A Cochrane review [Abstract] 1 included 37 trials with a total of 4215 subjects. The trials included mainly female and older patients. The poor quality and heterogeneity in terms of patient characteristics, interventions compared and outcome measurement, of the included trials mean that no meta-analyses were undertaken. The following results were extracted:
- Pronation or not? Wrist anatomy after reduction held better and need for further reduction was less if the hand was held in pronation.
- Palmar flexion, neutral position or dorsi-flexion? Two trials (Blatter 1994, Gupta 1991) involving 254 patients with displaced fractures compared wrist positioned in either palmar flexion or neutral with dorsi-flexion. Anatomical results for both trials were better in the dorsi-flexion group. Overall functional outcome was also better in the dorsi-flexion group.
- Ulnar deviation? Van der Linden (1981) concluded that the method of immobilisation (ulnar deviation or full plaster cast) was of only minor importance and that final outcome depended more on the original displacement of the fracture and success of reduction.
- Three or five weeks of immobilisation? Christensen (1995) and Hansen (1998) compared three weeks with five weeks immobilisation in a plaster back slab in 133 patients. All 33 patients in Christensen and over half in Hansen had minimally displaced distal radial fractures. Both trials reported that there were no statistically significant differences in either anatomical or functional outcomes, but only data for long-term pain were available. McAuliffe (1987) and Millet (1995) included both undisplaced and displaced fracture patients, and involved 108 and 90 patients respectively. In McAuliffe fractures were remanipulated if necessary, after an initial application of a cast for one week. Immobilisation in a plaster cast was then continued for a furher three weeks or five weeks. There were no significant differences reported between groups for anatomical otucomes at either three or twelve months. Significantly less pain and greater grip strength were reported in the early group when assessed by an independent physiotherapist. An improvement in range of movement was also noted in the early group. Millet (1995) compared three weeks immobilisation followed by two weeks in a flexible cast with five weeks plaster immobilisation. The regain of grip strength and wrist movement was more rapid in the early mobilisation group. Radiological examinations at three years were reported to show a statistically significant increase in the average radial tilt (2 degrees) and decreased radioulnar joint space (0.3 millilitres) in the five week group, but no statistical difference in numbers with osteoarthritis.
- One or three weeks of immobilisation? Jensen (1997) compared one week with three weeks of immobilisation in 62 patients with undisplaced or minimally displaced Colles fractures. Radiological examination of 48 patients at 6 months showed no cases of non-union and no statistically significant difference in excess angulation or axial radial shortening. Additional pain was experienced by patients at cast removal at 1 week. Stoffelen compared one week with three weeks of immobilisation in 114 patients with undisplaced or minimally displaced Colles fractures. Stoffelen reported no further displacement in either group. Functional outcome was similar. More cases with algoneurodystrophy were seen in the three week group in Stoffelen's trial, but the difference was not significant.
The reviewers summarise that there is no evidence of difference in outcome between different methods of plaster and brace management or manipulation listed below:
- Forearm held in different positions by plaster
- Plaster cast type A versus type B
- Foreartm held in different positions by brace
- Plaster cast for different durations
- Brace versus plaster cast
- Bandage (minimal support) versus plaster cast or brace
- Different types of cast material
- Manipulation versus no manipulation
- Delayed manipulation versus immediate manipulation.
Comment: The quality of evidence is downgraded by severe study limitations and heterogeneity of populations, interventions and outcomes.
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