (Higgins 2005) (see Appendix 2).

N = quasi-randomised. A modification of the quality assessment tool used in the current ’umbrella’ review was used. Any disagreement was resolved by discussion. Titles of journals. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Assessment of methodological quality In this review. Data extraction and management Using a data extraction form. Two of the review authors (HH and JH) independently assessed methodological quality of the newly included trials using a prepiloted form. each item was graded based on whether the quality criterion was met: ’Y’ (met). HH entered the data into RevMan. Results were collected for the final follow-up time for which these were available. Instead of scores. One author (HH) repeated her assessment of the trials already included in Handoll 2003a.Cochrane code (see Handbook): Clearly concealed prior to allocation? signment. Not sure = B. The rating scheme covering 11 aspects of trial validity plus brief notes of coding guidelines for selected items are given in Table 2. We contacted trialists of trials not reported in full journal publications for additional information or data. ? = small but possible chance of disclosure of assignment or unclear. names of authors or supporting institutions were not masked at any stage. and one author (HH) repeated data extraction of trials already included in Handoll 2003a and checked for consistency with her previous data extraction. risk of bias is implicitly assessed in terms of methodological quality. a general impression of the expected gain. Table 2. Methodological quality assessment scheme Items Scores Notes (1) Was the assigned treatment adequately Y = method did not allow disclosure of as. and anticipated or known difficulty in locating trial authors. Contact with other trial authors was dictated by the vintage of the publication. ’?’ (possibly or only partially met) or ’N’ (not met). Clearly no = C. All disagreements were resolved by discussion. 7 . yes = A. Ltd. Published by John Wiley & Sons. Any disagreements were resolved by discussion. We also noted instances where clinically important differences had been reported at intermediate follow-up assessments. or open list or tables. When appropriate.Data collection and analysis Selection of studies All review authors independently assessed potentially eligible trials for inclusion using a pre-piloted form. two of the review authors (HH and JH) independently extracted trial details and data for new trials. extraction of results from graphs in trial reports was performed where data were not provided in the text or tables.

identical? ? = clear but trivial differences. type of fracture. or not mentioned (unless double-blind). ? = inadequately defined. difference in rehabilitation. . (4) Were important baseline characteristics Y = good comparability of groups. or conreported and comparable? founding adjusted for in analysis. duration of intervention. or possible but not done. N = large potential for confounding. or some evidence of comparability. N = no mention. (6) Were the treatment providers blind to Y = effective action taken to blind treatment assignment status? providers. or some blinding of outcomes attempted. or not discussed. (3) Were the outcome assessors blinded to Y = effective action taken to blind assessors. N = not defined. (9) Were the outcome measures used clearly Y = clearly defined.Y = effective action taken to blind particisignment status after allocation? pants. inadequate mention. or probably no withdrawals. Methodological quality assessment scheme (Continued) (2) Were the outcomes of participants who Y = withdrawals well described and acwithdrew described and included in the counted for in analysis. N = not mentioned or clear and important differences in care programmes. ? = confounding small. analysis (intention-to-treat)? ? = withdrawals described and analysis not possible. or not mentioned (unless double-blind). treatment status? ? = small or moderate chance of unblinding of assessors. or obvious differences and no adjustment. (8) Were the inclusion and exclusion crite. or possible but not done. operator experience. N = not mentioned or not possible. (7) Were care programmes. gender. Examples of clinically important differences in other interventions are: time of intervention. N = not defined. N = not possible. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. mentioned but not adjusted for. 8 Although many characteristics including hand dominance are important.Y = clearly defined (including type of fracria for entry clearly defined? ture). Ltd. ? = small or moderate chance of unblinding of participants. anaesthetic used within broad categories. defined? ? = inadequately defined. the principal confounders are considered to be age. ? = small or moderate chance of unblinding of treatment providers.Table 2. or comparability reported in text without confirmatory data. Published by John Wiley & Sons. other than the Y = care programmes clearly identical. trial options. (5) Were the trial participants blind to as. N = not possible.

duration of Y = optimal. Unit of analysis issues No unit of analysis issues arose in this review. for the outcome measures listed above (see ’Types of outcome measures’) are presented in the analyses. but considered inappropriate. quantitative data. We were alert to the potential mislabeling or non identification of standard errors for standard deviations.g. Ltd.1 year) N = not defined. Categories of effectiveness (definitions) Rank Category Definition When considered appropriate. Assessment of reporting biases There were insufficient data to assess publication bias. Presentation in separate subgroups was also considered where there was a fundamental difference in the method of external fixation (such as bridging versus non-bridging external fixation. Assessment of heterogeneity Heterogeneity was assessed by visual inspection of the forest plot (analysis) along with consideration of the test for heterogeneity and the I² statistic (Higgins 2003). Published by John Wiley & Sons. 9 . we have investigated the effect of drop outs and exclusions by conducting worse and best scenario analyses. Sensitivity analysis There were no data available to carry out our pre-specified sensitivity analyses examining various aspects of trial and review methodology. we have performed intention-to-treat analyses to include all people randomised to the intervention groups. results of comparable groups of trials were pooled. To a limited extent. Data synthesis (meta-analysis) Table 3. by preparing a funnel plot. for example. extraarticular versus intra-articular fractures). We also considered using the random-effects model. Subgroup analysis and investigation of heterogeneity There were no data available to carry out our pre-specified subgroup analyses by age. of ? = adequate. the outcome measures adequate. these clinically useful and did they include active follow up? (11) Was the timing (e. outcome assessor blinding and reportage of surgical experience). (6 months . both dichotomous and continuous. not adequate.Table 2. not adequate. especially where there was unexplained heterogeneity. we did not assume values in order to present these in the analyses. Dealing with missing data Where appropriate. including the study quality (specifically allocation concealment. Y = optimal. Interpretation of the evidence We graded the findings of the treatment comparison(s) according to the six categories of effectiveness used by contributors to Clinical Evidence (BMJ 2006) (see Table 3) to assist our interpretation of the evidence. Unless missing standard deviations could be derived from confidence interval data. To test whether the subgroups are statistically significantly different from one another. (< 6 months) Measures of treatment effect Where available. (> 1 year) surveillance) clinically appropriate? ? = adequate. Initially we used the fixed-effect model and 95% confidence intervals. and were N = not defined. the use of supplementary percutaneous pinning). gender and type of fracture (primarily. with consideration of observer variation. Methodological quality assessment scheme (Continued) (10) Were the accuracy and precision. we tested the interaction using the technique outlined by Altman and Bland (Altman 2003). External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Relative risks and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes.

Details of the methods. participants. India (1). Characteristics of excluded studies. China (1). Jenkins 1989. A translation from Chinese was obtained for Zheng 2003. 10 . Pring 1988 being the earliest. Aside 2 Likely to be beneficial 3 Trade off between benefits and harms 4 Unknown effectiveness 5 Unlikely to be beneficial 6 Likely to be ineffective or harmful RESULTS Description of studies See: Characteristics of included studies. whose study ID has been changed to reflect the identification of a full report. Sweden (2). Interventions for which effectiveness is less well established than for those listed under “beneficial”. Stein 1990) provided no information on the gender composition of their study populations. updates of MEDLINE. Setting The publication dates of the main reports of these trials span 18 years. the Kreder trial was listed as ongoing in Handoll 2003a. Each trial took place in one of nine countries: Canada (1 trial). and the UK (5). The three additional trials (Hegeman 2004. Kreder 2006. Israel (1). Interventions for which there is currently insufficient data or data of inadequate quality. Spain (1). Of 21 potentially eligible studies put forward for study selection. Results of the search The search for trials predated the development of this review. The Netherlands (2). For the rest. All were all single-centre studies apart from Kreder 2006. which is essentially a reworked update of part of a previously published review (Handoll 2003a) covering all surgical intervention for these fractures. five were excluded and one is in ’Studies awaiting assessment’. Roumen 1991. Categories of effectiveness (definitions) (Continued) 1 Beneficial Interventions for which effectiveness has been demonstrated by clear evidence from randomised controlled trials. Most were conducted in teaching hospitals. which had three centres. Interventions for which lack of effectiveness is less well established than for those listed under “likely to be ineffective or harmful” Interventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence. Participants Age and gender The 15 included trials involved a total of 1022 participants. Included studies External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 15 were included. Ltd. Joint and Muscle Trauma Group Specialist Register (2). All of the included studies were fully reported in medical journals. Interventions for which clinicians and patients should weigh up the beneficial and harmful effects according to individual circumstances and priorities. We have not documented the numbers of references retrieved by electronic searches. the percentage of females ranged from 17% (Rodriguez-Merchan 92) to 91% (Hegeman 2004). interventions and outcome measures of individual trials are provided in the ’Characteristics of included studies’ table. Twelve of the included trials were previously included in Handoll 2003a. and for which expectation of harms is small compared with the benefits. this includes Young 2003. New Zealand (1). Howard 1989. MEDLINE (5). EMBASE and CINAHL are now generated on a weekly basis. Published by John Wiley & Sons. PubMed (1) and bibliography checking (1). Zheng 2003) have been included in the current review.Table 3. Five trials (Horne 1990. The rest were located in the following ways: The Cochrane Bone. Six of the included trials were initially located by handsearching. The mean ages of the trial populations ranged from 36 years (Rodriguez-Merchan 92) to 72 years (Horne 1990).

no data on gender mix were provided for Horne 1990. Interventions All 15 trials compared external fixation with plaster cast immobilisation. pin insertion and pin placement. Roumen 1991) further restricted the trial population to more mature adults: above 55. Kapoor 2000 included both dorsally and volarly displaced intra-articu- lar fractures. timing and details of the interventions for the 15 trials is given in Table 4. Rodriguez-Merchan 92: 45 years. 45 and 55 years respectively. One trial ( Pring 1988) used pins incorporated into plaster. Hegeman 2004: 80 years. McQueen 1996. Lagerstrom 1999. Table 4. Howard 1989. Lagerstrom 1999. Kreder 2006. Horne 1990. Zheng 2003) and non-linear or multi-planar fixators used in three trials (Howard 1989. the distal wires were orientated so that they transfixed comminuted fractures (such as die punch fractures) of the distal fragment before the external fixator was assembled. Pring 1988. One trial (Jenkins 1989) applied a (multiplanar) fixator that did not bridge the wrist joint. The duration and extent of immobilisation in both the external fixation and conservative treatment groups also varied among trials. Types of fractures Two trials (McQueen 1996. whereas the other 13 trials involved primary treatment of people with acute fractures. Six trials (Horne 1990. • Four trials (Hegeman 2004. Published by John Wiley & Sons. fracture type. The majority of participants were women in five of these trials. Roumen 1991) restricted their population to older people. Zheng 2003 categorised their fractures according to the universal system (Cooney 1993). Lagerstrom 1999: 75 years. It is clear that the vast majority of participants in the included trials were skeletally mature: in particular. fractures and interventions External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. of the severely displaced and comminuted Colles’ fractures of this trial were intra-articular. Stein 1990. Rodriguez-Merchan 92. Kapoor 2000. if not most. RodriguezMerchan 92. Explicit use of optional percutaneous K-wire fixation to stabilise the fracture was referred to in three trials (Kreder 2006. albeit some with an upper age limit (generally 75 years). Young 2003: 75 years). however. four trials to the AO system and two trials to Older’s system. considerable variety in the devices used for external fixation and in surgical techniques such as methods of reduction. The configurations of the external fixator frames used in Hegeman 2004 and Kreder 2006 were not clear. Kreder 2006 set an upper limit of the extent of dorsal angulation and metaphyseal comminution as well as stipulating joint congruity. Howard 1989: 75 years. some. A concise summary of the participants. which also includes whether the fractures were reducible. There was. Roumen 1991) recruited people whose fractures had redisplaced by two weeks. Kapoor 2000. Both intra-articular and extra-articular fractures were clearly included in the remaining trials except Howard 1989. Lagerstrom 1999. no data on gender mix were provided for Howard 1989 and Stein 1990. Four trials (Hegeman 2004. • Seven trials (Abbaszadegan 1990. Jenkins 1989. Horne 1990. McQueen 1996. Rodriguez-Merchan 92. Overall the trials in terms of age and gender of their study populations appear to fall into three categories: • Four trials (Jenkins 1989. Kapoor 2000. In Jenkins 1989. Young 2003. Of the 13 trials applying or reporting fracture type according to an established classification system. Stein 1990. this was explicit in Kreder 2006 and Zheng 2003. Rodriguez-Merchan 92. The majority of participants in three of these trials were women. Young 2003) excluded children either by explicitly setting a minimum age limit or stipulating that the participants should be adult or skeletally mature. Rodriguez-Merchan 92. Jenkins 1989: 65 years. Zheng 2003). Roumen 1991. however. but were probably uniplanar. Kapoor 2000. Only the age range (18 to 52 years) of the study population was provided for Zheng 2003. Kreder 2006: 75 years. three trials (Kapoor 2000. Horne 1990. Pring 1988. this reflected the inclusion criteria of another concurrent trial involving more displaced fractures (Kreder 2005).from restricting trial participation to people over 55 years. Zheng 2003) provided no criteria of the extent of the displacement required for trial entry. Stein 1990). 11 . Young 2003) included a general adult population. Lagerstrom 1999. Ltd. Zheng 2003) had predominantly younger adult populations. no data on gender mix were provided for Jenkins 1989. Seven trials referred to the Frykman system. 60. Upper age limits were applied in eight trials (Abbaszadegan 1990: 75 years. Roumen 1991). Linear or uniplanar fixators which bridged the wrist joint were clearly used in eight trials (Abbaszadegan 1990. Only intra-articular fractures were included in six trials (Hegeman 2004. two trials grouped fractures according to more than one classification system. No trial referred to people with open fractures and it is likely that all fractures were closed. There were more males than females in three of these trials. Several descriptions were used to define the types of fracture in the included trials. Key characteristics of participants. Kreder 2006. Roumen 1991 provided no information on age. Fourteen trials gave explicit reference to the inclusion of dorsally displaced or Colles’ fractures (including the use of Older’s classification: Older 1965) or presented radiological results indicating that fractures were dorsally displaced.

care surgery after years. 77% female. Stab incision for Closed reduction pins. age) (N. 5 and 8. Colles’. and plaster cast for 5 Trans-articular fixa.Displaced. ture clinic. Displaced (> 10 demean age 70 years.tion and plaster cast ening).Not stated but day known. but after X-ray examination.Severely disknown.and plaster cast for 4 lar fixation. lar and intra-articular. day of injury or following day. Operation on Frykman. The distal wires transfixed the comminuted (if present) distal radial fragment. Non-bridging and plaster cast for 4 fixation (not across weeks. Stab Closed reduction incision for pins. reduction. External weeks Hoffman fixator for 4 weeks. Jenkins 1989 153. ticular. tion.Timing of surgery/ Fixation sification Reduction Conservative treatment Abbaszadegan 1990 47. Extra-ar. mean age 72 ticular and intra-ar. 4. MediumC-Hoffman external fixator for 5 to 6 weeks. radial short. AO C2 or C3. Intra-articular fractures included. % female un. Colles’. Hoffmann II compact external fixator for 6 weeks Closed reduction and below elbow plaster cast for 6 weeks Horne 1990 37. (Colles’ im.for 1-3 days. clinic. Published by John Wiley & Sons. Older 3 & 4. grees dorsal angulation and < 20 degrees radial inclination and > 3 mm positive ulnar variance) unstable intraarticular. Key characteristics of participants. No details of pin insertion. Not stated. Trans-articu. Closed reduction and below elbow plaster cast for 5 to 6 weeks. Howard 1989 50. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 2. “Careful” pin insertion. Hegeman 2004 32. mean age 44 ticular and intra-ar. Skin incision for Closed reduction pins. Ltd.Probably closed reknown. Trans-articular fixation. Reduction during external fixation. 12 . Modified AO tubular external fixator for 5 weeks.presentation to fracplied) Frykman 1. dorsal angulation / > 10 mm radial shortening) comminuted Colles’ fracture. AO/ASIF external mini-fixator for 4 weeks. fractures and interventions (Continued) Study ID Participants gender. Timing of intervention: not stated. 91% female. % female un. extra-articu. Trans-articular fixation. Reduction (probably closed).duction at fracture years. wrist joint). ticular.Displaced extra-ar. Fracture Type/Clas.weeks. mean age 47 placed (30 degrees years.Table 4. Closed 3. Displaced (5+ mm After closed reducmean age 63 years. % female un. usually next available trauma list.

Extra-articular and intra-articular. Not stated but within 1 week of injury. weeks.and plaster cast for 6 ular fixation. but acute injury treatment. Cast removed after 5 weeks.Closed reduction sertion. Ltd. Extra-articular and intra-articular (stable congruous joint).from injury. Optional percutaneous K-wire fixation: removed 4 to 6 weeks. 25% female. Small AO fixator for 6 to 8 weeks. grees dorsal angulation / radial angulation. Frykman (3. Kreder 2006 113. Transarticular fixation. Pennig external fixaAO types A and C tor for 6 weeks. 7 and 8) and AO. degrees dorsal tilt/ angulation) with metaphyseal comminution (< 1/3rd of radius diameter). Lagerstrom 1999 Not stated. removed 6 to 8 weeks. 86% female. Frykman 5 to 8. 90 of 120 in comparison. fractures and interventions (Continued) Kapoor 2000 61 of 90 in comparison. Trans-articular cast for 5 weeks. then long arm cast which was reduced to a short arm cast at 3 to 4 weeks. articular fixation. Displaced mean age 62 years. radial shortening). No details of pin in. McQueen 1996 Redisplaced (> 10 Within 2 weeks Open incisions for Closed reduction degrees dorsal angu. for 6 to 7 weeks. 13 . Closed reduction under regional anaesthesia. No details of pin Below elbow plaster insertion. PerClosed reduction cutaneous pin inser. Not stated. 35. Light (in cast for 6 weeks. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 3+ mm radial shortening) intra-articular Colles’ fracture. Closed reduction and long arm splint for up to 2 weeks. mean age 64 years. weight) non-cylindrical AO external fixator for 6 weeks. 81% female.and forearm plaster tion. mean age of whole trial group was 39 years. Ball (extra-articular and joint released for intra-articular). Colles’ fracture. 90% female. Displaced (dorsal or volar). Skin incision for insertion of pins into radial shaft. No details of reduction method. All intra-articular. Trans-artic. Pins incorporated into plaster cast. but probably acute. Roger to 7 weeks. Displaced (10+ demean age 58 years. After accident and emergency attendance and closed reduction using Chinese finger traps. Displaced (but < 10 mean age 53 years. Key characteristics of participants.and plaster cast for 6 lation or > 3 mm reduction. AO A and C. Published by John Wiley & Sons. Pring 1988 75. 4. Closed pin insertion. No details of reduction method. and Anderson external fixator. fixation. limited wrist motion in 30 participants at 3 weeks. Trans. rigid frame. 65% female.Table 4.

fractures and interventions (Continued) RodriguezMerchan 92 70. age over 55 fracture reduction. cast for 6 weeks. Admission to hospital for 24 hours or day care facility for surgery. Frykman: all grades (18). All intra-articular. Closed reduction. Closed No details of pin Plaster cast continknown. Closed reduction. Comminuted intra.ued for 5 weeks. Trans-ar. % female un. grees dorsal angulation or > 2 mm radial shortening) distal radial fractures. 4C (intra-artic- Not stated. 2C (extra-articular). lar fractures. insertion. Optional K wire inserted for 3 weeks if joint unstable. Clyburn dynamic external fixator for 7 weeks. Trans-articular fixation likely. Pins inserted Closed reduction through skin inci. ing). articular fractures.cast for 6 weeks.Probably closed remean age 36 years. 62. Small size Zhongjia SGDtype unilateral mul14 Zheng 2003 29.Table 4.52 years tal radial fracture. Published by John Wiley & Sons. 78% female. Ace angulation or > 5 Colles external fixamm radial shortentor for 5 weeks. % female un. Trans-articular fixation. Stein 1990 Young 2002 125. 17% female. (>10 degrees dorsal ticular fixation. . Closed unstable disrange 18 . Not stated but after presentation to fracture clinic. Hospital admission for external fixation. years. Ball joint released for limited wrist motion at 3 weeks. after injury and operation then or next day. Ltd.and forearm plaster sions. Pins Closed reduction driven into bone. Closed or open reduction. Not stated.Comminuted disknown.Redisplaced Colles’ At 2 weeks. Colles’. No details of pin insertion. duction on first day Frykman 3 to 8.cast for 7 weeks. lar fixation. “Small” AO external tubular fixator for 6 weeks. direct vision for insertion into radial shaft. Displaced (> 10 demean age 57 years. and forearm plaster Trans-articular fixa. Closed reduction and above-elbow plaster cast for 6 weeks. tion. Key characteristics of participants. PercutaClosed reduction neous pin insertion and forearm plaster for 2nd metacarpal. 48% female. Rouman 1991 43. Extra-articular and intra-articular. Frykman (5 to 8) and Sarmiento. Pennig external fixator for 6 weeks. mean age 50 placed intra-articuyears. 4B. Participants were either outpatients or inpatients. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Posterior splint applied for 3 weeks if joint disrupted. Trans-articu. Older 3 and 4 (thus Colles’). Universal classification (Cooney) 2B.

Quality assessment results for individual trials (see Table 03 for scheme) Study ID Study ID Items and grades Item 1: Allocation concealment Item 2: Intention-totreat analysis Item 3: Outcome assesItems and grades Item 5: Participant blinding Item 6: Treatment provider blinding Items and grades Notes Item 9: Well defined out.) Ongoing studies No ongoing studies were identified. These will be considered further in the ’Discussion’. Risk of bias in included studies The quality of trial methodology. A summary of the results for individual items of quality assessment is given below. together with some notes on specific aspects. is disappointing. Studies awaiting assessment The possible inclusion of Moroni 2004 requires a response from the lead author concerning the numbers allocated to each group. Table 5. Fixator removed after 6 weeks. Information specific to the first three items of the quality assessment is given in the methods sections of the ’Characteristics of included studies’ table. Optional Kirschner wire for unstable fractures.Table 4. . published only as an abstract. Fixator made dynamic and K-wire removed from week 4. Key characteristics of participants. Published by John Wiley & Sons. fractures and interventions (Continued) ular). performance. Four studies were found not to be randomised trials and there was insufficient information on one quasi-randomised trial (Sprenger 1988). Excluded studies Five studies were excluded for reasons stated in the ’Characteristics of excluded studies’ table. of the quality assessment for the individual trials are shown in Table 5. assessment and attrition) leading to questions about internal validity. and issues of clinical relevance and applicability or external validity. Ltd. The results. judged using the 11 quality criteria listed in Table 2. Associated with this is a high potential for the key systematic biases (selection. tifunctional external fixator.Comments and explanacome measures tions for specific items Item 10: Optimal outcome assessment 15 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. (The latter trial appeared as an included trial in Handoll 2003a.

?. N. N N. N. N. Quality assessment results for individual trials (see Table 03 for scheme) (Continued) sor blinding Item 7: Identical care Item 4: Comparable programmes baseline characteristics Item 8: Clearly defined inclusion criteria Item 11: Optimal timing of follow up (> 1 year) In brackets: date of last follow up. ? Kapoor 2000 ?. N. N. ? (1 year. N. Y External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 2%) Item 4: separate age. Y (mean 4 years. N. Item 4: baseline data not provided for all participants. N. Y. Y. N (4 . Y (13 months. N. ? Y. ?.Table 5. Y (10 years. N. N. ?. N. N. Y Jenkins 1989 N. N. Y N. Y. sex and type of fracture data not provided. N N. Y. 0%?) Horne 1991 ?. Y (2 years. 19%) Item 4: There was a 10 year difference in the mean ages of the two groups (38 versus 48). Y. Y N.15 months. ?. Y. Y. 25%) Item 7: regional aneasthesia was used in the external fixation group and haematoma block in the plaster group. ? N. ? Kreder 2006 Y. Item 8: The maximum age differed between 65 in the Masters thesis and 60 in the 2 journal publications. Y. ?. N. Published by John Wiley & Sons. 16 . N. Ltd. N. Y Y. ? N. N. N N. % lost to last follow up Y. Y. Item 2: no mention of 33%) loss to follow up but fewer participants in the analyses at 4 years. Y. ?. ? (1 year. N. ?. N. 20% or Item 2: although “Y” 22%) there were some data discrepancies between the two abstracts reporting the long-term follow up. Abbaszadegan 1990 ?. Howard 1989 ?. ?. Item 7: method(s) of anaesthesia not given. Y Hegeman 2004 ?. Item 2: discrepancies in 22%) numbers followed up in the two groups. ?.

N N. ?. N Y. Y Y. There were males (5/18) in the external fixation group but none (0/17) in the plaster group. N. N. ?. 6%) Item 4: key patient characteristics were not split by group except for gender. N. N. ? ?. 12%) Item 2: 9 people from the plaster group were given external fixation and reportedly analysed separately but no data were given. ?. ? (6 months to 4 Item 10: The final folyears. N. ? (6 months. 0%?) Item 4: Insufficient information but also imbalance in number of males (5 versus 10). ?. Item 2: It is possible that some patients who were lost to follow up (17) or had died (2) from the initial group of 126 people with displaced fractures would have be included in the trial should their fractures have redisplaced. Y N. 31%) Y. N. Rodriguez-Merchan 92 ?. 17 . Y ?. 0%?) low up of participants. N. ?. N. N N. 0%?) Stein 1990 N. Young 2003 Zheng 2003 ?. ?. ? (6 months. Y (2 years. ?. ? (1 year. N. ?. N. ranged from 6 months to 4 years. Y. N. ?. Item 1: though described as “double-blind”. N N. Y (7 years. 0%?) Roumen 1991 ?. N. ? External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. N. N. N. ? N. ? N.Table 5. 9%) Y. Y Y. ?. Quality assessment results for individual trials (see Table 03 for scheme) (Continued) Lagerstrom 1999 ?. ?. recruited over a 4 year period. N N. ?. N. ? (1 year. no details were given of the method of randomisation. ?. Y. N. N. ?. Y. ?. Ltd. Y Y. N. Y N. ?. N. Published by John Wiley & Sons. McQueen 1996 Pring 1988 ?. ? N. Y. N. ? (1 year.

Nearly a third of participants were missing from the final analyses of Kapoor 2000 and Young 2003. although we judged it highly likely in two trials (Howard 1989. Total blinding of outcome assessment is impractical for trials testing surgical interventions but it is possible for some outcomes and more so at longerterm follow up. . age and type of fracture. Description of inclusion criteria (item 8) Ten trials provided sufficient trial inclusion and exclusion criteria to define their study populations. The latter trial. post-randomisation exclusions. Systematic differences between the arms of a trial. Horne 1990. noted but not rated. Length of follow up (item 11) Follow up ranged from a minimum of four months (Horne 1990) to 10 years (Howard 1989). For instance. For some of the trials appearing to have no losses. Roumen 1991). the results are presented for the basic comparison. inappropriate analyses and lack of accountability of losses were reasons for a ’N’ rating for four trials (Horne 1990. Three of these used envelopes (Hegeman 2004. McQueen 1996. despite the evident variation among the trials in patient characteristics and interventions (see Table 4). McQueen 1996. were instances where adjustments were made for hand dominance. Pring 1988. Kreder 2006) provided sufficient information indicating the similarity in the baseline characteristics of gender. These systems. Kreder 2006. Pring 1988. Hegeman 2004. The three remaining trials used quasi-randomised methods based on dates of birth (Jenkins 1989). Of note is the grading or scoring of overall functional outcome according to nonvalidated scoring systems in several trials. Kapoor 2000. which often included anatomical and clinical outcomes. It was unclear whether allocation was concealed prior to randomisation in 11 trials. Care programme comparability (item 7) We found it difficult to confirm comparability of care programmes other than the trial interventions. This item was rated ’N’ (“not met”) in Pring 1988 where no details of the type of fractures included were available aside from “Colles”’. which used sealed opaque sequentially marked envelopes. can change the actual comparison under test. were found in Jenkins 1989 (age). gave a full account of the losses at seven years whereas losses were not explained in Kapoor 2000. Howard 1989. Intention-to-treat analysis (item 2) Clear statements of participant flow with evidence of intentionto-treat analysis were available for six trials (Abbaszadegan 1990. Young 2003) had active follow up and applied clearly relevant measures of function. Kreder 2006. namely external fixation versus plaster cast immobilisation. Definition of outcome measures and quality of outcome measurement (items 9 and 10) The definition of outcome measurement was clear enough to give a good idea of what was recorded in all of the included trials except Stein 1990. included modifications of other scoring systems such as that of Gartland and Werley (Gartland 1951). Furthermore. Failure to provide the numbers assigned to each group at randomisation. Howard 1989. Loss to follow up (not rated) Loss to follow up was substantial in several trials (see ’Characteristics of included studies’ table and Table 5). Blinding of outcome assessors (item 3) No trial reported blind outcome assessment although four trials ( Howard 1989. day of hospital admission (Stein 1990) and admission number (Zheng 2003). Two trials (Horne 1990. it may be the case that these were not reported. Only Kreder 2006 was rated as having ’optimal’ quality outcome measurement. however. Lagerstrom 1999). Kapoor 2000. Stein 1990) were considered to have inadequate outcome measurement. Published by John Wiley & Sons. which included use of validated patient assessed quality of life instruments and active follow up. may be a potential cause of bias in Horne 1990 (4 to 15 months) and Stein 1990 (6 months to 4 years). Young 2003). Young 2003).Allocation concealment (item 1) Only one trial (Kreder 2006). Potentially important imbalances between treatment groups in participant characteristics. Pring 1988. Roumen 1991). the pooling of data from the two trials studying treatment of redisplaced fractures in older 18 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. McQueen 1996. Also. several other trials (including Hegeman 2004. and in the methods and timing of outcome assessment and selection of reported outcomes (see below and ’Characteristics of included studies’ table). Rodriguez-Merchan 92. such as the different methods of anaesthesia for closed reduction in Kreder 2006. one used a computer (Lagerstrom 1999) and seven trials provided no information (Abbaszadegan 1990. Blinding of patients and treatment providers (items 5 and 6) These are unlikely in these studies and none was claimed. Lagerstrom 1999 (gender) and Zheng 2003 (gender). Follow up of variable duration at times where participants are at different stages of recovery. The variety of schemes used and other outcome measures reported by the trials is evident from inspection of the ’Characteristics of included studies’ table. Young 2003) referred to independent assessors for some outcomes. Effects of interventions In the following. few of the trials are sufficiently similar to fall neatly into specific sub-categories. Comparability of baseline characteristics (item 4) Two trials (Hegeman 2004. Ltd. which included follow up of variable duration. where information was provided. Nonetheless. was considered to have satisfied the criteria for secure allocation concealment.

we considered that. Jenkins 1989 and Stein 1990 presented results split by subjective and objective gradings.30 versus 4. RR 0. whilst some exploratory analysis has taken place. 95% CI 0.09. Kreder 2006. Functional outcome and impairment Final overall functional outcome. Kapoor 2000 found a marginally statistically significantly better restoration of grip strength in the external fixation 19 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons. Kreder 2006 found non-significant trends to better functional results for the surgical group in the upper extremity function part of the Musculoskeletal Function Assessment tool (see Analysis 01. Kapoor 2000. None of the differences were significant at one year for Hegeman 2004. Hegeman 2004. one year or two years (see Analysis 01.02 and 0. Ltd. Jenkins 1989. the trialists considered that the differences were not clinically significant.01. The significant heterogeneity (P = 0.people (McQueen 1996.47 to 0. Stein 1990. Though some statistically significant differences in some aspects of function were apparent at one year follow up in Young 2003. ’Functional’ scores ’Functional’ scoring systems were used in 13 of the trials ( Abbaszadegan 1990.25). the numbers with an unsatisfactory outcome (either fair or poor gradings) were statistically significantly fewer in the external fixation group (62/308 versus 83/304. in other words. this was significant for fine hand co-ordination (see Analysis 01. Grip strength The greater grip strength in the external fixation groups of Jenkins 1989 and Young 2003 (1 year data) was statistically significant (see Analysis 01. Young 2003. most were modifications of Gartland and Werley’s scheme (Gartland 1951).47 to 1. was considered better in the external fixation group in eight studies ( Abbaszadegan 1990. some trials reported results for combined categories (such as fair or poor) only. Kapoor 2000. The mean ’demerit’ Scheck score (Scheck 1962) for function was better. these pooled results from non-validated ’functional’ scoring schemes favour external fixation in terms of more people with excellent results (depicting a good recovery) and fewer people with an unsatisfactory outcome (either ’fair’ or ’poor’ result). whilst various complications were included in that used by six trials (Hegeman 2004. the re-reduction of fractures in the conservative treatment group and the inclusion of extra-articular fractures in McQueen 1996 but not in Roumen 1991). This was not statistically significant when using the random-effects model (RR 0. ’good’. Lagerstrom 1999. Separate data for participants in the three trials with optional supplementary pinning were not available. Hence. Analysis 01. more people in the external fixation group of Hegeman 2004 had problems with some activities of daily living. Kapoor 2000. Pring 1988 and Roumen 1991.4%) is lost on the removal of the results of Roumen 1991 and the result is again statistically significant (RR 0.08). Analysis 01. Young 2003. RodriguezMerchan 92). or some aspect of function.98.01: 134/256 versus 166/265. RR 0. Howard 1989. Horne 1990. Zheng 2003).02 shows a worst-case (for conservative treatment) and then a best-case analysis for this outcome. a lower proportion of people treated with external fixation had a “not excellent” grading (see Analysis 01. ’fair’ and ’poor’). Kapoor 2000. nonetheless we have presented these as well as the seven year results in the analyses. as shown by the results of sensitivity analyses (e. McQueen 1996.82. A higher proportion of people treated with external fixation achieved an excellent functional grading. Horne 1990. Analysis 01.71 to 0. Young 2003). I² = 41. subgroup analysis was not appropriate.73.04 presents the separate subjective and objective results reported in Jenkins 1989 and Stein 1990: here it is notable that the trial participants of Jenkins 1989 rated the end functional result less favourably than the result using objective measures.05). in the external fixation group of Pring 1988 at six months (3. Hegeman 2004.06). In summary.65. The functional scores were usually graded into four categories (’excellent’.g. but not statistically significantly so. The subjective end gradings from Jenkins 1989 and Stein 1990 were pooled with the overall functional gradings from the other studies in Analyses 01. The result strongly favours external fixation when it is assumed that all participants lost to follow up or excluded (not possible for Horne 1990) in the external fixation group had an excellent result compared with none of those lost or excluded from the conservative treatment group.95 to 1.06). Stein 1990. However. Roumen 1991) would appear valid but there remains clear dissimilarity in the known characteristics of the trials (e. 95% CI 0. No statistically significant differences in final functional outcome were reported by seven studies (Horne 1990. In the converse case. Young 2003 found similar numbers of people in the two groups experiencing difficulties with specific functional tasks at seven years (see Analysis 01.03.55 to 0.88. The time to return to work or normal activities averaged 70 versus 75 days in Young 2003 (statistical significance not reported). Pring 1988. analysis not shown). 95% CI 0. Pring 1988. 01. Howard 1989. fixed-effect model).19). 95% CI 0. Kreder 2006. More people in the external fixator group achieved excellent grades at 10 years in Howard 1989 but the data presented in the two abstract reports for long-term follow up were inconsistent.95). 95% CI 0. on the whole. However. Roumen 1991.72. Zheng 2003).g.03. Activities of daily living At three months.07. Jenkins 1989.02) such findings are not robust. and in the results for the bodily pain domain of the SF-36 and JebsenTaylor (Jebsen 1969) hand function scores (data reported as standard deviations from the norm for these outcomes are not presented in the Analyses). Rodriguez-Merchan 92. . RodriguezMerchan 92. Pring 1988. Occupation There was no significant differences between the two groups of Kreder 2006 in the numbers of people who changed their job because of their injury at six months. Roumen 1991.07). different types of external fixator. a neutral result is obtained (RR 1. As shown in Analysis 01. Howard 1989.09: analysis not shown). Some consideration of deformity was present in the schemes used by Abbaszadegan 1990.

15).49) did not resolve with cleansing and antibiotics or. There is no statistically significant difference 20 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Kreder 2006 reported there was no statistically significant differences in wrist and forearm range of motion at any of the follow ups.05).08).11). reported P < 0. Kreder 2006. Similarly. but not in McQueen 1996 (see Analysis 01. separate data by intervention group were not available) and Young 2003 (see Analysis 01. Surgical curettage of the pin tracks was required for two people in Kreder 2006.13).17. Ltd.08). Lagerstrom 1999 (see Analysis 01. Jenkins 1989. There was a marked excess of nerve related complications in the conservative treatment group in Howard 1989 that was not so apparent in the other trials.0002). and in favour of plaster cast for supination. Clinical outcome and complications Complications The various complications suffered by the participants of these trials are presented in Analysis 01. during movement and ulnar compression pain. Jenkins 1989. McQueen 1996 also found no difference in the overall range of motion. Two infections resulted in fixator removal in McQueen 1996. in Kreder 2006. notably the constant pain on movement of the wrist in two people in the external fixation group was sufficient for them to adapt their activities to avoid using the wrist. when not using the Bonferroni correction. Lagerstrom 1999. are not known but are likely to be minor (see Analysis 01.08). often a short term sensory disturbance of the superficial radial nerve. Pring 1988 reported several complications for external fixation including thumb pain and various pin-related problems (see ’Characteristics of included studies’ table) but failed to distinguish between primary and secondary external fixation. in favour of the external fixator group. McQueen 1996.group (70% versus 63% of unaffected arm. for Kreder 2006 at two years in favour of external fixation in flexion and radial deviation. these were not pooled. I² = 77. RodriguezMerchan 92). Published by John Wiley & Sons.16). Pain Pain was reported as being significantly less in the external fixator group in Abbaszadegan 1990 (final mean visual analogue score (0 to 10 severe): 0 versus 1. the exceptions being three participants whose external fixator was distracted to combat radial shortening in Howard 1989. on the application of the Bonferroni correction for multiple comparison testing.16. one participant given open reduction and internal fixation in Kreder 2006 and three participants who underwent remanipulation in Young 2003. There are 10 other cases of pin loosening or other pin site problems (see Analysis 01.6% versus 63. One person in the external fixator group in Young 2003 at seven years had persistent wrist weakness necessitating a wrist splint.12). The difference in the flexion/extension arc values were reported as being statistically significant. There were no statistically significant differences in range of motion outcomes at one year for Jenkins 1989 (see Analysis 01. Due to the statistically significant heterogeneity (P = 0. Pin-site infections in 10 of the 69 people with pin-track infections (61/444 versus 1/402.02. recurrent instability of already redisplaced fractures were significantly more common in conservatively treated participants. Pring 1988 (mass grip strength as % of normal side: 67. The two infections in Stein 1990 resolved on fixator removal. The clinical implications of the significant findings. The differences between the two groups in mass grip strength were found not to be statistically significant at final follow up in seven trials: Abbaszadegan 1990. RR 12.17). Roumen 1991 reported the numbers of patients experiencing pain: at rest. two infections were recurrent and resulted in fixator removal and one developed into the only reported case of osteomyelitis. found that the recovery in grip strength was slower in the external fixator group and considered there was some indication for specific physiotherapy for patients treated by external fixation. In addition. There were no statistically significant differences for any of these three measures (see Analysis 01.002) but numbers with persistent pain were reported to be similar in Hegeman 2004. Radial nerve neuropathy. in Abbaszadegan 1990 (% of normal wrist: 95% versus 83%.6%) in the results of the four trials (Hegeman 2004. who measured isometric grip strength. Kapoor 2000. There was no indication in Kapoor 2000 as to whether the superior range of motion in the external fixator group was reflected in statistically significant differences in the losses in the following three parameters: dorsi-palmar flexion (19 versus 37 degrees). Range of movement The available data for range of movement are presented in Analyses 01. and the third required curettage. Young 2003 also gave details of the circumstances for persistent pain at seven years. Some reference to care of pin sites was made in six trials (Howard 1989. redisplacement or.10). radial-ulnar deviation (13 versus 16 degrees). as in McQueen 1996. reported P = 0. McQueen 1996 (see Analysis 01. Only wrist extension was better in the external fixation group at one year in Hegeman 2004.8%) and Young 2003 (7 year results: see Analysis 01. Though statistically significant. requiring many months of intensive physiotherapy to resolve. reported P = 0. 95% CI 5. radial nerve symptoms in the plaster cast group were reported in a few cases of Howard 1989 and Young 2003.09). Redisplacement resulting in secondary treatment mainly occurred in the conservative treatment groups. pronation-supination (23 versus 40 degrees). with the early removal of supplementary percutaneous pins. Hegeman 2004 (see Analysis 01.07 to 28. Lagerstrom 1999 (19% overall had persistent pain after two years. the differences between the two groups in ulnar deviation and pronation at one year follow up in Young 2003 are not clinically important (see Analysis 01. .13 to 01. Of the three serious infections in Jenkins 1989. it is not clear whether this was premature. Null events have also been entered when reported. McQueen 1996. The majority of cases of reflex sympathetic dystrophy (RSD) were reported as serious.004. was more common in the external fixator group.13). Kreder 2006 (see Analysis 01. there were no statistically significant differences in range of motion outcomes at seven year follow up of this trial (see Analysis 01. Young 2003) providing data for grip strength.14).

Ltd. Roumen 1991) including redisplaced. radial shortening). 90/202 versus 148/169. RR 1. plaster cast group: external fixation if remanipulation was unsuccessful).25 to 0. Jenkins 1989 (dorsal angulation. The severity of the arthritic changes at 10 years in Howard 1989 was not reported (see Analysis 01. often significantly so. External fixation group participants with serious infection and plaster cast group participants requiring remanipulation were excluded from the rest of the analyses in Jenkins 1989. Howard 1989 (external fixator group: distraction of the fixator increased for loss in radial length. Cosmetic outcomes There were no significant differences between the two groups in overall cosmetic deformity (Kapoor 2000) or various features of cosmetic deformity described in Hegeman 2004 (see Analysis 01. Zheng 2003 (dorsal angulation.20). RR 0.32) in RSD. Differences between the one year and seven year results for radial shortening (see Analysis 01. Young 2003 found there was no difference between the two groups in the few people who were dissatisfied with their wrist at seven years (see Analysis 01. and hence unstable. Stein 1990). Pring 1988 (radial angulation. despite closed reduction being used in both groups. in the external fixation group in all trials except Horne 1990.18) was set to examine the difference in the direction of effect of the two subgroups (primary displaced fractures versus redisplaced fractures). Stein 1990 (plaster cast group: remanipulation) and Young 2003 (both groups: remanipulation) all retained those participants confirmed as having secondary treatment for redisplacement.74 to 2. Anatomical outcome (anatomical restoration and residual deformity) Overall anatomical results at final radiological follow up were better. As before.09 to 0.17. I² = 67%) in Analysis 01. 95% CI 0. there were similar numbers of people in the two groups with redisplacement and treated redisplacement in Young 2003. radial shortening). but six in another report (Jenkins 1988). loss in radial angulation.44).17). Published by John Wiley & Sons. 17/214 versus 96/186. Exceptionally. radial shortening). 95% CI 0. radial shortening). 95% CI 0.02. It should also be noted that the differences between the two treatment groups in either subgroup of trials did not reach statistical significance. RR 0. In Young 2003.21 Anatomical grading: not excellent. It is of concern to note that four people were recorded as requiring remanipulation in the full report of this trial. radial angulation). only one was symptomatic. in contrast to most of the other included trials.191) more evidence is required to establish if external fixation has a greater risk of RSD in older people with proven unstable fractures. the only complaint being that the fixator made it difficult to use the hand. 95% CI 0.23) and dorsal angulation (see Analysis 01.11 to 0.77). This may be associated with the significantly better postreduction results in the external fixation group of this trial.31. . RR 0. may also influence these results. As the difference between the two results is not statistically significant (P = 0.19). plaster cast group: remanipulation). Statistically significantly fewer people in the external fixator group had recurrent instability in McQueen 1996 (14/60 versus 16/30. in Handoll 2003a. and Analysis 01. RR 1.61. 95% CI 0. Most cases with arthritis at seven years had mild cases of joint space narrowing in Young 2003 (11 versus 12). fractures as well as older participants had more cases of RSD in the external fixator group. Secondary treatment for redisplaced conservatively treated fractures consisted of remanipulation and external fixation in Abbaszadegan 1990. between the two treatment groups in the mean values of individual radiological parameters were reported to be statistically significant. these participants were then analysed as a separate group in these three trials. an exploratory analysis (see Analysis 01. Stewart 1985) which was derived from the scheme used by the two other trials (Roumen 1991.17: 7/356 versus 51/338. Hegeman 2004 (dorsal angulation.22 Anatomical grading: fair or poor. 95% CI 0. Radiological parameters The differences. Young 2003 (dorsal angulation (at one year). Redisplacement requiring secondary treatment occurred in 15% of conservatively treated fractures over nine trials (see Analysis 01. in eight trials: Abbaszadegan 1990 (dorsal angulation.21. in favour of the external fixation group.28 to 9. ulnar angulation.45 to 0.17. All the other trials indicated that external fixation held the reduced position better than plaster cast immobilisation. Kreder 2006 (external fixator group: open reduction and internal fixation. from graph). It should be noted that the removal of the highly favourable results for the external fixation group of Stein 1990 shows these to be the basis of the statistically significant heterogeneity (P = 0. including the reduction in the sample size at seven years. 13 of the 36 people available at seven year follow up had “unsightly” forearm scars at the proximal pin insertion sites. McQueen 1996 (dorsal angulation). one person in the external fixation group had stabilisation of this joint by ulnar styloid repair. Howard 1989 (dorsal angulation. The results of Horne 1990 may in part reflect the choice of radiological parameters (Van der Linden 1981) reported in Horne 1990 and the small numbers of participants ( Axelrod 1991). Kreder 2006 reported that similar numbers had distal radius ulnar joint instability at six weeks (3/54 versus 2/59.24) in Young 2003 probably reveal a trend for deterioration over time but other factors.44. RR 0.32).27).53. Previously. Rodriguez21 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Anatomical scores Four of the six trials rating overall anatomical results used the same rating scheme (Stewart 1984. it was noticed that the two trials (McQueen 1996. often without confirmatory data.between the two groups (25/384 versus 17/347. Howard 1989 reported that the pin-track scars were accepted by the patients. radial shortening. Most of the 27 redisplacements occurring in the conservative treatment group in Rodriguez-Merchan 92 were probably remanipulated.64. but this was not stated explicitly in the trial report. Lagerstrom 1999 and Pring 1988. The pooled results from these six trials give a consistent picture of the significantly superior anatomical results for external fixation (see Analysis 01.

41 to 0. There was no report of the cost implications of remanipulation of redisplaced fractures or of the routine care of pin sites or additional care resulting from pin site infection. As discussed below. Limitations of the review methods As this review abided by the criteria and methods set out in a published protocol. the incidence of malunion in those patients available at seven years follow up in Young 2003 was similar in the two groups (RR 0. The first is the question of whether trials have been missed or inappropriately excluded in our search and selection processes.24 mm versus -0.Merchan 92 also reported superior results in the external fixator group. The data presented in the analyses for Jenkins 1989 pertain to the time of fracture union and removal of cast and fixator at around four weeks. if so. Trialist-defined ’malunion’ (based on dorsal angulation and radial shortening) reported by McQueen 1996 and Young 2003 was significantly less in the external fixation group at one year (36/108 versus 47/90. namely external fixation versus plaster cast immobilisation. and in their methods. DISCUSSION This review of a common surgical intervention for one of the most common fractures has 15 included trials involving a total of only 1022 participants. made one exception by subgrouping according to primary and secondary displaced fractures for RSD (see Analysis 01. Limitations of the review evidence Overall. we have restricted our comments to two issues. This reflected a previously set up hypothesis in Handoll 2003a. Ltd. with two exceptions (Horne 1990: dorsal displacement. However. An inclusive and benefit-of-doubt approach during trial searches has been maintained throughout by the lead author (HH).47).5 degrees) and loss of radial length (mean: 0.05). the available evidence is limited in scope and quantity. methodology) and quality of the studies in the different age groups. the difference was reported to be statistically significant in both the draft and published reports (P < 0.63 to 1. . The second issue concerns decisions made regarding pooling and subgroup analysis. we decided that any findings would be impossible to interpret given the other differences in characteristics (types of fracture and interventions. We decided to pool the results of evidently heterogeneous trials in an attempt to address the basic question of whether external fixation of any kind produces significantly different results compared with conservative treatment (plaster cast) in adults with distal radial fractures. particularly if unpublished and inadequately reported. these may still not be suitable for inclusion.96. Jenkins 1989 found a better reduction and fixation of die-punch fractures in the external fixation group. including outcome assessment. this may reflect the particular design of non-bridging fixator used in this trial where the distal pins also transfixed the fracture fragments.18). pooling was not performed.9%) was evident for radial shortening. Kreder 2006 reported the trend for better restoration in radial length and palmar tilt (volar angulation) in the external fixation group was not statistically significant. This shows that all losses in these parameters were less in the external fixation group. Resource use No trial provided quantitative data on resource use and costs. McQueen 1996: radial shortening). Residual deformity Several other measures of structural deformity are presented in Analysis 01.23. assessment of outcome.24) but the variation in the definitions of dorsal angulation and “normal” values makes the results hard to interpret. Since statistically significant heterogeneity (I² = 94. Radial length shortening had worsened in both groups of Young 2003 at seven year follow up and the difference between the two groups was no longer statistically significant (see Analysis 01. Thus we concluded that the subgrouping the 15 trials into smaller separate categories was not viable. Losses in various radiological parameters in those trials providing sufficient data are presented in Analysis 01.58.70 mm).23). Stein 1990 referred to admission to hospital for 24 hours or to a day-care facility.81). Our search was comprehensive and built on searches carried out over many years prior to the separate development of this review (Handoll 2003a). Superior anatomical values for dorsal and radial angulation and radial length were usually evident and claimed for the external fixation group (see Analysis 01. We guarded against study selection bias by the independent selection of eligible trials by all three review authors. dorsal angulation (mean: 0. there was considerable variation in the trials especially in terms of patient characteristics and interventions (see Table 4). We. in particular to examine the results in good quality bone in the younger age group compared with osteoporotic bone in the older age group. trial authors of unpublished trials have been sent requests for information and trial reports.25.1 mm). Later data at one year for this trial showed a further loss in mean radial length in the external fixator group compared with a slight gain in the cast group (mean loss: 1. It is possible that we have missed some potentially eligible trials but. Though essentially these trials evaluated one basic comparison.5 mm versus 4. We considered grouping trials by participant age and gender according to the three categories described in ’Description of studies’. It has included the handsearch of conference proceedings and checks for ongoing trials. however. RR 0. In contrast. Published by John Wiley & Sons. 95% CI 0. The usual reservations of the reliability 22 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Additionally. It is not known how many people receiving surgery were day cases. 95% CI 0. Overnight hospital admission was routine for surgical patients in Rodriguez-Merchan 92 whereas Horne 1990 referred to a day-care facility. however.2 versus 9. and is of uncertain validity. for example. our overall approach has important implications in terms of the interpretation of review findings. thus avoiding the costs of a hospital bed.

Shoulder. EF is associated with a high risk of complications. Considerable caution is needed when interpreting these. Moreover. pain. Applicability of the review evidence Generalising the findings of the included trials. and Hand questionnaire (DASH) and the Patient-Rated Wrist Evaluation (PRWE) (MacDermid 2000).increased risk of iatro- External fixation (EF) 3: Trade off between EF reduces redisversus conservative treat.benefits and harms placement requiring secment ondary treatment (usually remanipulation under anaesthesia in the plaster cast group) and yields better anatomical results. we were careful to avoid mis-interpreting inconclusive evidence as ’evidence of no effect’. that combine aspects of function. deformity and complications are particularly crude indicators of outcome. Kreder 1996b). good. and type. These help to standardise functional assessment in a meaningful way and assist interpretation (Amadio 2001). Published by John Wiley & Sons. For example. Pin site infection. metaphyseal comminution of the fracture and ulnar variance were the most important factors in predicting instability of distal radial fractures ( MacKenney 2006). A study of 4024 patients concluded that the patient age. However. the two fracture classifications used by trials in this review (the AO and Frykman) place different emphases on various fracture patterns and anatomical components. There remains a possibility of suboptimal application of plaster casts in some trials. Especially. is generally re- External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. patient characteristics. the Disability of the Arm. Table 6. a large retrospective study found that neither classification system was useful for predicting clinical outcome (Flinkkila 1998). This with other factors. this was much less a concern with Kreder 2006. Studies have revealed unsatisfactory interobserver reliability and intraobserver reproducibility for both classification systems (Andersen 1996. (4) Compromised methods of several trials means that serious bias cannot be ruled out. Kreder 2006 proved an exception. Non-validated outcome measures. Moreover. the evidence of a better functional outcome from EF is weak. Comments Minimal details were usually provided for the conservative treatment intervention which always involved plaster cast immobilisation. fair or poor. Some EF techniques were not optimal . and proven for the two trials of redisplaced fractures (McQueen 1996. while common.of evidence from small and underpowered trials apply. Ltd. However. technique and timing of EF not resolved. Summary of the evidence We have summarized the evidence using the categories described in BMJ 2006 (see Table 3). such as variations in anatomical reference points. Many trials predated the development of validated patient functional assessment instruments such as Short Form-36 (SF-36). Again. exclusion or assessment bias. both fracture classification systems have been shown to have serious limitations. Kreder 1996a found quite broad margins of error (“tolerance limits”) for anatomical measurements in general. especially when the scores have been reduced into categories such as excellent. Generally though it is not established how best to predict fracture instability. Systematic bias. is hampered by inadequate reporting of study details: in particular. Nine trials in this review stipulated criteria for anatomical displacement of the fracture for trial entry. (2) Incomplete functional and long term outcome. all of which are key determinants of treatment and prognosis. Another limitation was the inadequate assessment of outcome. Category of effectiveness for external fixation versus conservative treatment Comparison Category Justification Qualifiers (1) Indications ( especially fracture types) for treatment. in the form of selection. which was the only trial with clearly concealed treatment allocation. particularly of function and in the long term. Roumen 1991). Thus. The effectiveness of external fixation compared with conservative treatment is graded as 3 (’Trade off between benefits and harms’) as defined in Table 3. Some supporting information is provided in Table 6 and below. Fracture instability was the inherent or explicit criterion for many of the included trials. performance. (3) Heterogeneous interventions. should these be valid. 23 . such as those based on the Gartland and Werley scoring system (Gartland 1951). and quality of bone. or a combination of these could not be ruled out for any trial. with associated issues of reliability and validity further complicates this area (Jupiter 1997) and hinders direct comparisons between trials. However. the type and severity of the fracture. again hinders treatment comparison. The variety of fracture classification systems.

External fixation was associated with a high number of complications but many of these were minor and some would probably have been avoided using a different surgical technique for pin insertion. are less common but often more serious. Sufficient data were not available to undertake meaningful subgroup analysis. Superior anatomical results.g. Implications for research Given that a distal radius fracture in adults is a common injury and given that there is limited knowledge about the best method of treatment. though external fixation was more effective in holding a reduced fracture position it comes at a price of a high number of associated complications.Table 6. Seitz 1993). RSD occurred in nearly six per cent of patients (42/731). Other complications. after primary reduction and recurrent instability after re-reduction in redisplaced fractures was a frequent complication of conservatively treated patients. Data for long-term complications and overall outcome were too limited for comments. here often termed redisplacement. the identification of the priority questions for the management of these fractures is required (Handoll 2003c). e. The updating of the evidence summaries of other surgical interventions for these fractures is likely to inform this process. we could not confirm that RSD was more common in patients with redisplaced fractures that had been treated by external fixation. The considerable variation in the trials genic complications. Published by John Wiley & Sons. However. Putative reasons for these two exceptions are given in the Results. patient characteristics. fracture pattern. Some clues as to the best methods of external fixation may arise from the pending systematic review of the evidence from direct comparisons of different methods of external fixation (Handoll 2007). albeit potentially favouring external fixation. Ltd. Most of the redisplacements resulted in a second reduction and application of a second plaster cast. 24 . both in maintaining the reduced fracture position and in final anatomy. the use of stab incisions in Horne 1990 rather than small incisions to visualise and retract soft-tissue during pin insertion was criticised (Axelrod 1991). As explained above. variations in the interventions. AUTHORS’ CONCLUSIONS Implications for practice There is some evidence from a set of 15 heterogeneous and generally methodologically weak trials to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. in the external fixation group were evident in all trials except Horne 1990 and Young 2003. means that only the basic question of whether external fixation confers some benefit is addressed here. Secondary displacement. including age. such as superficial radial nerve paraesthesia. further research is called for (Handoll 2003a). there are insufficient data to explore the effects of different trial characteristics. Radial nerve injury was more common in the external fixation group and can be a consequence of poor pin placement resulting from suboptimal surgical technique (Ahlborg 1999. Although some redisplacements might be explained by operator error. However. that is to a great extent based on functional grades from non validated scoring systems that also rate radiological deformity. rather than embark on yet more small single-centre trials. Category of effectiveness for external fixation versus conservative treatment (Continued) solvable with local treatment. particularly those with inadequate methodology that are unlikely to provide the good quality generalisable evidence required. there was insufficient evidence to confirm a superior overall functional or clinical result. There was not enough evidence to prove or disprove a difference in more serious complications between the two groups. ACKNOWLEDGEMENTS External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. The functional results of the included trials presented a mixed and incomplete picture. While the evidence shows that external fixation maintains reduced fracture positions and prevents late collapse and malunion compared with plaster cast immobilisation. either conservative or surgical. this finding is a reasonable indication of the instability of fractures in the trial populations. aside from their general absence. Most of the complications related to external fixator pins were pin-track infections that resolved with cleansing and antibiotics and there was a low incidence of pin loosening and premature removal of the external fixator. on functional results.

Howard PW.70(3):507. External fixation or manipulation and plaster for severely displaced comminuted Colles’ fractures? [Abstract]. Burke FD. McKee MD. REFERENCES References to studies included in this review Abbaszadegan 1990 {published data only} Abbaszadegan H. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radius fractures [letter. External fixation or plaster cast for severely displaced Colles’ fractures? Prospective 1-year study of 46 patients. Published by John Wiley & Sons. Journal of Bone and Joint Surgery . Devane P.61(6):528–30. Isik M. Journal of Orthopaedic Trauma 2006. Devane P.31(2):75–9.British Volume 1998. Journal of Bone and Joint Surgery . Injury 1988. Jonsson U. Johnson SR. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction. External fixation or manipulation and plaster for severely displaced comminuted Colles’ fractures? [Abstract]. Orthopaedic Transactions 1989. We thank the following for helpful comments and input at the editorial and external review of the protocol: Joanne Elliott. Hegeman 2004 {published data only} Hegeman JH. Horne G. Burke FD. Agarwal A. Atherton WG. Jones DG. External fixation and recovery of function following fractures of the distal radius in young adults. Dhaon BK. Hind RE.80 Suppl 1:53. Stephen D. comment]. Van der Palen J.5(2):246.British Volume 1988. ∗ Howard PW. Kapoor 2000 {published data only} Kapoor H. The role of external fixation in treating the Colles’ fracture [Abstract]. A randomized.British Volume 1989. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures [see comments].British Volume 1989. We thank Xiaoyan Chen for a translation from Chinese. Jones DG.69(2):207–11. Howard PW. Acta Orthopaedica Scandinavica 1990. Journal of Orthopaedic Trauma 1991. Aktuelle Traumatologie 2004. Journal of Bone and Joint Surgery . An anatomical study. Vicki Livingstone and Janet Wale.British Volume 1987. Stewart HD. Freeman BJC. Journal of Bone and Joint Surgery . Is external fixation necessary for distal radius fracture without joint incongruity? [letter].British Volume 2000. Lindsey Shaw and Janet Wale. External fixation of Colles’ fractures. who provided clarification and further information on their trials. controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: 25 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Primary external fixation versus plaster immobilization of the intra-articular unstable distal radial fracture in the elderly. Purdie G. Injury 2000. Mintowt-Czyz WJ. Horne JG.4(1):30–4. Jenkins NH.19(4):235–8. at the British Orthopaedic Association. personal communication October 10 2006.20(5):374. Howard 1989 {published data only} Freeman BJC. Devane P. 1988. personal communication October 10 2006. We thank Joanne Elliott and Lindsey Shaw for their help during editorial processing of the review. Journal of Bone and Joint Surgery .71(1):68–73. Journal of Orthopaedic Trauma 1991. .13(3): 531. Horne G. Mintowt-Czyz WJ. The treatment of Colles’ fracture [Masters thesis: Winner of Robert Jones Gold Medal and Association Prize 1989]. Jones DG. Jenkins NH. We thank Jean Goodman. Cebesoy O. A prospective randomised trial of external fixation and plaster cast immobilisation in the treatment of distal radial fractures [Abstract]. Ltd. ∗ Kreder HJ. Jesse Jupiter. ∗ Hegeman JH.5:114–5.We thank Lesley Gillespie for her help with the search strategy. Kreder 2006 {published and unpublished data} Agel J. Journal of Bone and Joint Surgery . for facilitating the perusal of the Jenkins’ trial thesis. in particular Claire Young for extensive feedback. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radius fractures. Bill Gillespie.34(2):64–70. We thank the following for helpful comments at the editorial and external review of the review: Lesley Gillespie.82 Suppl 2:171. Vierhout PAM. Oskam J. Jenkins NH. external fixation and open reduction with internal fixation. Horne 1990 {published data only} Axelrod TS. A prospective trial comparing external fixation with closed reduction and cast immobilisation in the treatment of distal radial fractures [Abstract]. Journal of Orthopaedic Trauma 1990. External fixation or plaster for severely displaced comminuted Colles’ fractures? A prospective study of anatomical and functional results. Burke FD. Jenkins 1989 {published and unpublished data} ∗ Jenkins NH. Atherton WG. Jesse Jupiter. ten Dius HJ. London: British Orthopaedic Association. ∗ Horne JG.71(2):340. Schemitsch EH. Agel J. We are also very grateful to those trialists. Mintowt-Czyz WJ. Hanel DP.

Hanel DP. Checketts RG. Young CF. Bunger C. Journal of Bone and Joint Surgery . External fixation of comminuted Colles’ fractures gives better results than conservative treatment. Recovery of isometric grip strength after Colles’ fracture: a prospective two-year study. Journal of Orthopaedic Trauma 2006. Hoerer D. Scandinavian Journal of Rehabilitation Medicine 1999.200:300. Kreder HJ.British Volume 1991. Ltd. Olerud C.24(6):358–60. Young 2003 {published and unpublished data} Nanu AM. Unstable fractures of the distal radius: a prospective randomized comparison of four treatment methods [Abstract]. Young CF. Checketts RG. 2002 Oct 3-5. A comparison of two treatment methods. Young CF.British Volume 1996. Kreder HJ. Nanu AM. Clinical Orthopaedics and Related Research 1989. Versicherungsmedizin und Berufskrankheiten 1989. Ontario. Seven year outcome study of Colles’ type distal radial fractures [Abstract]. Rahme H. Pring 1988 {published data only} ∗ Pring DJ. Orthopaedic Review 1992.82 Suppl 1:83. Horesh Z. Plaster immobilisation versus Pennig external fixator for distal radius fractures [Abstract]. ∗ Young CF. Sprenger 1988 {published and unpublished data} Sennwald G. Injury 1988. Nanu AM. 2000 May 10-14. Riva del Garda. Williams DJ.31(1):55–62. Zhang Y. Court-Brown CM. Journal of Bone and Joint Surgery . McKee MD.85(Suppl 1):27. Plaster cast versus external fixation for unstable intraarticular Colles’ fractures.htm (accessed 01/11/02). A comparative study of early results following external fixation. spanning external fixation. Sennwald G. McQueen 1996 {published data only} McQueen MM.76 Suppl 2 & 3:149. Holmich LR. Roumen 1991 {published data only} Roumen RM.27 (1):57–61. Hesp WL. Agel J. A randomised trial of external fixation for redisplacement. 2002 Oct 11-13. Solund K. Galindo E. Journal of Clinical Orthopaedics 2003. Lagerstrom 1999 {published data only} Lagerstrom C.82(2):99–105. Hajducka C. Italy 2000. Laudy FG.British Volume 1986.78(3):404–9. Lind B. Toronto. Bruggink ED. or dorsal plaster immobilization.109(1):34–8. Checketts RG.61(5):453–6. Orthopaedic Transactions 1997. Weber BG. [A comparison of conservative and surgical treatment of distal radius unstable fracture]. Redisplaced unstable fractures of the distal radius. Rodriguez-Merchan 92 {published data only} Merchan EC. Nanu AM. Plaster cast versus Clyburn external fixation for fractures of the distal radius in patients under 45 years of age. Young CF. Christiansen TC. 2002:http://www. van Dijk 1996 {published data only} Van Dijk JP. Williams DJ. Nanu AM. Riva del Garda. Young CF. et al.21(2):595–6.British Volume 2003. Plaster cast vs the Pennig dynamic fixator for Colles’ fracture . Bipolar fixation of fractures of the distal end of the radius: a comparative study. Journal of Hand Surgery .closed reduction and casting versus closed reduction. Breton AF. Archives of Orthopaedic and Trauma Surgery 1989.68(4):666. ∗ Lagerstrom C. Kongsholm 1989 {published data only} ∗ Kongsholm J. Checketts RG. American Society for Surgery of the Hand 57th Annual Meeting. Orthopaedic Trauma Association Annual Meeting. Pring DJ. 2002. Evaluation of grip strength measurements after Colles’ fracture: a methodological study. Displaced distal radius fractures. Nordgren B. . Hanel DP. A randomized controlled trial of closed reduction and casting versus closed reduction and external fixation for distal radius fractures with metaphyseal displacement but without joint incongruity [Abstract]. Journal of Bone and Joint Surgery .(241):57–65. Solgaard 1989 {published data only} Solgaard S. Acta Orthopaedica Scandinavica 1990. Court-Brown CM. personal communication August 18 2002. ∗ McQueen MM. Checketts RG. Barber L. 28(5):422–6. Beltran J. 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Fernandez 1996 Fernandez DL. Hamalainen M. Duckworth T. Flinkkila 1998 Flinkkila T.CD000314] Handoll 2003c Handoll HHG. Journal of Bone and Joint Surgery . Evaluation of healed Colles’ fractures. Frykman 1967 Frykman G. Orthopedic Clinics of North America 1993. Mancini GB. Faldini C. AO and Frykman’s classifications of Colles’ fracture. Outcome assessment in hand surgery and hand therapy: an update. The wrist. Scandinavian Journal of Surgery 2004. Cast vs external fixation: a comparative study in elderly osteoporotic distal radial fracture patients. Carr AJ editor (s). Linscheid RL. Clinical Orthopaedics and Related Research 2006. Cochrane Database of Systematic Reviews 2003. BMC Musculoskeletal Disorders 2003. Altman 2003 Altman DG.References to studies awaiting assessment Moroni 2004 {published data only} Moroni A. Raatikainen T. Josefsson PO. No prognostic value in 652 patients evaluated after 5 years.70(2):116–8. Cooney 1993 Cooney WP. Acta Orthopaedica Scandinavica 1998.com/ceweb/about/guide. 4th Edition.American Volume 1951. Dobyns JH. Cochrane Database of Systematic Reviews 2003. Epidemiology of osteoporosis and osteoporotic fractures.(206):202–10. Published by John Wiley & Sons. A practical approach to management.24(2):327–31. Handoll 2003b Handoll HH. . Jupiter JB. Orthopedic Clinics of North America 1993. Handoll 2003a Handoll HH.93 (1):64–7. 27 Additional references Ahlborg 1999 Ahlborg HG. Axelrod 1991 Axelrod TS. Andersen 1996 Andersen DJ. Surgical interventions for treating distal radial fractures in adults (Cochrane review). Conservative interventions for treating distal radial fractures in adults (Cochrane Review). Cummings 1985 Cummings SR. External fixation techniques for distal radius fractures.British Volume 1989. No. Fractures of the distal radius. Long-term results of conservative treatment of fractures of the distal radius. New York: Springer-Verlag. Hess AV. Gartland 1951 Gartland JJ. Journal of Orthopaedic Trauma 1991. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radius fractures [letter. Complications of Colles’ fractures. Clinical Orthopaedics and Related Research 1986. Pederson WC editor(s). Steyers CM Jr.62(4):613–9. Giannini S. Brandser EA. Clinical Evidence Online http:// www. Journal of Hand Therapy 2001. Epidemiologic Reviews 1985. comment] [see comments]. Interaction revisited: the difference between two estimates.[Art. Journal of Hand Surgery . Antenucci R. DOI: 10. Acta Orthopaedica Scandinavica 1999. Fernandez 1999 Fernandez DL. In: Green DP. Concomitant skeletal and soft tissue injuries. Palmer AK. Madhok R. Algodystrophy following Colles’ fracture.108:3–153. Fractures of the distal radius. Bland JM.7:178–208. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility.jsp (accessed 24 March 2006). Pegreffi F.14(2):63–7. Kelsey JL. 1st Edition. Atkins 1989 Atkins RM. O’Dowd KJ. Amadio 2001 Amadio PC. Vannini F. Capo 2006 Capo JT. Nevitt MC. Classification of musculoskeletal trauma. Fiacca C. Swan KG Jr. Ltd. Green’s Operative Hand Surgery. Adams BD.326(7382):219.14 (2):161–4. Journal of Hand Surgery .5(1):114–5. Madhok R.33(4): 895–910.clinicalevidence. Journal of Bone & Joint Surgery . Fairbank JC. Cooney 1980 Cooney WP 3rd. 1996. Belsole 1993 Belsole RJ. 1999: 929–85. In: Pynsent PB. Fractures of the distal radius. Chitnavis 1999 Chitnavis J. Blair WF. Altissimi 1986 Altissimi M. Atkins 2003 Atkins RM. Aspects of current management: Complex regional pain syndrome. Issue 2. Werley CW. A modern treatmentbased classification. 1999:146–70. 445:30–41.: CD000314.4 (27).American Volume 1996. el Khouri GY.21(4):574–82. Madhok R.American Volume 1980. A clinical and experimental study.85(8):1100–6. disturbance in the distal radioulnar joint and impairment of nerve function. BMJ 2006 A guide to the text. Kanis JA. From evidence to best practice in the management of fractures of the distal radius in adults: working towards a research agenda. Acta Orthopaedica Scandinavica Supplementum 1967. New York: Churchill Livingstone.British Volume 2003. Hotchkiss RN.1002/14651858.24 (2):211–6. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Journal of Bone and Joint Surgery . Pin-tract complications in external fixation of fractures of the distal radius. Tan V. Oxford: Butterworth Heinemann.69(1):77–81. Fracture of the distal radius including sequelae-shoulder-hand-finger syndrome. Issue 3. BMJ 2003.

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Ltd. Bone 2001. Dennison EM.63(8): 1285–8. Leufkens HG. Published by John Wiley & Sons.American Volume 1981. 29 . Epidemiology of fractures in England and Wales. ∗ Indicates the major publication for the study External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Cooper C.Journal of Bone & Joint Surgery .29(6): 517–22. Van Staa 2001 Van Staa TP.

overall grading (Lidstrom 1959) including activities of daily living. 4.CHARACTERISTICS OF STUDIES Characteristics of included studies [ordered by study ID] Abbaszadegan 1990 Methods Method of randomisation not stated Assessor blinding: not reported Intention-to-treat analysis: possible (5 in POP group analysed separately but data given) Loss to follow up: 1 died in Ext-fix group Teaching hospital. pain. 8. Published by John Wiley & Sons. Pain (VAS 0 to 10: worst). grip strength. but after X-ray examination (1) External fixation: closed reduction under local anaesthesia. patient consent Exclusion criteria: age > 75 years. transient sensory disturbance of the superficial radial nerve. Sweden 47 participants Inclusion criteria: “severely displaced Colles’ fracture”. neuromuscular disturbance or warfarin treatment Classification: Older (type 3 and 4) (extra. (3) Anatomical: X-ray initially. pin loosening (none). radial deviation. then below elbow plaster cast for 4 weeks (mean 31 days) Length of follow up: 1 year. after 10-12 days. Five in plaster group required remanipulation and had external fixation. (1) Functional: subjective function (VAS: 0 to 10: normal).75 years Assigned: 23/24 [Ext-fix / POP] Assessed: 22/24 (at 1 year) Timing of intervention: not stated. Radial shortening and dorsal angulation. 12 and 24 weeks. Separate data were provided for this group. pin track infection (all resolved).Unclear External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B . 30 . Fixator removed at 4 weeks (mean 31 days) (2) Conservative treatment: closed manipulation under local anaesthesia. ulnar deviation. range 22 . temporary dorsal plaster cast. Ltd. mental incapacity. External Hoffman fixator applied at 1 to 3 days under regional anaesthesia: 2 pins inserted through 1 cm skin incision through middle of second metacarpal and 2 pins in radius. also assessed at 10-12 days. forearm rotation). range of movement (flexion. osteomyelitis (none). addicts.and intra-articular) Sex: 36 female Age: mean 63 years. loss of motion and deformity. displaced (= or > 5 mm radial shortening) distal radial fracture (Older type 3 and 4). 4 and 8 weeks. at reduction. extension. (2) Clinical: complications: redislocation resulting in secondary external fixation.

radial deviation. residual deformity and complications. transient neuropraxia. pin track infection. dorsal angulation. RSD. Length of follow up: 1 year. radial inclination. Age 55 to 80 years. Published by John Wiley & Sons. radial deviation of hand.Hegeman 2004 Methods Randomised by random selection of envelopes containing a piece of paper with the treatment allocation Assessor blinding: not reported Intention-to-treat analysis: likely Loss to follow up: probably none Teaching hospital. ulnar variance. Exclusion criteria: previous distal radial fracture or unable to perform functional evaluation Classification: AO (type C2 or C3) (all intra-articular) Sex: 29 female Age: mean 70 years Assigned: 15/17 [Ext-fix / POP] Assessed: 15/17 (at 1 year) Timing of intervention: not stated. (1) Functional: problems in daily life (lifting cup. Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B . Fixator removed after 6 weeks (2) Conservative treatment: closed manipulation then below elbow plaster cast for 6 weeks Physiotherapy started after 6 weeks. Ltd. extension. (3) Anatomical: X-ray initially. Radial shortening. but after X-ray examination (1) External fixation: reduction then application of Hoffmann II compact external fixator: 2 pins inserted into the second metacarpal and 2 pins in radial shaft. Dupuytren contracture. The Netherlands 32 participants Inclusion criteria: unstable intra-articular distal radial fracture (> 10 degrees dorsal angulation and < 20 degrees radial inclination and > 3 mm positive ulnar variance) (AO C2 or C3). swollen thumb). (2) Clinical: complications: “complications of plaster immobilisation” (loose plaster. heavy load bearing). also assessed at 6 weeks. and all follow-up times.Unclear External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. pronation. after treatment. wringing. and 3 and 6 months. Pain (in joints). grip strength (hand and index finger). Intra-articular alignment: step off. supination). range of motion. 31 . Deformity: prominent dinner fork deformity. overall grading (Gartland 1951) including subjective evaluation of impairment. fine hand co-ordination. range of movement (flexion. Details on method of randomisation and plaster cast complications received from Dr Hegeman on 10 October 2006. ulnar deviation.

(Implied Colles’ fractures. Published by John Wiley & Sons. also assessed at 1 and 5 weeks. Informed consent.91 years Assigned: ?/? [Ext-fix / POP] Assessed: 15/14 or 16/13 (see notes) (at final follow up 4-15 months) Timing of intervention: not stated but after presentation at fracture clinic. The two measures of displacement: dorsal displacement and radial displacement (Van der Linden 1981) are not in common use and prevent comparison with other trials. (1) Functional: overall grading (not referenced but seems to be Stewart 1985. Abstract (Devane 1988) gives an inconsistent report of trial: 34 patients. radial/median neuritis) measures. modification of Gartland 1951) including subjective (pain. and final follow-up.) Exclusion criteria: none stated Classification: Frykman (included Frykman 1. for 5 weeks. 2. New Zealand 37 participants Inclusion criteria: displaced fractures of the distal radius judged as requiring reduction by resident on call. RSD (none) (3) Anatomical: X-ray initially. minimum 6 months followup.Horne 1990 Methods Method of randomisation not stated Assessor blinding: not reported Intention-to-treat analysis: no. patients in the surgical group were admitted to a day-care facility. (2) Clinical: complications: remanipulation (none). (1) External fixation: closed reduction under ischaemic arm block then modified AO tubular external fixator for 5 weeks: 2 pins placed at right angles in 2nd metacarpal. Response from Horne did not address these issues. “Stab incisions” of pins. Highly critical letter from Axelrod 1991. Participants Interventions Outcomes Notes Risk of bias Item Authors’ judgement Description External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. baseline information or interim results not given for 8 participants. Numbers at final follow up in each group varied in the main trial report (15/14 or 16/13). disability. movement limitation) and objective (range of movement. finger flexion. 32 . Physiotherapy afterwards if wrist or hand stiffness. Ltd. 3. discrepancies in numbers followed in the two groups Loss to follow up: 5 lost and 3 dead by final follow up (4 to 15 months) Teaching hospital. Comments on entry criteria (how displaced were the fractures?). grip strength. external fixation group held reduction significantly better. some correlation between radiological result and functional outcome.and intra-articular) Sex: not given Age: of 29 analysed. 2 pins placed at right angles into dorsoradial aspect of distal radius. mean 72 years. (2) Conservative treatment: closed reduction under ischaemic arm block then below-elbow backslab. activity restriction. advised small open incisions instead of percutaneous pinning. at reduction. 4. range 61 . Dorsal displacement and radial displacement (Van der Linden 1981). Age > 60 years. 5 and 8) (extra. length of follow up. radial nerve neuritis (26%). no mention of radial nerve irritation. pin track problems (21%). 1015 degrees palmar flexion and ulnar deviation. Length of follow up: 4 to 15 months.

radial shift. Dorsal angulation. 33 . 2 into radial shaft. and all follow-up times. Removed after 5 to 6 weeks. (2) Conservative treatment: closed manipulation under Bier’s block and below-elbow backslab. pin track infection. Published by John Wiley & Sons. patient satisfaction. Slight discrepancies between the two abstracts in the numbers lost to follow up at 10 years and final functional result for the fixation group. ulnar nerve compression. Fixator locked after reduction (under image intensifier). Plaster cast for 5 to 6 weeks. completed next day (remanipulation if initial reduction was unsatisfactory). surgery was usually done on the next available trauma list. radial shortening and radial deviation. 10 years follow up reported in two separate abstracts (Freeman 1998. Freeman 2000). 5 and 13 weeks and 6 months.Unclear Method of randomisation not stated Assessor blinding: not reported. also assessed at 1. radiological deformity (Dias 1987). All had physiotherapy afterwards. (2) Clinical: complications: remanipulation. finger flexion. radial/median neuritis) measures. activity restriction.25 years). radial nerve neuritis. 2. (1) Functional: overall grading (Gartland 1951. at reduction. Sudeck’s atrophy (none). osteoarthritis. osteoarthritis (3) Anatomical: X-ray initially. Stewart 1984) including subjective (pain.Horne 1990 (Continued) Allocation concealment? Howard 1989 Methods Unclear B . independent assessment of functional and 10 year radiological outcome Intention-to-treat analysis: likely Loss to follow up: 6 (or 7) lost and 4 dead at 10 years General hospital. (1) External fixation: medium-C Hoffman external fixator: 2 pins inserted into middle of 2nd and 3rd metacarpals. tendon (EPL) rupture. movement limitation) and objective (range of movement. arthritis (Knirk and Jupiter 1986) Anatomical results presented graphically in main paper. UK 50 participants Inclusion criteria: severely displaced (30 degrees of dorsal angulation or over 10 mm radial shortening) comminuted Colles’ fracture Exclusion criteria: age > 75 years Classification: not stated (intra-articular definitely included) Sex: not given (both sexes) Age: mean 47 years Assigned: 25/25 [Ext-fix / POP] Assessed: 21/19 (or 21/18) (at 10 years) Timing of intervention: not stated. Cosmetic appearance. fixator distraction increased. Participants Interventions Outcomes Notes Risk of bias Item Authors’ judgement Description External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. disability. Overall anatomical score (Stewart 1984). grip strength. Length of follow up: 10 years (mean 10. but probably soon after hospital admission. median nerve compression. Ltd.

and intra-articular) Sex: not given Age: mean 44 years Assigned: 84/69 [Ext-fix / POP] Assessed: 68/56 (13+ months) Timing of intervention: probably reduction at fracture clinic. and 1 and 13 months post union. Wrist usually mobile but no physiotherapy. UK 153 participants Inclusion criteria: displaced distal radial fracture (Colles’ fractures) requiring manipulation. There was no formal physiotherapy. Length of follow up: 13 months (12 months after union). Two proximal Kirschner wires at right angles into radial shaft (stab incisions) and 2 distal wires at right angles transfixed comminuted distal fragments. pin track infection. (1) External fixation: closed reduction and usually overnight hospital admission (tended to be day cases later on in trial) for AO/ASIF external mini-fixator (in ’Z’ or box configuration) application under general anaesthesia. completed at 1 week. (2) Conservative treatment: closed manipulation under intravenous sedation. RSD (2/24 of the POP group had shoulder-hand syndrome in the 1987 report) (3) Anatomical: measured at post reduction. including 17 with follow up < 12 months after fracture union. radial length. osteomyelitis. Overall and changes in anatomical grading (Stewart 1985) 34 Participants Interventions Outcomes External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Cast removed after 4 weeks. Overall grading (Stewart 1985. modification of Sarmiento) including subjective and objective outcomes. Ltd. serious infection (recurrent and deep). 3 allocated external fixation (2 had premature removal of fixator due to recurrent infections and 1 had an iatrogenic radial shaft fracture) and 4 allocated plaster casts who were given external fixation after remanipulation. ulnar nerve problems (none).Unclear Randomised by date of birth Assessor blinding: not done Intention-to-treat analysis: problems including disparities in reported inclusion criteria and 24 excluded from analyses. Insertion under image intensified using a power drill. Loss to follow up: 29 (including 24 exclusions) Teaching hospital. mass grip strength. then dorsal plaster slab. premature frame removal. age < 65 years (or < 60 years in journal publications: see Notes) Exclusion criteria: radiographic evidence of osteoporosis Classification: Frykman (extra. Crepe bandage and mobilisation. supination) . Immobilisation increased by one week if non-union at 4 weeks. unstable distal radial-ulnar joint restricting supination* (2 of 3 had reconstructive surgery. extension. sensory changes in superficial radial nerve (11 of which 2 permanent in Ext-fix group). Dorsal angulation. radial and ulnar deviation. (1) Functional: range of movement (flexion. radial shortening. Fixator removed after 4 weeks. unilateral. (2) Clinical: complications (* = no data given for POP group): remanipulation (4 in POP group in Masters thesis but 6 in 1988 report). external fixation on day of injury or next day. also assessed at 1 and 4 weeks and 2 and 4 months. pronation. pin site fracture (radial shaft). Published by John Wiley & Sons. .Howard 1989 (Continued) Allocation concealment? Jenkins 1989 Methods Unclear B . union (4 weeks). median nerve compression (none).

the results presented in this thesis replaced those presented previously. but acute injury. Risk of bias Item Allocation concealment? Authors’ judgement No Description C . Range of movement (flexion. Published by John Wiley & Sons. supination). this trial was reported as 2 trials: Jenkins 1987 and Jenkins 1988. (2) Clinical: complications: redisplacement (not enumerated). rather than exactly 12 months from union. pin track infection. Exclusion criteria: not given Classification: Frykman 3. objective evaluation. then mobilisation. Dorsal or volar displacement. in the first version of the overall review. Fixator removed 6-7 weeks. India 61 participants (in review comparison: see Notes) Inclusion criteria: acute displaced intra-articular distal radius fracture. Another is that there were 6 remanipulations in the POP group registered in the 1988 report but only 4 (all leading to external fixation and subsequent exclusion from the analyses) in the thesis. 4. also assessed at 1 week and 6 to 7 weeks (certainly Ext-fix and POP groups). (2) Conservative treatment: closed reduction and plaster cast. finger 35 Participants Interventions Outcomes External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. There were several inconsistencies noted between the various trial reports. (1) Functional: overall grading (Sarmiento 1975) including subjective evaluation. and complications. Ltd. loss to follow up deduced from paper Loss to follow up: 20 (at 4 years) Teaching hospital. CTS (resolved). 7 & 8 (and AO) (intra-articular) Sex: 15 female Age: mean 39 years (of 90) Assigned: 28/33 [Ext-fix / POP] Assessed: 18/23 (at 4 years) Timing of intervention: not stated. ulnar deviation. pronation. Immobilisation for 6 to 7 weeks. radial deviation.Inadequate Kapoor 2000 Methods Method of randomisation not stated Assessor blinding: not reported Intention-to-treat analysis: not known. 2 into radius shaft. One is that the upper age limit was stated to be 60 years in the journal publications and 65 years in the thesis. In Handoll 2003a. extension. Length of follow up: average 4 years. Splint for 2 days after removal of fixator. It is likely that the date of last follow up was set up as at least 12 months from union. (1) External fixation: Roger and Anderson external frame fixator: 2 pins into 2nd and 3rd metacarpals. Remanipulated once if necessary. . Similarities were noted and we suggested that there may be shared patients. This was confirmed on communication with the lead trialist who indicated that these were both “pilot studies” in an overall larger study which formed his Masters thesis. residual deformity. adult.Jenkins 1989 (Continued) Notes Initially. Patients encouraged to use limb (eating etc) and rotate forearm. and some participants may have been followed up for 3 years.

Overall grading (no reference) Notes Trial with 90 participants had 3 intervention groups.and intra-articular) Sex: 74 female Age: mean 53 years Assigned: 54/59 [Ext-fix / POP] Assessed: 44/41 (at 2 years) Timing of intervention: within 1 week of injury. (2) Conservative treatment: closed reduction under haematoma block (and fluoroscopy). Residual cosmetic deformity (3) Anatomical: X-ray at reduction. articular step off. Classification: AO (extra. Discrepancies between functional grading in Table 2 and account in report abstract. reduced to short arm cast at 3 to 4 weeks. Ltd. Splint converted to long arm cast within 14 days. Fixator removed between 6 to 8 weeks. definitive treatment could not be administered within 1 week. and wrist exercises post immobilisation. Radial shortening. Skeletally mature. Optional wires removed 4 to 6 weeks.reduction repeated if necessary. . detectable step or gap at joint surface. Canada 113 participants Inclusion criteria: displaced distal radial fracture with metaphyseal comminution but without joint incongruity.Unclear Participants Interventions External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. other significant system injuries. Open fracture. mentally incompetent. Exclusion criteria: comminution > 1/3rd the anterior-posterior diameter of radius. dorsal tilt > 10 degrees. associated ipsilateral extremity injuries.Kapoor 2000 (Continued) stiffness (all resolved). Stable congruous joint. small T-plates or both. unable to write in English. not fit for surgery. All participants received 36 Authors’ judgement Unclear Description B . Risk of bias Item Allocation concealment? Kreder 2006 Methods Randomised by sealed opaque sequentially marked envelopes based on computer-generated random number sequences Assessor blinding: no (although independent research assistants) Intention-to-treat analysis: likely Loss to follow up: 28 3 teaching hospitals. aged 16 to 75 years. 70% of the whole trial population had fractures resulting from a road traffic accident. removed 6 to 8 weeks. Excluded from this review are the 29 participants receiving open reduction and internal fixation using Kirschner wires. history of previous wrist fracture. Additional (in 19 cases) smooth Kirchner wires inserted from the radial styloid or dorsum of the radius across the fracture fragments at surgeon’s discretion. Application of the small spanning AO fixator: 2. volar angulation. and probably other times (see above). congenital anomaly or other severe wrist problem. Published by John Wiley & Sons. Patient consent. (1) External fixation: closed reduction under regional anaesthesia. then long arm splint with wrist in neutral and elbow at 90 degrees . Finger exercises during fixator or cast use.5 mm pins into 2nd metacarpal and 4 mm pins into radius via 1 cm skin incision. dorsal tilt. RSD (resolved).

pad and chuck strengths. supination). pin track infection. (2) Clinical: complications: secondary treatment resulting from redisplacement (open reduction and internal fixation for I Ext-fix and external fixation for 5 POP). Classification: Frykman (5 to 8) (intra-articular) Sex: 30 female Age: mean 58 years. (1) External fixation: light (in weight) non-cylindrical AO external fixator. extension. Job change because of injury. 4 and 6 weeks. range of movement (flexion. (2) Conservative treatment: cylindrical below elbow plaster cast for 6 weeks. (3) Anatomical: X-ray at reduction. Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A . Ltd. Five in POP group who received secondary external fixation were analysed separately. and other times up to 6 months (see above). radial shortening and palmar tilt restoration. range 45 . Union. also assessed at 1. superficial infection. Further details of method of randomisation and rehabilitation received from Julie Agel on 10 October 2006. grip. Immobilised for 6 weeks. 37 Participants Interventions External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. deep infection.Kreder 2006 (Continued) supervised physiotherapy [until maximum range of motion was achieved]. 10+ degrees dorsal or 10+ degrees radial angulation of the radius) distal intra-articular Colles’ fracture involving distal radio-ulnar joint. Age 45 to 75 years. radial deviation. pinch. 3. No mention of method of reduction. Some percentages in Table 1 in the trial report giving baseline data and results did not correspond to stated numbers available at baseline or at follow up times.72 years (of 33) Assigned: 18/17 [Ext-fix / POP] Assessed: 16/15 (at 2 years) Timing of intervention: not stated. RSD. Published by John Wiley & Sons. data from the 5 males in the Ext-fix group also remove from the analyses of grip strength Loss to follow up: 2 (excluded) Teaching hospital. Outcomes Length of follow up: 2 years. .Adequate Lagerstrom 1999 Methods Randomised using computer. “within 6 unit blocks” Assessor blinding: not reported Intention-to-treat analysis: problems including 2 exclusions. 2. and 6 and 12 months. distal radial ulnar joint instability (one Ext-fix had ulnar styloid repair). (1) Functional: Musculoskeletal Function Assessment (upper extremity) and SF-36 (bodily pain domain) questionnaires. Feasible to use plaster cast or external fixator Exclusion criteria: medical conditions or language difficulties that might interfere with outcome. ulnar deviation. pronation. Jebsen Taylor hand function (Jebsen 1969). Sweden 35 participants Inclusion criteria: displaced (3+ mm radial shortening.

(2) Clinical: complications: redisplacement requiring treatment change. then forearm cast for 6 weeks.Unclear Participants Interventions Outcomes External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. This group was analysed separately. flexion and extension).86 years (of 120 patients) Assigned: 30/30/30 [Ext-fix / Ext-fix with early mobilisation / POP] Assessed: 28/26/28 (at 1 year) Timing of intervention: under 2 weeks from injury (1) External fixation: closed reduction and Pennig external fixator. Ball joint locked. all in the external fixation group. (3) Conservative treatment: closed manipulation. CTS. Published by John Wiley & Sons. Five in POP group required remanipulation and had external fixation. (1) Functional: activities of daily living (own scale). pain (VAS 0 to 10: no data). Two pins inserted into 2nd metacarpal and 2 into radial shaft using an open technique. > 2 weeks from injury to recognised instability. dorsal medial 38 Authors’ judgement Unclear Description B . (3) Anatomical: no information. range of movement (overall. (1) Functional: grip strength. (2) External fixation: as above (1) but release of ball joint of fixator at 3 weeks to allow wrist movement. Ltd. mass grip strength. mental incapacity Classification: AO (A and C) (extra-articular and intra-articular) Sex: 81 female Age: mean 63 years. . Outcomes Length of follow up: 2 years. Separate analyses were also undertaken for the 5 male patients. and pain during grip measurements. Length of follow up: 1 year. malunion. Notes Risk of bias Item Allocation concealment? McQueen 1996 Methods Randomised by closed envelopes Assessor blinding: not reported Intention-to-treat analysis: likely Loss to follow up: 8 (at 1 year) Teaching hospital. displaced articular fragments requiring open reduction. Redisplacement with 10 days. also assessed at up to 10 days.Lagerstrom 1999 (Continued) Physiotherapy started soon (same day or next day) after fracture had been immobilised. 6. range 16 . in both groups. 3 and 6 months. (2) Clinical: complications: recurrent instability. refracture. other grips. pin track infection. Fixator removed after 6 weeks. previous malunion. RSD. 10 and 18 weeks and 1 year. UK 90 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. Patients did not receive physiotherapy when the fixator was in place. also assessed at 6 weeks. Physiotherapy prescribed on “purely clinical grounds”.

Published by John Wiley & Sons. wrist appearance. pin loosening or infection (7) 39 Authors’ judgement Unclear Description B . carpal collapse. Excluded from this review are the 30 participants receiving open reduction and bone graft held in place with a single Kirschner wire. (2) Clinical: complications: redisplacement (all in POP group treated with external fixation). displaced distal radius fracture Exclusion criteria: not stated Classification: extra. Notes Trial with 120 participants had 4 intervention groups. Two half pins inserted percutaneously into the radial shaft and secured in both cortices and one pin through the thumb metacarpal at 90 degrees to the radial pins. 2. (1) Functional: overall grading (Scheck 1962: based on Gartland 1951) included subjective evaluation. In both groups. the results from 9 people allocated plaster cast but treated with external fixation after redisplacement were stated as being put into a separate group for “purposes of analysis”. (2) Conservative treatment: plaster of Paris forearm cast applied under traction with wrist in neutral position and forearm pronated.McQueen 1996 (Continued) neuropraxia (superficial radial nerve?). Ltd. Dorsal angulation. (3) Anatomical: X-ray at all follow-up times.Unclear Participants Interventions Outcomes External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. migrated pin (1). Loss to follow up: 9 (at 6 months) District general hospital. which was after 5 weeks. EPL rupture (none). carpal malalignment. Early hand function was encouraged. Risk of bias Item Allocation concealment? Pring 1988 Methods Method of randomisation not stated Assessor blinding: not reported. participants attended a daily hand class before and after cast removal. radial shortening. the completed casts were split down the ulnar border. also assessed at 1. . They were presented in the surgical group for surgical complications. malunion. Grip strength. grip. All those (45) who had external fixation including 9 people allocated POP: thumb pain (9 ). wrist and finger movements. but at accident and emergency department after closed reduction via traction using finger traps under a haematoma block (1) External fixation: “bipolar fixation”.and intra-articular Sex: 61 female Age: mean 62 years Assigned: 36/39 (40 fractures) [Ext-fix / POP] Assessed: ?/? (66 available at 6 months) Timing of intervention: not stated. If necessary. radiological assessment. 5. fracture through pin hole (1). two assessors worked independently of each other Intention-to-treat analysis: No. 7 and 12 weeks. Pins incorporated into a padded forearm cast with wrist in neutral position. Length of follow up: 6 months. UK 75 participants with 76 fractures Inclusion criteria: Colles’ fracture.

Clyburn dynamic external fixator: 2 pins driven into radial diaphysis and 2 into diaphysis of 2nd metacarpal. Pin sites dressed by medical staff at weekly intervals (2) Conservative treatment: closed manipulation under local anaesthesia. tendon or nerve injuries (none). Device removed after 7 weeks. claimed to be “double-blind” Assessor blinding: not stated Intention-to-treat analysis: likely Loss to follow up: probably none Teaching hospital. radial angle. RSD (Sudeck’s atrophy requiring intensive physiotherapy). (1) Functional: overall grading (Horne 1990.Pring 1988 (Continued) (3) Anatomical: X-ray at reduction. Overall grade (Stewart 1985 based on Lidstrom 1959 and Sarmiento 1975) First author listed as Merchan ECR in article. Before discharge. (1) External fixation: reduction under general anaesthesia or brachial block. external fixation on first or next day. patients were given instructions to mobilise fingers and shoulder. Spain 70 participants Inclusion criteria: comminuted intra-articular distal radial fracture. 3 and 7 weeks. Notes Risk of bias Item Allocation concealment? Rodriguez-Merchan 92 Methods Method of randomisation not stated. Authors’ judgement Unclear Description B . 1. Overnight hospital admission. thus probably based on Stewart 1985) based on subjective and objective outcomes. pin loosening. (2) Clinical: complications: remanipulation (offered).Unclear Preliminary results presented at a conference (Pring 1986) were for 51 participants. radial length. Frykman 3 to 8 Exclusion criteria: > 45 years Classification: Frykman (3 to 8) (intra-articular) Sex: 12 female Age: mean 36 years. Length of follow up: 1 year. Posterior splint applied for 3 weeks if joint disrupted. transverse pin inserted for 3 weeks if joint unstable. osteomyelitis (none). radial shortening. premature frame removal (none). pin breakage (none). volar angle. then forearm plaster. 2. joint infection (none). Published by John Wiley & Sons. Ltd. pin track infection. Total 7 weeks. also assessed at 1. range 20 . Dorsal angulation. 3 and 7 weeks. non-union (none) (3) Anatomical: X-ray at 1. Remanipulation at 1 week if position unacceptable. Radial length. unless problems when kept for 1 more week.45 years Assigned: 35/35 [Ext-fix / POP] Assessed: 35/35 (1 year) Timing of intervention: probably reduction on first day. Participants Interventions Outcomes Notes Risk of bias External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Journal is now American Journal of Orthopedics. 40 . 5 and 12 weeks.

on movement. under local anaesthesia and treated with plaster backslab. (1) Functional: overall grading by de Bruijn 1987 and Lidstrom 1959 systems. radial angle and radial shift. EPL rupture. Cosmetic appearance: specially not noted.see above General hospital. CTS (no data). Also volar angle. pin track infection (none). which we assume was completed to a forearm plaster cast.Unclear Method of randomisation not stated Assessor blinding: not reported Intention-to-treat analysis: not known. (2) Clinical: complications: pin loosening. (3) Anatomical: X-ray post re-MUA and on removal of plaster cast or external fixator. > 55 years Assigned: ?/? reported 21/22 [Ext-fix / POP] Assessed: 21/22 (6 months) Timing of intervention: all patients had initial fracture reduced. RSD (serious RSD: 2/1). Ltd. pain (at rest. Allocation at 2 weeks if fracture redisplaced (see inclusion criteria). A third group of patients who did not have redisplacement at 2 weeks were also followed up. (1) External fixation: fracture remanipulated under regional anaesthesia and Ace Colles external fixator applied for 5 weeks (2) Conservative treatment: forearm plaster cast continued for a further 5 weeks Length of follow up: 6 months. Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B . Seen 1. Age > 55 years (all intra-articular) Exclusion criteria: not stated Classification: Frykman and Sarmiento (intra-articular) Sex: not given (predominantly female) Age: not given.Unclear External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. The Netherlands 43 participants followed up Inclusion criteria: redisplaced Colles’ fracture with dorsal angulation > 10 degrees or radial shortening > 5 mm. also assessed post manipulation and 5 weeks on removal of plaster cast or fixator. radial shortening. Overall grading Lidstrom 1959 and Sarmiento 1980. 41 . tenosynovitis (no data). Lost to follow up: not known . within 6 hours of injury. 7 and 14 days.Rodriguez-Merchan 92 (Continued) Item Allocation concealment? Roumen 1991 Methods Authors’ judgement Unclear Description B . on ulnar pressure). but some of the 19 patients who had died (2) or were lost to follow up (17) from the original study group may have belonged to the randomised trial. Published by John Wiley & Sons. grip strength.

Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement No Description C .Stein 1990 Methods Randomised by day of hospital admission Assessor blinding: not reported Intention-to-treat analysis: not known Lost to follow up: not stated. usually for 6 weeks. perhaps none Teaching hospital. Length of follow up: 6 months to 4 years (mean 3 years).79 years Assigned: 40/22 [Ext-fix / POP] Assessed: 40/22 Timing of intervention: not stated but after presentation at fracture clinic. (1) Functional: overall grading split by subjective (pain. Dorsal angulation. Published by John Wiley & Sons. (2) Conservative treatment: closed reduction then above-elbow plaster cast with the forearm in pronation. participants of the surgical group were either admitted into hospital for 24 hours or to a day-care facility. RSD (3) Anatomical: X-ray initially and at all follow-up times. grip strength. also assessed at 1. breakage (none). Fractures reduced under regional or general anaesthesia. Overall grading of deformity (Van der Linden 1981). superficial radial nerve irritation (temporary). Results for another 64 patients with extra-articular fractures were treated with an above-elbow plaster cast were also presented in the trial report. 2. Exclusion criteria: none stated Classification: Older (type 3 and 4) (all intra-articular) Sex: not given Age: mean 50 years. osteomyelitis (none). Israel 62 participants Inclusion criteria: displaced comminuted distal radial fracture (Older type 3 and 4: Colles’ fracture). radial shortening. 42 . range 19 . pin loosening. inability to return to previous activities) and objective results using Gartland 1951. Ltd. deformity. radial angulation and shift.Inadequate External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. (1) External fixation: closed reduction then the “small” AO external tubular fixator. usually for 6 weeks: 2 pins placed in 2nd metacarpal. Shortening of distal radius 1 to 4 mm below distal ulna (Older type 3) or greater. 4 and 6 weeks. these were not part of the trial. pin track infection (all resolved). 2 pins placed into radial shaft. (2) Clinical: complications: remanipulation. However.

43 . radial shift. range 16 . dorsal angulation > 10 degrees. Radial shortening. The trial appeared as Young 2002 in Handoll 2003a. 2. osteoarthritis (signs: just one with symptoms).Young 2003 Methods Randomised using closed envelopes Assessor blinding: not reported (independent physiotherapist at 7 years) Intention-to-treat analysis: losses accounted for. malunion. Miss Young provided copies of the drafts of 3 papers. Ltd. unilateral. These include the general use of medians in the published report and the exclusion of data for one person with rheumatoid arthritis. also assessed at 1. extension. Use of wrist splint. radial and dorsal angulation. submitted for journal publication. For Handoll 2003a. remanipulation. age 16 . flexion. There are differences in presentation between the draft and published reports of the 7 year results. EPL tendon rupture. pre-operatively at reduction and all the above times. Pins inserted percutaneously into 2nd metacarpal and under direct vision into the radial shaft. Published by John Wiley & Sons. die punch fractures. and as Nanu 1994 in first version of that review.75 years Exclusion criteria: bilateral fracture. supination. (1) Functional: difficulties in two aspects of activities of daily living. 6 and 9 weeks. Persistent wrist pain (1 in conservative group had rheumatoid arthritis at 7 years). 6. Participants Interventions Outcomes Notes Risk of bias Item Authors’ judgement Description External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. (Late decision to exclude data for a person with rheumatoid arthritis) Loss to follow up: 39 (at 7 years) General hospital. radial nerve neuropathy. RSD (including 1 versus 3 persistent at 1 year. Time to return to normal activities and work. 12 and 18 months and 2 years. unsightly forearm scars (from external fixator) (3) Anatomical: X-ray initially. UK 125 participants Inclusion criteria: displaced Colles’ fracture. Malunion. median nerve neuropathy. then completed to full below-elbow plaster cast at 1 week and removed at 6 weeks Length of follow up: 7 years (mean 7. radial shortening > 2 mm. fixator removed at 6 weeks (2) Conservative treatment: manipulation under regional or general anaesthesia and application of below elbow plaster backslab. unable to understand purpose of study Classification: Frykman (extra-articular and intra-articular) Sex: 97 female Age: mean 57 years. and also provided answers to further queries.75 years Assigned: 59/66 [Ext-fix / POP] Assessed: 48/60 (at 1 year).8 years). Distal ball joint unlocked at 3 weeks. associated fractures of ipsilateral limb. grip strength. pin site infection (all superficial). Overall grades (Gartland 1951) at 7 years. 36/50 or 36/49 (at 7 years) Timing of intervention: not stated (1) External fixation: manipulation and application of bridging Pennig dynamic fixator under general anaesthesia. and 1 versus 0 at 7 years). multiple injuries. Patient satisfaction. range of movement ( pronation. (2) Clinical: complications: redisplacement by 2 weeks. 3. Osteoarthritis (Knirk 1986) The full publication of the 7 year results is new to this review and is the first full report of this trial previously only reported in abstracts. radial and ulnar deviation) from 9 weeks onwards.

then. (1) Functional: overall grading (Sarmiento 1975) including subjective evaluation of activity restriction and pain. Then application of small size Zhongjia SGD-type unilateral multifunctional external fixator: 2 pins inserted through skin incisions (0.Unclear Randomised by admission number Assessor blinding: not reported Intention-to-treat analysis: not known Lost to follow up: not stated. elbow and shoulder from week 2. wrist joint mobilisation and strengthening activities from week 4. after treatment. Published by John Wiley & Sons. slight extension and ulnar deviation or volar flexion (opposite to the direction of the injury). Functional training was done before and after removing the cast. position changed after 2 weeks to “medial”. Fixator made dynamic and K-wire removed from week 4. Ltd. China 29 participants Inclusion criteria: closed unstable distal radial fracture Exclusion criteria: none stated Classification: Universal classification (Cooney) IIB. IVB. Kirschner wire added if fracture was still unstable. Fixator removed after 6 weeks. finger. Anatomical assessment (Stewart 1984). (1) External fixation: closed (5 participants) or open (7 participants) reduction under brachial plexus block.Young 2003 (Continued) Allocation concealment? Zheng 2003 Methods Unclear B . IVC (intra-articular) Sex: 14 female Age: range 18 . injured superficial radial nerve. Participants were either outpatients or inpatients. also assessed at 2 and 6 weeks. objective evaluation of function. and all follow-up times. range of motion (loss of flexion or extension rated) and grip strength. Immediate functional training finger mobilisation.7 cm) into the second metacarpal and 2 pins through skin incisions in radial shaft.52 years Assigned: 12/17 (if none lost to follow up) [Ext-fix / POP] Assessed: 12/17 (at 1 year) Timing of intervention: not stated. radial shortening. probably none Military (police) hospital. (3) Anatomical: X-ray initially. . (2) Conservative treatment: manual reduction under haematoma block with X-ray monitoring. carpal tunnel syndrome.Inadequate 44 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. ulnar angulation Translated from Chinese by Xiaoyan Chen Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement No Description C . IIC (extra-articular). Cast removed after 6 weeks. volar angulation. Plaster of Paris short-arm (forearm) cast applied. (2) Clinical: complications: loosened nail. Length of follow up: 1 year. Wrist fixed in medial position.

British Volume 1987. Sinclair WF. Journal of Bone & Joint Surgery . Functional treatment of Colles fracture. Functional bracing of Colles’ fractures: a prospective study of immobilization in supination vs. Insufficient information to include. Includes patients from a randomised trial of conservative treatment but the patients in the external fixator group were not randomised. Acta Orthopaedica Scandinavica Supplementum 1959. 45 Kongsholm 1989 Solgaard 1989 Sprenger 1988 van Dijk 1996 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 69(3):463-7. *Dias 1987 Dias JJ. Fractures of the distal end of the radius. A clinical and statistical study of end results. *Sarmiento 1975 Sarmiento A.<: less than >: more than AO: Arbeitsgemeinschaft fur Osteosynthesefragen / Association for the Study of Internal Fixation (or ASIF) CTS: carpal tunnel syndrome DISI: dorsal intercalated segment instability EPL: extensor pollicis longus (tendon) Ext-fix: external fixation hypoaesthesia: decrease in sensation K-wires: Kirschner wires paraesthesia: numbness. pronation. 146:175-83. Not a randomised comparison. Use of historic controls. Jones JM. Published by John Wiley & Sons. Quasi-randomised trial (60 participants) reported only in an abstract. Journal of Bone & Joint Surgery . Characteristics of excluded studies [ordered by study ID] Christensen 2001 Not a randomised comparison. Functional bracing in supination. The value of early mobilisation in the treatment of Colles’ fractures. “pins and needles” sensation POP: plaster of Paris ROM: range of movement (wrist and forearm) RSD: reflex sympathetic dystrophy VAS: visual analogue scale VISI: volar intercalated segment instability X-pins: crossed percutaneous pinning References (listed above but not in Additional references) * de Bruijn 1987 de Bruijn HP. the likelihood of getting further information or the trial ever being published seems remote. Gregg PJ. tingling. Zagorski JB. 41:5-118. Pratt GW. Compares treatment with external fixation at one hospital with plaster cast at another hospital. Retrospective comparison.American Volume 1975. 223:1-95. Sinclair WF. . Clinical Orthopaedics & Related Research 1980. 57(3):311-7. Wray CC. Acta Orthopaedica Scandinavica Supplementum 1987. * Lidstrom 1959 Lidstrom A. *Sarmiento 1980 Sarmiento A. (Superior radiological results were reported for the external fixator group). Berry NC. Ltd. Colles’ fractures. Though one trialist provided brief details of the method of randomisation (alternation) and setting (emergency department).

82 [0.09 [0. Fixed. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H. Fixed. Fixed. Fixed.55. 95% CI) Mean Difference (IV.7 Heavy load bearing at 3 months 6. of studies 9 9 No. 95% CI) Risk Ratio (M-H. Fixed. 1. Fixed.2 Subjective grading: fair/ poor 4.6 Fine hand co-ordination at 1 year 6. 95% CI) Risk Ratio (M-H.74] 1. Fixed. 95% CI) Risk Ratio (M-H. 0. 95% CI) Risk Ratio (M-H.71. Fixed. Fixed. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H.55.4 Objective grading: fair/ poor 5 Upper extremity function part of Musculoskeletal Function Assessment tool (0 to 100: maximum disability) 5.3 At 2 years 6 Difficulties in activities of daily living 6. .1 Sensitivity analysis 1: worst case for plaster cast 2. Worst and best case scenarios sensitivity analyses 2. 0. Published by John Wiley & Sons. 0.25] 0. 95% CI) Risk Ratio (M-H.1 Subjective grading: not excellent 4.5 Fine hand co-ordination at 3 months 6.2 Lifting cup at 1 year 6. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H.2 Sensitivity analysis 2: best case for plaster cast 3 Functional grading: fair or poor 4 Subjective and objective functional evaluation 4. 95% CI) Risk Ratio (M-H.4 Hand wringing at 1 year 6. Fixed. Fixed. Fixed. 95% CI) Effect size 0.DATA AND ANALYSES Comparison 1. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. Fixed.1 Lifting cup at 3 months 6. 95% CI) Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable 46 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 95% CI) Risk Ratio (M-H.1 At 6 months 5. Fixed. Fixed. Fixed. Fixed. Fixed. 95% CI) 0.98] Totals not selected Not estimable Not estimable Not estimable Not estimable Totals not selected 1 1 1 2 1 1 1 1 1 1 1 1 Mean Difference (IV.73 [0.95] Subtotals only 9 9 11 2 1 2 1 2 1 610 610 612 Risk Ratio (M-H. Fixed. Fixed.64 [0. Fixed. Fixed. Fixed. 95% CI) Risk Ratio (M-H.95.8 Heavy load bearing at 1 year No.2 At 1 year 5. External fixation versus plaster cast Outcome or subgroup title 1 Functional grading: not excellent 2 Functional grading: not excellent. 95% CI) Risk Ratio (M-H.3 Hand wringing at 3 months 6.3 Objective grading: not excellent 4. of participants 521 Statistical method Risk Ratio (M-H. Ltd.

6. Fixed. Fixed. 95% CI) Not estimable Not estimable 1 1 1 1 4 4 1 1 Risk Ratio (M-H.2 Radiocarpal pain at 1 year 11.3 Pinch strength at 2 years 10 Maximal voluntary contraction: injured .5 Supination 13. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H. Fixed. 95% CI) Risk Ratio (M-H. Fixed. Random. Fixed. chuck and pinch strengths (injured . 95% CI) Totals not selected Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Totals not selected 1 1 1 1 Mean Difference (IV. 95% CI) Mean Difference (IV. Fixed. Fixed. Fixed.1 Grip strength at 2 years 9. 95% CI) Mean Difference (IV.6 Pronation 13.2 Extension 13. 95% CI) Risk Ratio (M-H.1 Flexion (degrees) 14. Random. Fixed. 95% CI) Mean Difference (IV.1 Results at 18 weeks 10. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV.1 At 6 months 7. 95% CI) Risk Ratio (M-H.uninjured side (Newtons) 10. Random.2 Results at 7 years follow up 9 Grip. 95% CI) Mean Difference (IV. Fixed. 95% CI) Risk Ratio (M-H.3 At 2 years 8 Mass grip strength (% of normal side) 8. Random.normal side) 14. Random.2 Results at 2 years 11 Persistent pain (1 year & 7 years) 11.1 Pain at rest 12.2 Chuck strength at 2 years 9. Fixed. Fixed.3 Ulnocarpal pain at 1 year 11. 95% CI) Risk Ratio (M-H.1 At 1 year 11.4 Ulnar deviation 13. Fixed.8 Overall range of movement 14 Range of movement at 2 years (injured . 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. Random. Fixed. 95% CI) Risk Ratio (M-H.3 Ulnar compression pain 13 Range of movement at 1 year (% of normal side) 13. Fixed. Fixed.3 Radial deviation 13.7 Flexion/extension 13. 95% CI) Mean Difference (IV. Fixed. Random.normal side): units not given 9. 95% CI) Mean Difference (IV.1 Flexion 13. 95% CI) Mean Difference (IV.2 Extension (degrees) 1 1 Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H. Fixed. . Fixed.2 At 1 year 7. Fixed.10 Difficulty in picking up small objects and turning door handles at 7 years 7 Job change because of injury 7.5 At 7 years 12 Pain (6 months) 12. Ltd. 95% CI) Risk Ratio (M-H. Fixed. 95% CI) Mean Difference (IV. Random. Fixed. 95% CI) Not estimable Not estimable Not estimable Totals not selected 1 1 2 1 1 1 1 1 1 1 1 1 3 2 2 1 1 1 1 1 1 1 1 1 Mean Difference (IV.9 Difficulty in turning keys or taps at 7 years 6. Fixed. Fixed. 95% CI) Mean Difference (IV. Fixed.4 Radioulnar pain at 1 year 11. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV. Random. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV. Published by John Wiley & Sons. Random. 95% CI) Mean Difference (IV. Fixed.1 Results at around 1 year 8. Fixed. Fixed. 95% CI) Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable 47 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.2 Pain on movement 12. 95% CI) Mean Difference (IV.

Fixed.1 Redisplacement / recurrent instability 17.4 Ulnar deviation (degrees) 16.68] 7. 4.01.2 Extension (degrees) 15. 33.28.5 Supination (degrees) 15. Fixed. 95% CI) Mean Difference (IV. Fixed.10 Tendon injury/rupture 17. 95% CI) Risk Ratio (M-H.3 Radial deviation (degrees) 14.5 Supination (degrees) 16. Fixed. Fixed. Fixed.02 [5. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV.9 Wound infection 17.3 Radial deviation (degrees) 15. Fixed. 19. 95% CI) Mean Difference (IV.26 [0.7 Premature frame/fixator removal 17.56] 0. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV.34] 2.50 [0.4 Ulnar deviation (degrees) 15.15] 422 694 113 32 846 433 313 332 90 339 90 32 508 3 4 2 204 291 203 Risk Ratio (M-H.49] 5. 95% CI) Risk Ratio (M-H.25 [0.39.71 [1.64 [0.54] 0.05. 95% CI) Mean Difference (IV. Fixed. 95% CI) Risk Ratio (M-H.09. Fixed. Fixed. 0.6 Pronation (degrees) 16 Range of movement at 7 years 16. Fixed. 95% CI) 2. Fixed. 1.23. 95% CI) Not estimable Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Totals not selected Not estimable Not estimable Not estimable Not estimable Not estimable Not estimable Subtotals only 0. Fixed.10.6 Pronation (degrees) 17 Complications 17.3 Distal radial ulnar joint instability 17. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. Fixed.14 Radial nerve neuritis or neuropathy 17. 95% CI) Risk Ratio (M-H.2 Redisplacement resulting in secondary treatment 17. 95% CI) Risk Ratio (M-H.13.4 Plaster cast problems (swollen thumb.32] 1.70] Not estimable 0. 59. 95% CI) Risk Ratio (M-H. Fixed. Fixed. Fixed.77.6 Pronation (degrees) 15 Range of movement at 1 year 15. 22. 3.5 Supination (degrees) 14. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H. 9. loose plaster) 17. 95% CI) Risk Ratio (M-H.34.8 Osteomyelitis 17.55 [0.1 Flexion (degrees) 16.97] External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Fixed.12 ”Transient neuropraxia” 17. 36.52 [0.2 Extension (degrees) 16.06. Fixed. 28.16 Ulnar nerve compression 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 15 5 9 1 1 11 7 3 4 1 5 1 1 6 Mean Difference (IV. Fixed. Fixed.27 [0.52] 1.01. Fixed.98.07.07 [1.13 Median nerve compression /Carpal tunnel syndrome 17. Fixed. 1. 95% CI) Risk Ratio (M-H.44] 0. Fixed.1 Flexion (degrees) 15.4 Ulnar deviation (degrees) 14. 27.47 [0. 48 .2 [0.11 ”Dorsal medial neuropraxia” 17. 6. 95% CI) Mean Difference (IV. Ltd. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV.32] 0. 95% CI) Risk Ratio (M-H. Fixed. Fixed. Fixed.5 Pin track infection 17.21. 95% CI) Mean Difference (IV. 95% CI) Mean Difference (IV. Fixed. Fixed.00] 2.15 Superficial radial nerve paraesthesia or injury 17. 95% CI) Mean Difference (IV.3 Radial deviation (degrees) 16.26] 3. Fixed. 95% CI) Mean Difference (IV. Fixed. Fixed. Published by John Wiley & Sons. Fixed. 95% CI) Risk Ratio (M-H.20 [0.14.35] 12. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H.17 [0.6 Pin loosening and other pin site problems 17. 95% CI) Mean Difference (IV. Fixed. 95% CI) Mean Difference (IV.23 [0. 0. Fixed.

Fixed.01. Fixed. Fixed. 95% CI) Risk Ratio (M-H. Fixed.3 Loss in radial length (radial shortening) (mm) at around 1 year follow up 23. Random. 0.40. Fixed.17 [0. 95% CI) Mean Difference (IV.41. 95% CI) Mean Difference (IV. 2. 95% CI) Risk Ratio (M-H.75.96 [0.6 Loss in radial displacement (mm) 24 Anatomical measurements 24. 1.11.3 Radial angulation (degrees) 24. Random.2 Malunion at 7 years follow up 11 1 1 2 1 11 9 2 2 1 1 1 1 1 5 6 5 0 1 4 731 61 32 121 35 Risk Ratio (M-H.1 Cosmetic deformity (undefined) 19. 95% CI) Mean Difference (IV. 1.53 [0. 95% CI) Risk Ratio (M-H.98] 2.31 [0. 95% CI) Not estimable 1 1 6 6 Mean Difference (IV. Fixed. Fixed. 65. 95% CI) Risk Ratio (M-H. Fixed. Random. Fixed. Fixed. Random. Fixed.47] Totals not selected Not estimable Not estimable Not estimable Not estimable Totals not selected 0.12.61] 0.34] 2. Fixed. Fixed.45.47] 198 86 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV. Fixed. Random. 95% CI) Risk Ratio (M-H.32] 0.4 Loss in radial length (radial shortening) (mm) at 7 years follow up 23. Fixed. 95% CI) Risk Ratio (M-H. 95% CI) Mean Difference (IV.58 [0.27] Totals not selected Not estimable Not estimable Not estimable 598 133 371 400 1 Mean Difference (IV. 1.2 Loss in radial angulation (degrees) 23.4 Residual dinner fork deformity 20 Patient dissatisfied with wrist 21 Anatomical grading: not excellent 22 Anatomical grading: fair or poor 23 Anatomical displacement 23. Fixed. Fixed.17. Fixed.5 Loss in dorsal displacement (mm) 23.67 [0.53. 95% CI) Mean Difference (IV. Fixed.29. 49 .1 Primary treatment 18. Fixed. 95% CI) Risk Ratio (M-H. 9.2 Dorsal angulation (degrees) at 7 years follow up 24. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. 95% CI) Not estimable Not estimable Totals not selected Not estimable 1 1 1 6 2 1 Mean Difference (IV. 0. 95% CI) Mean Difference (IV.4 Ulnar variance (mm) 25 Structural deformity 25. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H.81] 0.63 [0.2 Redisplaced fractures 19 Cosmetic deformity 19.1 Dorsal angulation (degrees) at 13 weeks to 13 months follow up 24. Random. Published by John Wiley & Sons.73 [0.1 Malunion (as defined by trialist) 25.34] Subtotals only 1. 95% CI) Mean Difference (IV. 95% CI) Risk Ratio (M-H.2 Prominent ulnar styloid 19.20 Arthritis 17.19 Dupuytren contracture 17.21 Refracture 18 Reflex sympathetic dystrophy exploratory analysis 18. 95% CI) Risk Ratio (M-H. Fixed. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H.13 [0. 95% CI) Risk Ratio (M-H.84 [0.18 Severe finger stiffness 17. Fixed. Fixed.63.74. Ltd.3 Radial deviation of hand 19.03 [0. 0. Random. 95% CI) Not estimable Not estimable Not estimable Subtotals only 0. 95% CI) 1.32] 5. 95% CI) Risk Ratio (M-H. 108. Fixed.1 Loss in dorsal angulation (degrees) 23.17 Reflex sympathetic dystrophy 17.63] 0. 95% CI) Risk Ratio (M-H. 2.

1.6 Step-off >/= 2 mm (intra-articular alignment) 25.71.8 Non-congruous joint surface for die-punch fractures 1 1 1 1 1 1 90 41 41 32 50 31 Risk Ratio (M-H.01. 1. I2 =3% Test for overall effect: Z = 2.91.40.97] Analysis 1. Fixed. Fixed. 1.3 Carpal collapse 25.68 [ 0.0079) 0.3 % 14. 1.29.95 ] Total events: 134 (External fixation).24.63] 0.68. 95% CI) Risk Ratio (M-H.25.Fixed.63] 0. 95% CI) 0. Comparison 1 External fixation versus plaster cast. Ltd. 1. 166 (Plaster cast) Heterogeneity: Chi2 = 8.10 ] 0.79] 1. 95% CI) Risk Ratio (M-H. 95% CI) Risk Ratio (M-H. 1.82 [ 0.73 [ 0. Published by John Wiley & Sons.12 ] 1. 2.5 % 11. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 1 Functional grading: not excellent Study or subgroup External fixation n/N Plaster cast n/N 16/25 16/24 11/17 8/13 41/56 21/23 23/35 9/22 21/50 Risk Ratio M-H.7 Loss in position postimmobilisation 25.74 [ 0.79 [ 0.86 [ 0.51.49 ] 0.Fixed.93 ] 0.1 0.0 % 0.14 [0. Fixed.91 [ 0. 0.82 [ 0.3 % 5. 50 .28 [0.4 % 10.40 ] Total (95% CI) 256 265 100.49.1.95% CI Weight Risk Ratio M-H.5 1 2 5 10 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 1. 1. 95% CI) Risk Ratio (M-H.31. df = 8 (P = 0.5 Volar angulation of distal fragment 25.46.23.63 [ 0.8 % 9.45] 0.4 % 27. 108.56 [ 0.64 [0.4 % 6.41).95% CI Howard 1989 Abbaszadegan 1990 Hegeman 2004 Horne 1990 Jenkins 1989 Kapoor 2000 Rodriguez-Merchan 92 Roumen 1991 Young 2003 9/25 10/22 8/15 9/16 43/68 12/18 17/35 14/21 12/36 9.55.68 ] 0. Fixed.66 (P = 0. 0.63 [0.59] 5.29.1 % 5.50.89 [0. 2.48 [0. 1.8 % 0. 1. Outcome 1 Functional grading: not excellent.02 ] 0.45.4 Dorsal tilt increase due to ”late collapse” 25. Fixed.2 0. 95% CI) Risk Ratio (M-H.17 ] 0.04 ] 0. 5. Fixed.21.

12.25 ] Total events: 184 (External fixation).6 % 13.93 ] 1.65 [ 0. 1. 1.0 % 11.0 % 0.2 0.50.93 ] 0. df = 8 (P = 0.63 ] Subtotal (95% CI) 306 304 100. Published by John Wiley & Sons. 1.2.3 % 11. 1. 1.Fixed.43.82 [ 0.38.0 % 1.74 ] Total events: 134 (External fixation).95% CI 1 Sensitivity analysis 1: worst case for plaster cast Howard 1989 Abbaszadegan 1990 Hegeman 2004 Horne 1990 Jenkins 1989 Kapoor 2000 Rodriguez-Merchan 92 Roumen 1991 Young 2003 9/25 10/23 8/15 9/16 43/84 12/28 17/35 14/21 12/59 16/25 16/24 11/17 8/13 54/69 31/33 23/35 9/22 37/66 7. Outcome 2 Functional grading: not excellent.02 ] 0.Analysis 1. 0.81 ] Subtotal (95% CI) 306 304 100.51. I2 =62% Test for overall effect: Z = 1.3 % 27.0 % 0.65 [ 0. 1.6 % 9. Worst and best case scenarios sensitivity analyses Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.91. df = 8 (P = 0. 1.74 [ 0.31.93. I2 =58% Test for overall effect: Z = 5.49.49 ] 0.29. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 2 Functional grading: not excellent. 0.26 (P = 0. 0.64 [ 0.18 [ 0.Fixed. 1. 51 .46 [ 0.49 ] 0. 0.3 % 17.21) 0.63 [ 0.91 [ 0.56 [ 0.20 ] 0. 1.46.46.36 [ 0.87. Ltd.21.89.72 [ 0.24. 1.8 % 5. 2.9 % 0.2 % 5.23 [ 0.74 [ 0.12 ] 0.02). Worst and best case scenarios sensitivity analyses.4 % 6.83 ] 0.31.50.12 ] 1.82 [ 0. 166 (Plaster cast) Heterogeneity: Chi2 = 21.02 ] 0.8 % 7.9 % 11. 205 (Plaster cast) Heterogeneity: Chi2 = 18.95% CI Weight Risk Ratio M-H. Comparison 1 External fixation versus plaster cast. 1.12 ] 1. 2.82 (P < 0.01).55.71 ] 0.95.68 ] 1.00001) 2 Sensitivity analysis 2: best case for plaster cast Howard 1989 Abbaszadegan 1990 Hegeman 2004 Horne 1990 Jenkins 1989 Kapoor 2000 Rodriguez-Merchan 92 Roumen 1991 Young 2003 9/25 11/23 8/15 9/16 59/84 22/28 17/35 14/21 35/59 16/25 16/24 11/17 8/13 41/69 21/33 23/35 9/22 21/66 9.3 % 28.68 ] 0.86 [ 1. 1.09 [ 0. 1.50 ] 1.56 [ 0.0 % 4.91 [ 0.2 % 4.5 1 2 5 10 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.49.1 0. 2.91.63 [ 0.6 % 5.9 % 13.70 ] 0.

95% CI Abbaszadegan 1990 Hegeman 2004 Horne 1990 Howard 1989 Jenkins 1989 Kapoor 2000 Rodriguez-Merchan 92 Roumen 1991 Stein 1990 Young 2003 Zheng 2003 3/22 2/15 5/16 6/25 18/68 4/18 7/35 9/21 4/40 2/36 2/12 10.98.95% CI Weight Risk Ratio M-H. 10.55.2 0.93 [ 0.15.16.1 % 13.31 [ 0.36 [ 0.07 (P = 0.4 % 3.00 ] 3. 83 (Plaster cast) Heterogeneity: Chi2 = 17.17 ] 0.9 % 18.35 [ 0.5 % 3.1 0. 2.05.12.07).65. Comparison 1 External fixation versus plaster cast.19 ] 1.76 [ 0.73 [ 0.04 ] 0.11.98 ] Total events: 62 (External fixation).Analysis 1.15. 1.86 [ 0. 4.08.34 ] 0.93 ] 1.26 ] 0.6 % 9.0 % 0.Fixed.4 % 4.5 1 2 5 10 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.1 % 0. 1. Outcome 3 Functional grading: fair or poor.039) 0.0 % 8.Fixed. Ltd. 1. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 3 Functional grading: fair or poor Study or subgroup External fixation n/N Plaster cast n/N 9/24 3/17 3/13 7/25 12/56 13/23 15/35 3/22 6/22 3/50 9/17 Risk Ratio M-H. 1.34.22. I2 =41% Test for overall effect: Z = 2.40. 52 .14 [ 0.37 [ 0.16 ] 0.63 ] 0.24 [ 0.00 ] 0. 1.3. 0.47 [ 0. 5. 3. df = 10 (P = 0.20 ] Total (95% CI) 308 304 100.3 % 3. Published by John Wiley & Sons. 2.1 % 9.5 % 16.39 [ 0.

10 ] 0.82 [ 0.95% CI Risk Ratio M-H.12. 1. Outcome 4 Subjective and objective functional evaluation.96 ] 16/68 18/56 0.37 [ 0.12.1 1 10 100 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.73 [ 0. Ltd. 0.34 ] 0. 5.01 0. Published by John Wiley & Sons.24 [ 0.68.66 ] 0. Comparison 1 External fixation versus plaster cast.16 ] 43/68 41/56 0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 4 Subjective and objective functional evaluation Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H. 53 .41.65. 1.Analysis 1. 1.10.4.30 ] 18/68 4/40 12/56 6/22 1.31 [ 0.95% CI 1 Subjective grading: not excellent Jenkins 1989 2 Subjective grading: fair/poor Jenkins 1989 Stein 1990 3 Objective grading: not excellent Jenkins 1989 4 Objective grading: fair/poor Jenkins 1989 Stein 1990 2/68 4/40 2/56 7/22 0.Fixed.86 [ 0. 2.Fixed.

2) -3.6) -6.02 ] -100 -50 0 50 100 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.31.Analysis 1. 2.07 ] 46 8. Outcome 5 Upper extremity function part of Musculoskeletal Function Assessment tool (0 to 100: maximum disability).6 (14.5.22. 7.2 (18. Published by John Wiley & Sons. 3.9) 41 15.7 (22.6 (23. Comparison 1 External fixation versus plaster cast.95% CI 1 At 6 months Kreder 2006 2 At 1 year Kreder 2006 3 At 2 years Kreder 2006 44 12.95% CI Mean Difference IV.87.60 [ -15.9) -2.11 ] 51 15. 54 .8 (20) 57 22.90 [ -12.9) 48 12. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 5 Upper extremity function part of Musculoskeletal Function Assessment tool (0 to 100: maximum disability) Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.Fixed.Fixed.60 [ -10.4 (25. Ltd.

Fixed.02 [ 0.64 ] 8/15 3/17 3. 5. Outcome 6 Difficulties in activities of daily living.36 ] 13/15 11/17 1. 2.00 ] 1/15 2/17 0. 1. Comparison 1 External fixation versus plaster cast.11 ] 0.10.98. 9.51 ] 2/15 5/17 0.95% CI Risk Ratio M-H.36 ] 10 Difficulty in picking up small objects and turning door handles at 7 years Young 2003 5/36 9/50 0.01 0.Fixed. 2.1 1 10 100 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.00 ] 10/15 3/17 3. Ltd.73.Analysis 1.6. 55 .57.95% CI 1 Lifting cup at 3 months Hegeman 2004 2 Lifting cup at 1 year Hegeman 2004 3 Hand wringing at 3 months Hegeman 2004 4 Hand wringing at 1 year Hegeman 2004 5 Fine hand co-ordination at 3 months Hegeman 2004 6 Fine hand co-ordination at 1 year Hegeman 2004 7 Heavy load bearing at 3 months Hegeman 2004 8 Heavy load bearing at 1 year Hegeman 2004 9 Difficulty in turning keys or taps at 7 years Young 2003 4/36 4/50 1. Published by John Wiley & Sons.28. 2.19 ] 9/15 10/17 1.27.77 [ 0. 1.06.45 [ 0. 11. 5.89.02 [ 0. 9.57 [ 0.02 [ 0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 6 Difficulties in activities of daily living Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.81 ] 12/15 13/17 1.78 [ 1.21 ] 8/15 3/17 3.39 [ 0.98.05 [ 0.34 [ 0.37.

51) 86 (14) 17 56 28 60 78 (19) 86.54 ] 7.00 [ 8. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 7 Job change because of injury Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.95% CI 1 Results at around 1 year Hegeman 2004 Jenkins 1989 McQueen 1996 Young 2003 2 Results at 7 years follow up Young 2003 36 96 (30) 50 99 (30) -3.Fixed. 11.83 ] -8.57 ] -100 -50 0 50 100 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.25 ] 12/51 11/57 1.52 ] 0.8.04.4) 59. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 8 Mass grip strength (% of normal side) Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.95% CI Mean Difference IV.85.88 (9.95 ] 1/46 4/48 0.6) 68 (28) 73 (9) -7. Outcome 8 Mass grip strength (% of normal side).47 [ 0.01 0.19 (29.85 ] 15 68 54 48 71 (32) 93.Random.54. 12.03.22 [ 0.83.43. Comparison 1 External fixation versus plaster cast. 4.7.81 [ -21.21 ] 13.95% CI 1 At 6 months Kreder 2006 2 At 1 year Kreder 2006 3 At 2 years Kreder 2006 1/44 2/41 0.00 [ -15. 2. 56 . Outcome 7 Job change because of injury.1 1 10 100 Favours fixation Favours plaster cast Analysis 1.00 [ -25. 4.23 [ 1.26 [ 0. Published by John Wiley & Sons. 17. Ltd.63. 9.Analysis 1.95% CI Risk Ratio M-H.65 (19. 2.59. Comparison 1 External fixation versus plaster cast.Fixed.Random.

7 (7) 3. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 10 Maximal voluntary contraction: injured . Ltd.normal side): units not given.17.Random.7) 41 -4.9.3 (48.1) 15 84.63 ] -100 -50 0 50 100 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.5) 41 0. 0.Random.9 (50.17 (1. 40.95% CI 1 Results at 18 weeks Lagerstrom 1999 2 Results at 2 years Lagerstrom 1999 11 21.23 [ -36.Random.5 (8.8) 0.33) 2. Comparison 1 External fixation versus plaster cast.9) -0. Outcome 9 Grip. 1. 57 .53 ] 11 86. Published by John Wiley & Sons.9) 15 24. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 9 Grip.Analysis 1.63 [ -39.uninjured side (Newtons).Random. Comparison 1 External fixation versus plaster cast.95% CI Mean Difference IV.93 (42.95) -3.28. 6. chuck and pinch strengths (injured .79. chuck and pinch strengths (injured .uninjured side (Newtons) Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.55 [ -1.95% CI 1 Grip strength at 2 years Kreder 2006 2 Chuck strength at 2 years Kreder 2006 3 Pinch strength at 2 years Kreder 2006 44 0.18 ] 44 -1.67 (48.15.4 (2.normal side): units not given Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.20 [ -0.17 [ -0. Outcome 10 Maximal voluntary contraction: injured . 32.5) 41 0.75.55 ] -10 -5 0 5 10 Favours plaster cast Favours fixation Analysis 1.10.95% CI Mean Difference IV.09 ] 44 -0.38 (1.23 (1.

Outcome 12 Pain (6 months).01 0. Comparison 1 External fixation versus plaster cast.11. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 12 Pain (6 months) Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.Analysis 1. 3.11. 5.50 ] 0.Fixed. 2.15.76 [ 0.1 1 10 100 Favours fixation Favours plaster cast External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.Fixed.96 ] 0.95% CI Risk Ratio M-H. Outcome 11 Persistent pain (1 year & 7 years).13.76 [ 0. 7.32 ] 2/21 4/22 0.86 ] 2/15 3/17 0.31.95% CI 1 At 1 year Young 2003 2 Radiocarpal pain at 1 year Hegeman 2004 3 Ulnocarpal pain at 1 year Hegeman 2004 4 Radioulnar pain at 1 year Hegeman 2004 5 At 7 years Young 2003 6/36 11/50 0.93 ] 2/15 3/17 0.93 ] 2/15 3/17 0.95% CI 1 Pain at rest Roumen 1991 2 Pain on movement Roumen 1991 3 Ulnar compression pain Roumen 1991 6/21 3/22 2. 3. 72. Ltd.44.93 ] 5/48 4/60 1.Fixed.15.56 ] 1/21 0/22 3.Fixed.15. 58 .10 [ 0.95% CI Risk Ratio M-H.01 0.14 [ 0. Comparison 1 External fixation versus plaster cast. 1. Published by John Wiley & Sons. 3.52 [ 0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 11 Persistent pain (1 year % 7 years) Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.76 [ 0.56 [ 0.60.12.76 [ 0.1 1 10 100 Favours fixation Favours plaster cast Analysis 1.

Comparison 1 External fixation versus plaster cast.56. 2.13 (15.93.69 (14.82 [ -6.25 [ -5.56 ] -1. 1.65 (13.Fixed.Fixed.56 (11.36.22 ] -1.61 ] 68 97.0 [ -12.73.95% CI Mean Difference IV.95 ] 15 68 88 (20) 94.18 ] 68 90.65) 28 83 (14) 3.09 ] -100 -50 0 50 100 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.48 (10.62 (8.45) 56 98.14 ] 68 95.77) 56 95. Published by John Wiley & Sons.58 (15.57) -3. 2.09) 0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 13 Range of movement at 1 year (% of normal side) Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.86 [ -2.99 [ -7.77 (7. 30. 12.13.86 ] 15 68 89 (19) 87. 3.11 [ -8. 1.98) -2.89 [ -5.42.28) -2.02) 56 96.Analysis 1.33) 56 93. 4.06) 17 56 72 (21) 95. Outcome 13 Range of movement at 1 year (% of normal side).29 (12. 9. 59 .78.35. Ltd.95% CI 1 Flexion Hegeman 2004 Jenkins 1989 2 Extension Hegeman 2004 Jenkins 1989 3 Radial deviation Jenkins 1989 4 Ulnar deviation Jenkins 1989 5 Supination Jenkins 1989 6 Pronation Jenkins 1989 7 Flexion/extension McQueen 1996 8 Overall range of movement McQueen 1996 54 89 (13) 28 93 (11) -4.00 [ 1.83 (14.00 [ -9.56 [ -2.88 (9.17 ] 68 92.39.54 (11.96.79) 17 56 89 (17) 89.63) 0.24) 16.12 (12.35 ] 54 86.49. 0.

3) 41 -14.5 (14.Fixed. Outcome 14 Range of movement at 2 years (injured .14.9) 41 -6.60 [ -1. Ltd.71 ] 44 -4.6 (8.5) 41 -3. 7.normal side).9) 41 -3. 5.9 (7.5 (8. 5.01 ] 44 -8. 60 .00 [ -1.2 (7.27 ] 44 0 (5.6) 41 -6 (12. -0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 14 Range of movement at 2 years (injured .8) 3.8) -0.50 [ 0.9) -6.1 (13.86 ] -100 -50 0 50 100 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.1) 1.normal side) Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.38.60 [ 0.29.27.95% CI Mean Difference IV. 6.95% CI 1 Flexion (degrees) Kreder 2006 2 Extension (degrees) Kreder 2006 3 Radial deviation (degrees) Kreder 2006 4 Ulnar deviation (degrees) Kreder 2006 5 Supination (degrees) Kreder 2006 6 Pronation (degrees) Kreder 2006 44 -4.2) 41 -1.70 [ -7. Comparison 1 External fixation versus plaster cast. Published by John Wiley & Sons.6 (20.9 (8.2) 5.34.4) 3.21.40 [ -12.Analysis 1.81 ] 44 -7.5 (15. 10.42 ] 44 -3 (6.81.Fixed.

2) 2.40.6) 60 88 (0.00 [ -2.1) 60 22 (4.74 ] 48 36 (4) 60 33 (5) 3. 2. Comparison 1 External fixation versus plaster cast.95% CI Mean Difference IV.10 ] -10 -5 0 5 10 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 2.70 ] 48 21 (3.95% CI 1 Flexion (degrees) Young 2003 2 Extension (degrees) Young 2003 3 Radial deviation (degrees) Young 2003 4 Ulnar deviation (degrees) Young 2003 5 Supination (degrees) Young 2003 6 Pronation (degrees) Young 2003 48 90 (0.00 [ -0.3) -1.Fixed.40 ] 48 60 (5. Ltd.41 ] 48 63 (5.41.Analysis 1. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 15 Range of movement at 1 year Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.00 [ 1.00 [ 1. 0.3) 60 61 (5.Fixed. Outcome 15 Range of movement at 1 year.82.00 [ -0. Published by John Wiley & Sons.7) 60 60 (7.0 [ -2.74.15. 2. 61 .8) 2.30. 4.10.1) 0.18 ] 48 87 (5) 60 86 (4) 1. 4.

2. Ltd. 5.02 ] 36 86 (7) 50 87 (8) -1.95% CI Mean Difference IV.22.00 [ -3.19 ] 36 41 (11) 50 40 (8) 1.22 ] 36 21 (9) 50 22 (8) -1. 0.Fixed.00 [ -3.Analysis 1. Published by John Wiley & Sons.39.34.Fixed.68 ] 36 65 (17) 50 71 (11) -6.02. 8.95% CI 1 Flexion (degrees) Young 2003 2 Extension (degrees) Young 2003 3 Radial deviation (degrees) Young 2003 4 Ulnar deviation (degrees) Young 2003 5 Supination (degrees) Young 2003 6 Pronation (degrees) Young 2003 36 88 (8) 50 87 (11) 1. Comparison 1 External fixation versus plaster cast.00 [ -4.00 [ -12.39 ] -10 -5 0 5 10 Favours plaster cast Favours fixation External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Outcome 16 Range of movement at 7 years.19.34 ] 36 60 (13) 50 57 (12) 3. 5. 2.16.00 [ -2.00 [ -4.68. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 16 Range of movement at 7 years Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV. 62 .

1.02 [ 0.40 ] 1.09.22 [ 0.1 Favours fixation 1 10 100 1000 Favours plaster cast (Continued . 3. ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Comparison 1 External fixation versus plaster cast. 51 (Plaster cast) 356 338 0.25.44 ] 0.45 ] 0.33 [ 0.32 ] Total events: 21 (External fixation).13.Fixed.00.94.0 ] 0. 0.09 ] 0. 1.32 ] 0.00001) 2 Redisplacement resulting in secondary treatment Abbaszadegan 1990 Horne 1990 Howard 1989 Jenkins 1989 Kreder 2006 Lagerstrom 1999 Pring 1988 Stein 1990 Young 2003 0/23 0/17 3/25 0/84 1/54 0/18 0/36 0/40 3/59 5/24 0/17 9/25 4/69 5/59 5/17 9/39 11/22 3/66 0.28. 9. Ltd. 1.20 [ 0.00.Analysis 1.01.67 ] 0.02 [ 0. Outcome 17 Complications. 0.65.0 [ 0.03.89 [ 0. 0.44 [ 0. 5.0.41 (P < 0. 0.18 ] Subtotal (95% CI) 230 192 0.77 ] 0.09 [ 0. .00.17 [ 0. 1.06 [ 0. I2 =77% Test for overall effect: Z = 6.17. 63 .Fixed. 0. I2 =30% Test for overall effect: Z = 5. df = 7 (P = 0. 1.12 [ 0.01.25.33 ] Subtotal (95% CI) Total events: 7 (External fixation).95% CI 1 Redisplacement /recurrent instability McQueen 1996 Pring 1988 Rodriguez-Merchan 92 Stein 1990 Young 2003 14/60 0/36 0/35 3/40 4/59 16/30 9/39 27/35 16/22 5/66 0.95% CI Risk Ratio M-H.03.00001) 3 Distal radial ulnar joint instability Kreder 2006 3/54 2/59 1. Published by John Wiley & Sons. 0.94 ] 0.55 (P = 0.44 ] Subtotal (95% CI) Total events: 3 (External fixation).81 ] 0.01.10.01 0.62 ] 0.06 [ 0.94 ] 0. 9. 73 (Plaster cast) Heterogeneity: Chi2 = 17.86 (P < 0.10 [ 0.64 [ 0. 0. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 17 Complications Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.19).32 ] Heterogeneity: Chi2 = 9. 2 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0.58) 54 59 1.00.28.09 [ 0.64 [ 0.001 0.23. . 0.09 [ 0. 0.001). df = 4 (P = 0.29 ] 0.

95% CI Continued) Risk Ratio M-H.99 (P = 0.47 ] 3. Published by John Wiley & Sons. df = 4 (P = 0.56 [ 0.88. loose plaster) Hegeman 2004 0/15 2/17 Plaster cast n/N Risk Ratio M-H.87 ] 0. .0 [ 0.36 ] (Continued .92).82 ] 5.017) 7 Premature frame/fixator removal Jenkins 1989 2/84 0/69 0.02 [ 5.47 [ 0.69 ] 5. 130.71 ] 9. 94.63 [ 0.65 (P < 0.40.0 ] 4.16 ] 43.97. 161.0.49 ] Heterogeneity: Chi2 = 3.37.50.07 ] 6.08 ] Subtotal (95% CI) Total events: 10 (External fixation). 0.0% Test for overall effect: Z = 5.10. df = 9 (P = 0. 133. Ltd.13 ] 0.0% Test for overall effect: Z = 2.1 Favours fixation 1 10 100 1000 Favours plaster cast 4.0.34.26 ] Heterogeneity: Chi2 = 0.12 [ 0.32) 5 Pin track infection Abbaszadegan 1990 Hegeman 2004 Howard 1989 Jenkins 1989 Kapoor 2000 Kreder 2006 McQueen 1996 Rodriguez-Merchan 92 Roumen 1991 Stein 1990 Young 2003 15 17 0.38 (P = 0.80 [ 0.56 [ 0.63 ] 5. 1 (Plaster cast) 444 402 12. 19. 531. 108.23 [ 0.35 ] Subtotal (95% CI) Total events: 0 (External fixation).37. 52. 116.58. 0 (Plaster cast) 230 203 5.0. 0.95% CI 0.50 ] 9.23 [ 0.18. 703. 28. 102.01.20.70 ] 2. 84.14.01 0. 4.Fixed.23 [ 0.25.(. I2 =0.25 ] Subtotal (95% CI) Total events: 69 (External fixation). Study or subgroup External fixation n/N 4 Plaster cast problems (swollen thumb. 2 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0.35 ] 3/23 2/15 2/25 26/84 1/28 6/54 9/60 4/35 0/21 2/40 14/59 0/24 0/17 0/25 0/69 0/33 1/59 0/30 0/35 0/22 0/22 0/66 7.07. 0. 160. .70 ] 7. .71.00 [ 0. . I2 =0.99).52 [ 0.0 ] 6. 59.15. 83. 64 . 99.15 [ 0.29.00 [ 0.66 [ 0.29. ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.65 [ 2.0 [ 0. 4.07 [ 1.01.0 [ 0.00001) 6 Pin loosening and other pin site problems Abbaszadegan 1990 Horne 1990 Jenkins 1989 Rodriguez-Merchan 92 Roumen 1991 Stein 1990 Zheng 2003 0/23 3/15 1/84 3/35 2/21 0/40 1/12 0/24 0/14 0/69 0/35 0/22 0/22 0/17 0.29 [ 0.0 ] 2.Fixed.001 0.00 [ 0.95 ] 32.82. 55.27.38 [ 1.

0% Test for overall effect: Z = 1.0 ] 0.01. 36.52 ] Heterogeneity: Chi2 = 0. 59. . 7.25 [ 0.26 (P = 0.95% CI 2.0.21 [ 0. 4.57 ] Subtotal (95% CI) Total events: 0 (External fixation).Fixed. 59.47 [ 0.0 ] Subtotal (95% CI) Total events: 0 (External fixation).0.0 [ 0.0 ] 0. . df = 1 (P = 0.0.06.47 [ 0.09 (P = 0.0. 0.14) 11 ”Dorsal medial neuropraxia” McQueen 1996 1/60 0/30 1. 0.0.11 ] 0. I2 =0.0. 0.Fixed.0 (P < 0.06. 1.54 [ 0.0 ] 2.81 ] 0.79) 12 ”Transient neuropraxia” 60 30 1.0 ] Subtotal (95% CI) Total events: 1 (External fixation).0 [ 0.49 (P = 0.01 0.70 ] 0. 0 (Plaster cast) 179 134 3.0 ] 0/25 0/60 0/35 0/21 0/36 1/25 0/30 0/35 2/22 2/50 0.0.05.39.28 [ 0.0% Test for overall effect: Z = 0.27) 8 Osteomyelitis Abbaszadegan 1990 Jenkins 1989 Rodriguez-Merchan 92 Stein 1990 0/23 1/84 0/35 0/40 0/24 0/69 0/35 0/22 0.34 ] 0.00001) 10 Tendon injury/rupture Howard 1989 McQueen 1996 Rodriguez-Merchan 92 Roumen 1991 Young 2003 60 30 0. 0.58) 9 Wound infection McQueen 1996 0/60 0/30 0.0 [ 0.82).0 [ 0. df = 2 (P = 0.33 [ 0.01.0. 5.00). 0.0 [ 0.0 ] 0. 0 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0. 27.0% Test for overall effect: Z = 1.0 [ 0.0 ] Subtotal (95% CI) Total events: 4 (External fixation). ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 0 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0. 0.0 [ 0. Ltd.34 ] Subtotal (95% CI) Total events: 1 (External fixation). 0. 36.52 [ 0.10. 51.05. I2 =0. 65 . 5 (Plaster cast) 177 162 0.(. 0.0 [ 0.05. Study or subgroup External fixation n/N McQueen 1996 Rodriguez-Merchan 92 2/60 0/35 Plaster cast n/N 0/30 0/35 Risk Ratio M-H.98).10.001 0. .0. I2 =0. 0 (Plaster cast) 182 150 2. df = 0 (P = 1.56 (P = 0.01.31 ] 0.13.70 ] Heterogeneity: Chi2 = 0. . Published by John Wiley & Sons.26 [ 0.95% CI Continued) Risk Ratio M-H.00 ] Heterogeneity: Chi2 = 0.1 Favours fixation 1 10 100 1000 Favours plaster cast (Continued .52 [ 0.

47 [ 0.77.95% CI 2. . 0.97 ] 0. . df = 3 (P = 0.01. 33.15 ] Heterogeneity: Chi2 = 2.56 ] Subtotal (95% CI) Total events: 2 (External fixation).1 Favours fixation 1 10 100 1000 Favours plaster cast 0. .02.18. 5 (Plaster cast) 99 105 2.13. 2. 72. 13. 0. 3.50 [ 0.0 [ 0. 315.27 [ 0.93 [ 0.82 ] 0.01.11 [ 0. 1 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0. 6.44 [ 0. Ltd.21.72 (P = 0.23. 3.70 (P = 0. 22.98.22.15 [ 0.94 [ 1.10).001 0.0 ] (Continued .0% Test for overall effect: Z = 2.39 [ 0. I2 =0.55 [ 0. 1.79). 73.49) 15 17 2.23.01. I2 =56% Test for overall effect: Z = 1.33 [ 0.20 [ 0. 0 (Plaster cast) 159 132 7.50 [ 0.04.52.21.13 [ 0.10) 14 Radial nerve neuritis or neuropathy Horne 1990 Howard 1989 Young 2003 4/15 1/25 8/59 0/14 3/25 2/66 8. 9.77 ] 0. 20.20 [ 0.78 ] 3. 22.16.27 [ 0.Fixed.23 ] 1. 94.73 ] 4.0 [ 0.50.0.71 [ 1. 143.0.51 ] Subtotal (95% CI) Total events: 7 (External fixation). df = 2 (P = 0.99 ] 4.84.54 ] Heterogeneity: Chi2 = 1.0065) 16 Ulnar nerve compression Howard 1989 Jenkins 1989 0/25 0/84 2/25 0/69 0.14. 66 .08 ] Subtotal (95% CI) Total events: 16 (External fixation).58).24 ] Subtotal (95% CI) Total events: 13 (External fixation).95% CI Continued) Risk Ratio M-H. ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.01 0.01 ] 18.96 ] 0. Published by John Wiley & Sons.63 (P = 0.0 ] 0. Study or subgroup External fixation n/N Hegeman 2004 2/15 Plaster cast n/N 1/17 Risk Ratio M-H.51 ] 0. . 1.(.68 ] Heterogeneity: Chi2 = 4. df = 4 (P = 0.06.91 (P = 0.99.0% Test for overall effect: Z = 1. I2 =0. 2.056) 15 Superficial radial nerve paraesthesia or injury Abbaszadegan 1990 Jenkins 1989 Stein 1990 Zheng 2003 1/23 11/84 3/40 1/12 0/24 0/69 0/22 0/17 3.56 ] 13 Median nerve compression /Carpal tunnel syndrome Howard 1989 Jenkins 1989 Kapoor 2000 McQueen 1996 Young 2003 Zheng 2003 0/25 0/84 0/28 3/60 4/59 0/12 4/25 0/69 1/33 1/30 6/66 3/17 0. 15 (Plaster cast) 268 240 0.Fixed.75 [ 0.

4 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 1.10 [ 0. 108.13 [ 0.Fixed.42.57.0 [ 0.26 ] 1.40.02 ] 2.36) 18 Severe finger stiffness Kapoor 2000 0/28 4/33 0.01.33.0% Test for overall effect: Z = 1.0. 2.52 [ 0.14 [ 0. 1. 39.00 ] Subtotal (95% CI) 384 347 1. .0 ] 0.07 ] 0.(.63 [ 0.65 ] 1. 98. 0.73 [ 0. ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.39 (P = 0.32 ] 2/15 0/17 5.0% Test for overall effect: Z = 0.01. 1.29) 17 Reflex sympathetic dystrophy Hegeman 2004 Horne 1990 Howard 1989 Jenkins 1989 Kapoor 2000 Kreder 2006 McQueen 1996 Rodriguez-Merchan 92 Roumen 1991 Stein 1990 Young 2003 4/15 0/15 0/25 0/32 1/28 1/54 7/60 0/35 4/21 1/40 7/59 1/17 0/14 0/25 2/24 0/33 2/59 1/30 2/35 2/22 0/22 7/66 4.32 ] Subtotal (95% CI) Total events: 0 (External fixation).52).50 [ 0.86 ] 3.02 ] 3.43.01.12 [ 0.06 (P = 0. 0. 83.0.13 [ 0.63 ] Subtotal (95% CI) Total events: 2 (External fixation).55 [ 0. 10.63 ] 8/19 1/36 11/16 0/50 0.20 [ 0. .16 ] 0.61 [ 0. 2.31 [ 0.45. 4.95% CI Continued) Risk Ratio M-H.53 [ 0.14 ] 4. 11 (Plaster cast) 55 66 0.0 ] 0.15. 3.01 0.0.74.15 [ 0. 17 (Plaster cast) Heterogeneity: Chi2 = 7.20 [ 0.97 ] Heterogeneity: Chi2 = 0. Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.32 ] Total events: 25 (External fixation).91 (P = 0. Published by John Wiley & Sons.95% CI Subtotal (95% CI) Total events: 0 (External fixation).01.11.001 0. I2 =0.68 [ 0.29.29.25) 20 Arthritis Howard 1989 Young 2003 15 17 5. I2 =0.0 [ 0. 3.23 ] 0. 3. 108.17. 0 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 1.Fixed.05.00). . df = 8 (P = 0.14 (P = 0. 2 (Plaster cast) 109 94 0. 67 . 5. 2.17) 19 Dupuytren contracture Hegeman 2004 28 33 0. df = 0 (P = 1.1 Favours fixation 1 10 100 1000 Favours plaster cast (Continued .63 [ 0.01. 27.34 ] 0. 36. Ltd.07.69 ] Subtotal (95% CI) Total events: 9 (External fixation). .

0. 0. df = 1 (P = 0. 4. Comparison 1 External fixation versus plaster cast. .15. . Study or subgroup External fixation n/N Heterogeneity: Chi2 = 1.95% CI 1 Primary treatment Hegeman 2004 Horne 1990 Howard 1989 Jenkins 1989 Kapoor 2000 Kreder 2006 Rodriguez-Merchan 92 Stein 1990 Young 2003 4/15 0/15 0/25 0/32 1/28 1/54 0/35 1/40 7/59 1/17 0/14 0/25 2/24 0/33 2/59 2/35 0/22 7/66 4. I2 =32% Test for overall effect: Z = 1. Outcome 18 Reflex sympathetic dystrophy .001 0.57.1 Favours fixation 1 10 100 1000 Favours plaster cast Analysis 1. Ltd.02 ] 3. 68 .exploratory analysis Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.Fixed.42.0 ] 0.0 [ 0.Fixed.15 [ 0.01 0.07 ] 0.01 0.01 (P = 0. 0 (Plaster cast) Heterogeneity: not applicable Test for overall effect: Z = 0.84 [ 0.Fixed. 65.18.20 [ 0.53.46).Fixed. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 18 Reflex sympathetic dystrophy .34 ] Subtotal (95% CI) Total events: 1 (External fixation). 14 (Plaster cast) Heterogeneity: Chi2 = 5.31) 21 Refracture Lagerstrom 1999 1/18 0/17 Plaster cast n/N Risk Ratio M-H.98 ] Total events: 14 (External fixation). ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.84 [ 0. df = 6 (P = 0. .12. 3. 39. 36.02 ] 1.23).0 ] 0.12.0.51) 18 17 2.65 (P = 0.95% CI Continued) Risk Ratio M-H.95% CI 2.0 [ 0.53 [ 0.65 ] 1. 5.46.12 [ 0.05. I2 =0. 1.(.0.00 ] Subtotal (95% CI) 303 295 1.52 [ 0.68 [ 0.01.03 [ 0. . Published by John Wiley & Sons. 65.exploratory analysis.86 ] 0.23 ] 0.1 1 10 100 Favours fixation Favours plaster cast (Continued .34 ] 0.01. 83. 3.95% CI Risk Ratio M-H.65.0% 0.55 [ 0.07.

(. . .
Study or subgroup External fixation n/N Test for overall effect: Z = 0.08 (P = 0.94) 2 Redisplaced fractures McQueen 1996 Roumen 1991 7/60 4/21 1/30 2/22 Plaster cast n/N Risk Ratio M-H,Fixed,95% CI

Continued) Risk Ratio

M-H,Fixed,95% CI

3.50 [ 0.45, 27.16 ] 2.10 [ 0.43, 10.26 ]

Subtotal (95% CI)
Total events: 11 (External fixation), 3 (Plaster cast)

81

52

2.67 [ 0.75, 9.47 ]

Heterogeneity: Chi2 = 0.16, df = 1 (P = 0.69); I2 =0.0% Test for overall effect: Z = 1.52 (P = 0.13)

0.01

0.1

1

10

100

Favours fixation

Favours plaster cast

Analysis 1.19. Comparison 1 External fixation versus plaster cast, Outcome 19 Cosmetic deformity.
Review: External fixation versus conservative treatment for distal radial fractures in adults

Comparison: 1 External fixation versus plaster cast Outcome: 19 Cosmetic deformity

Study or subgroup

External fixation n/N

Plaster cast n/N

Risk Ratio M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 Cosmetic deformity (undefined) Kapoor 2000 2 Prominent ulnar styloid Hegeman 2004 3 Radial deviation of hand Hegeman 2004 4 Residual dinner fork deformity Hegeman 2004 0/15 1/17 0.38 [ 0.02, 8.57 ] 2/15 3/17 0.76 [ 0.15, 3.93 ] 7/15 12/17 0.66 [ 0.35, 1.23 ] 2/18 0/23 6.32 [ 0.32, 123.86 ]

0.001 0.01 0.1 Favours fixation

1

10 100 1000 Favours plaster cast

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Analysis 1.20. Comparison 1 External fixation versus plaster cast, Outcome 20 Patient dissatisfied with wrist.
Review: External fixation versus conservative treatment for distal radial fractures in adults

Comparison: 1 External fixation versus plaster cast Outcome: 20 Patient dissatisfied with wrist

Study or subgroup

External fixation n/N

Plaster cast n/N 4/50

Risk Ratio M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI 0.69 [ 0.13, 3.59 ]

Young 2003

2/36

0.1 0.2

0.5

1

2

5

10

Favours fixation

Favours plaster cast

Analysis 1.21. Comparison 1 External fixation versus plaster cast, Outcome 21 Anatomical grading: not excellent.
Review: External fixation versus conservative treatment for distal radial fractures in adults

Comparison: 1 External fixation versus plaster cast Outcome: 21 Anatomical grading: not excellent

Study or subgroup

External fixation n/N

Plaster cast n/N 23/25 62/65 22/35 22/22 19/22

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

Howard 1989 Jenkins 1989 Rodriguez-Merchan 92 Roumen 1991 Stein 1990

11/25 42/81 16/35 14/21 7/40

14.3 % 42.9 % 13.7 % 13.7 % 15.3 %

0.48 [ 0.30, 0.76 ] 0.54 [ 0.44, 0.68 ] 0.73 [ 0.47, 1.13 ] 0.67 [ 0.50, 0.92 ] 0.20 [ 0.10, 0.41 ]

Total (95% CI)

202

169

100.0 %

0.53 [ 0.45, 0.61 ]

Total events: 90 (External fixation), 148 (Plaster cast) Heterogeneity: Chi2 = 12.13, df = 4 (P = 0.02); I2 =67% Test for overall effect: Z = 8.06 (P < 0.00001)

0.1 0.2

0.5

1

2

5

10

Favours fixation

Favours plaster cast

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Analysis 1.22. Comparison 1 External fixation versus plaster cast, Outcome 22 Anatomical grading: fair or poor.
Review: External fixation versus conservative treatment for distal radial fractures in adults

Comparison: 1 External fixation versus plaster cast Outcome: 22 Anatomical grading: fair or poor

Study or subgroup

External fixation n/N

Plaster cast n/N 6/25 36/65 16/35 22/22 9/22 7/17

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

Howard 1989 Jenkins 1989 Rodriguez-Merchan 92 Roumen 1991 Stein 1990 Zheng 2003

2/25 5/81 4/35 5/21 0/40 1/12

5.9 % 39.2 % 15.7 % 21.6 % 11.9 % 5.7 %

0.33 [ 0.07, 1.50 ] 0.11 [ 0.05, 0.27 ] 0.25 [ 0.09, 0.67 ] 0.26 [ 0.12, 0.53 ] 0.03 [ 0.00, 0.48 ] 0.20 [ 0.03, 1.44 ]

Total (95% CI)

214

186

100.0 %

0.17 [ 0.11, 0.27 ]

Total events: 17 (External fixation), 96 (Plaster cast) Heterogeneity: Chi2 = 4.90, df = 5 (P = 0.43); I2 =0.0% Test for overall effect: Z = 7.77 (P < 0.00001)

0.01

0.1

1

10

100

Favours fixation

Favours plaster cast

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Analysis 1.23. Comparison 1 External fixation versus plaster cast, Outcome 23 Anatomical displacement.
Review: External fixation versus conservative treatment for distal radial fractures in adults

Comparison: 1 External fixation versus plaster cast Outcome: 23 Anatomical displacement

Study or subgroup

External fixation N Mean(SD)

Plaster cast N Mean(SD)

Mean Difference IV,Random,95% CI

Mean Difference IV,Random,95% CI

1 Loss in dorsal angulation (degrees) 2 Loss in radial angulation (degrees) Jenkins 1989 81 2.4 (5.04) 65 6.97 (7.49) -4.57 [ -6.70, -2.44 ]

3 Loss in radial length (radial shortening) (mm) at around 1 year follow up Jenkins 1989 McQueen 1996 Young 2003 Zheng 2003 81 54 48 12 0.73 (2.67) 2.52 (2.57) 0.9 (0.5) 1.01 (0.76) 65 28 60 17 4 (4.28) 2 (3) 1.6 (1) 5.11 (1.96) -3.27 [ -4.46, -2.08 ] 0.52 [ -0.79, 1.83 ] -0.70 [ -0.99, -0.41 ] -4.10 [ -5.13, -3.07 ]

4 Loss in radial length (radial shortening) (mm) at 7 years follow up Young 2003 5 Loss in dorsal displacement (mm) Horne 1990 6 Loss in radial displacement (mm) Horne 1990 15 1.67 (2.19) 14 2.64 (2.5) -0.97 [ -2.69, 0.75 ] 15 3.13 (2.1) 14 2.29 (2.81) 0.84 [ -0.98, 2.66 ] 36 1.5 (2) 50 2 (2) -0.50 [ -1.36, 0.36 ]

-10

-5

0

5

10

Favours fixation

Favours plaster cast

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1) -9.66 ] 36 4 (9) 50 3 (10) 1.49) 13 (11) 3.87 ] 2 Dorsal angulation (degrees) at 7 years follow up Young 2003 3 Radial angulation (degrees) Hegeman 2004 4 Ulnar variance (mm) Hegeman 2004 15 3.5) 10.56 [ -11.5 (7.2 (2. -10.Analysis 1.5) 1 (8. -0.7) -6.90 ] -5.8) 17 25 65 28 60 17 12. -1.60 [ -18.65) -0.95% CI 1 Dorsal angulation (degrees) at 13 weeks to 13 months follow up Hegeman 2004 Howard 1989 Jenkins 1989 McQueen 1996 Young 2003 Zheng 2003 15 25 81 54 48 12 2.6) 17. -3.Fixed. Outcome 24 Anatomical measurements.12 (11.18.3) 17 2.60 [ -5.44 (12.73.9 (3.42 ] -14. 5.00 [ -3.10 [ -1.04 ] -100 -50 0 50 100 Not applicable Not applicable External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.7 (14.85.87 (12.27 ] -4.26.3 (10. -1.94 ] -6.24.47 ] -9.04.37. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 24 Anatomical measurements Study or subgroup External fixation N Mean(SD) Plaster cast N Mean(SD) Mean Difference IV.80 [ -18.20 [ 0.05 ] 15 22. Comparison 1 External fixation versus plaster cast.8) 5.6) 7. 4.70.12 [ -16.35) 6. 9.85.73 (9.5 (8. Published by John Wiley & Sons.95% CI Mean Difference IV.7 (2.9) 17 17.3 (5.74.7 (4.Fixed.6) 1. 73 .80 [ -11. -0.9 (11) 11. Ltd.

41.64 [ 0. 1. . 1.32. I2 =0. 5.60 [ 0.25.0 % 0.55.40.47 ] Total events: 18 (External fixation). 1. 26 (Plaster cast) 25/60 14/30 100.0 % 0. ) External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration.63 ] (Continued .89 [ 0.23.0 % 0.95% CI Weight Risk Ratio M-H.89 [ 0.64 [ 0.33 (P = 0.86) 3 Carpal collapse McQueen 1996 36 50 100. 1.79 ] Total events: 4 (External fixation).46 (P = 0.63. df = 1 (P = 0.39) 5 Volar angulation of distal fragment Kapoor 2000 18 23 100.29.4 % 0.65) 4 Dorsal tilt increase due to ”late collapse” Kapoor 2000 60 30 100.001 0. Comparison 1 External fixation versus plaster cast.63 [ 0.1 Favours fixation 1 10 100 1000 Favours plaster cast 100. 1.05.95% CI 1 Malunion (as defined by trialist) McQueen 1996 Young 2003 24/60 12/48 20/30 27/60 52. 47 (Plaster cast) Heterogeneity: Chi2 = 0.6 % 47.28 [ 0.0 % 1.56 [ 0.81 ] Total events: 36 (External fixation). 0.45 ] Total events: 25 (External fixation).0015) 2 Malunion at 7 years follow up Young 2003 18/36 26/50 100. Ltd.0 % 1. 108. Review: External fixation versus conservative treatment for distal radial fractures in adults Comparison: 1 External fixation versus plaster cast Outcome: 25 Structural deformity Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H.0% Test for overall effect: Z = 3.01 0. 1.0 % 0. Published by John Wiley & Sons. 0.63. 0.96 [ 0.58 [ 0. 74 .Analysis 1.98 ] Subtotal (95% CI) 108 90 100.47 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 0.Fixed.85 (P = 0.55.96 [ 0.0 % 5.29.74) 18 23 100.59 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 0.0 % 0.79 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 0.23.17 (P = 0. 3 (Plaster cast) 6 Step-off >/= 2 mm (intra-articular alignment) Hegeman 2004 2/15 0/17 0. 8 (Plaster cast) 3/18 3/23 100. 5.59 ] Total events: 3 (External fixation).45 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 0. .Fixed.82).29.28 [ 0.18 (P = 0.90 ] 0. Outcome 25 Structural deformity. 14 (Plaster cast) 4/18 8/23 100.0 % 0.0 % 0.

97 ] Total events: 7 (External fixation).63 ] Total events: 0 (External fixation).63 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 1. Search strategy for MEDLINE (OVID-WEB) 1.01.0 % 0.14 (P = 0.25) 7 Loss in position post-immobilisation Howard 1989 15 17 100.(. Abstract or Keywords in all products #5 (colles or smith or smiths) in Title. Wrist Injuries/ 3.ab. Search strategy The Cochrane Library (Wiley InterScience) #1 MeSH descriptor Radius Fractures explode all trees in MeSH products #2 MeSH descriptor Wrist Injuries explode all trees in MeSH products #3 (#1 OR #2) #4 ((distal near radius) or (distal near radial)) in Title. 4.040) 20 11 100.48 [ 0. 0 (Plaster cast) 0/25 3/25 100.Fixed. . 3 (Plaster cast) 8 Non-congruous joint surface for die-punch fractures Jenkins 1989 7/20 8/11 100.29. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).24. or/1-3 External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. 8 (Plaster cast) 0.63 [ 0.14 [ 0.14 [ 0. 0. Abstract or Keywords in all products #6 wrist* in Title.05 (P = 0. 108.Fixed.19) 25 25 100. 2.1 Favours fixation 1 10 100 1000 Favours plaster cast APPENDICES Appendix 1. 0.ti.01 0.001 0. exp Radius Fractures/ 2.95% CI Weight Continued) Risk Ratio M-H.95% CI Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 1. Abstract or Keywords in all products #9 (#7 AND #8) #10 (#3 OR #9) Appendix 2.48 [ 0.0 % 0.0 % 0. 75 .97 ] Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 2.0 % 5.0 % 0. Ltd. Study or subgroup External fixation n/N Plaster cast n/N Risk Ratio M-H. .63 ] Total events: 2 (External fixation).31 (P = 0. Abstract or Keywords in all products #7 (#4 OR #5 OR #6) #8 fractur* in Title. 2. Published by John Wiley & Sons.01.24.

Radius Fractures/ 2.tw.tw. The mechanical construct which one can achieve with wires or screws inserted into the bone and then wrapped in plaster is in no way comparable to the use of a device specifically designed to stabilise a distal radial fracture.tw.07): The authors are to be congratulated on this extensive review of a common problem in current trauma practice. exp Randomized Controlled trial/ 5. or/1-2 4.12. and/3. or/4-8 9. The validity of their conclusions are let down however by a glaring error in the abstract. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)). clinical trial.18 EMBASE 1. Reply We thank Mr Shaw for his interest in our review and for his feedback. 10.tw. and/5. 13. or/9-13 15. exp Comparative Studies/ 9. or/8.14 16.pt. The use of “pin and plaster” as a form of external fixation was only ever routinely applied to unstable tibial fractures or possibly in third world or battlefield situations. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).ab. 2. Published by John Wiley & Sons. 14. Search strategies for CINAHL and EMBASE (OVID-WEB) CINAHL 1. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)). ((clinical or controlled or comparative or placebo or prospective or randomi#ed) adj3 (trial or study)). In relation to the choice between fracture fixation and manipulation. 5. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$) ).tw. 13.Appendix 3.tw.tw. exp Crossover Procedure/ 8. only one of the most relevant questions relates to the risks of redisplacement and the benefit of remanipulation as opposed to defaulting to operative stabilisation if fracture reduction has been lost at some time after manipulation has been used as the primary treatment. exp Single Blind Procedure/ 7. 12. Animal/ not Human/ 17.tw.17 19. or/11. or/1-2 4.ti. exp Clinical Trials/ 7. exp Crossover Design/ 10. 17. Wrist Injuries/ 3. or/6-10 12. (((distal adj3 (radius or radial)) or wrist or colles or smith$2) adj3 fracture$).tw. 15 not 16 18. 15.17 FEEDBACK Inclusion of ’pins and plaster’ external fixation Summary Comment from Mr David L Shaw (04. or/3-4 6. 14. (((distal adj3 (radius or radial)) or wrist or colles$2 or smith$2) adj3 fracture$). ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)). 11. 76 . 11. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Colles Fracture/ or Radius Fracture/ or Wrist Fracture/ or Wrist Injury/ 3. exp Evaluation Research/ 8. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)). or/12-16 18. (cross?over$ or (cross adj1 over$)).tw. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$) ). Ltd.tw. 16. exp Double Blind Procedure/ 6. (cross?over$ or (cross adj1 over$)).

the actual contribution of quantitative evidence from the only trial testing pins and plaster external fixation to the review and the conclusions was minimal. 77 .12. Contributors Comment from Mr David L Shaw (04. which includes a comparison of external fixation versus pins and plaster fixation. Mr Shaw may be interested to read our review on “Different methods of external fixation for treating distal radial fractures in adults”. HH searched for trials and contacted trial authors.07) Response from HHG Handoll and WJ Gillespie (18. Rajan Madhok (RM) and Jim Huntley (JH). We agree there is a distinction between primary and secondary (upon redisplacement) fixation and consider in our review that both situations represent fracture instability.07) WHAT’S NEW Last assessed as up-to-date: 16 May 2007.12. HH completed the first draft of the review in RevMan. External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. This was critically reviewed by the other two authors. Although its results were consistent with the review conclusions. Our conclusion of “unknown effectiveness” for this comparison reflects the inadequate evidence from two trials available to address this comparison but it is still notable that the evidence from neither trial condemned the use of plaster and pins fixation. HH repeated her review of the other included trials that had been quality assessed previously by RM and HH. All three authors performed study selection. HH and JH reviewed those trials that had not been included in a previous review covering all surgical interventions. All versions were scrutinised by the other two authors.Cochrane reviews are intended for a world-wide audience. Published by John Wiley & Sons. 9 May 2008 Amended Converted to new review format. It is thus appropriate that lower-cost methods such as ’pins and plaster’ are considered. Helen Handoll is the guarantor of the review. 2007 CONTRIBUTIONS OF AUTHORS This review was initiated by Helen Handoll (HH) who prepared the first draft of the protocol. HISTORY Protocol first published: Issue 4. 2006 Review first published: Issue 3. Ltd.

Surgical. Background. Bone Nails.DECLARATIONS OF INTEREST None known. Wrist Injuries [surgery. Published by John Wiley & Sons. Colles’ Fracture [surgery]. Radius Fractures [∗ surgery. Male. Middlesbrough. External sources • No sources of support supplied NOTES Some of the wording in each of several sections of this review (in particular: Synopsis. Methods. Discussion and Implications) is taken either entirely or in only a slightly modified form from a related review on Percutaneous pinning for distal radial fractures in adults. therapy]. Female. 78 . Middle Aged External fixation versus conservative treatment for distal radial fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. SOURCES OF SUPPORT Internal sources • University of Teesside. UK. therapy] MeSH check words Adult. This has been done to make the review self-contained and to ensure consistency between related reviews without requiring unnecessary cross-referring by readers. Fracture Fixation [∗ methods]. Humans. Randomized Controlled Trials as Topic. INDEX TERMS Medical Subject Headings (MeSH) ∗ Casts. Ltd. Aged.