Despite the popularity of surgical treatment, most displaced distal radius fractures (DRFs) are initially managed with closed reduction and immobilization.
Radiological outcomes were not significantly different between mechanical reduction using finger-trap traction and manual reduction.
Compared to procedural sedation, local anesthesia (hematoma block) is a safe and effective alternative anesthesia for reduction of DRFs, which provides excellent pain relief in adult and pediatric patients.
Immobilization using a sugar-tong or above-the-elbow splint is equivalent to a short-arm splint for maintaining the reduction and quality of molding has more influence on maintaining reduction than the length of the cast.
The evidence of the benefit of routinely repeating reduction or routine preoperative reduction in DRFs is insufficient
Repeated reduction should be reserved for experienced teams in selected patients, such as those with minimal comminution, those who fail to get appropriate reduction due to inadequate anesthesia or those who have relative contraindications to surgery.
A 46-year-postmenopausal woman visited the emergency department with a swollen and deformed right wrist after falling on an outstretched hand. Radiographs showed a displaced distal radius fracture with a 40 degrees dorsal angulation and metaphyseal comminution ( Fig. 1 ). How is her fracture most effectively reduced and maintained?
Importance of the Problem
Distal radius fractures (DRFs) are a common orthopedic condition among adults and high incidence is reported worldwide. Multiple treatment options are available for patients with DRFs, including cast immobilization, percutaneous pinning, external fixation, and open reduction with internal fixation (ORIF) using a plate. The optimal choice depends on several factors such as patient age, fracture pattern, displacement, fracture instability, and surgeon preference. Over the recent decades, surgical approaches such as ORIF have been increasingly used. Despite the popularity of ORIF, most displaced DRFs are initially managed with closed reduction and subsequent orthosis. Closed reduction of DRFs is commonly performed in the emergency department to obtain acceptable fracture alignment and maintain stability. In some cases, two or more reduction attempts are performed to achieve these goals.
What is the most effective technique for closed reduction and immobilization in the treatment of DRFs?
The initial management of DRFs typically consists of closed reduction and immobilization in the emergency department. The quality of reduction can influence definitive management; thus, some authors have suggested that significant efforts should be made to obtain anatomical reduction when possible. Therefore, a combination of closed reduction and cast immobilization remains a preferred treatment option in most cases. However, the optimal method for closed reduction remains to be determined.
Closed reduction of a fracture is considered acceptable when the following radiologic conditions are obtained: radial inclination ≥ 15 degrees, loss of radial height ≤ 5 mm, dorsal angulation ≤ 15 degrees and palmar angulation ≤ 20 degrees. The classic method of closed reduction for DRFs requires two people pulling in opposite directions to produce and maintain longitudinal traction. This is termed manual reduction . The mechanical methods of reduction usually include the use of “finger traps.” In finger-trap traction, the injured arm is suspended using finger traps attached to two or more fingers, and a counterweight is suspended over the upper arm. Although manual manipulation is widely used, several studies have recommended finger-trap traction as a more gentle method of reduction. Finger-trap traction can be applied without the need for an assistant, and it allows for easier application of the plaster cast. However, during molding of the plaster, the traction tends to pull the wrist straight, making ulnar deviation, and flexion difficult to achieve.
To reduce the pain during reduction, regional anesthesia (hematoma block) or procedural sedation is commonly performed. After closed reduction, a sugar-tong splint or above-elbow cast is commonly used to prevent pronation and supination, although a short-arm cast is deemed to be equivalent. It has been suggested that the quality of molding has more influence on maintaining reduction than the length of the cast.
Finding the Evidence
A literature search was conducted in PubMed, Embase, and the Cochrane Library. The following search terms were used: ( colles, fracture OR colles fracture OR colles fractures OR colles OR distal radius fracture OR distal radius fractures OR distal radial fracture OR distal radial fractures ) AND ( traction jig OR finger stretch OR finger stretch traction OR finger trap OR finger trap traction OR manual reposition OR manual repositioning OR reposition OR repositioning OR manual reduction OR reduction OR closed reduction OR closed manual reduction ). A manual search for additional eligible studies that were not found during the abovementioned search was performed using the reference lists of the included studies and relevant review articles.
Bibliographies of the eligible articles
Articles that were not in the English, French, or German were excluded.
The search of the abovementioned databases was performed by a trained Cochrane librarian.
Quality of the Evidence
Systematic Reviews/Metaanalyses: 2
Randomized trials: 8
Randomized trials with methodological limitations: 1
Retrospective comparative studies: 6
Finger-Trap Versus Manual Reduction
Kongsholm et al. performed a prospective randomized study to compare finger-trap and manual reductions for DRFs. They reported that finger-trap reduction was significantly less painful than manual reduction, even without anesthesia. However, the radiological outcomes of both reduction techniques were similar, and both techniques resulted in acceptable reduction in terms of volar angle and radial length.
Holkenborg et al. also performed a randomized study and reported that the mean visual analog scale (VAS) score, satisfaction level, and radiological outcomes after reduction did not differ between the finger-trap and manual reduction groups. Although finger-trap traction seemed more technically challenging, they reported a significantly better Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score, and reduced incidence of carpal tunnel syndrome and complex regional pain syndrome in the finger-trap reduction group.
Earnshaw et al. conducted a prospective randomized study to compare the results of conventional manipulation with those of finger-trap traction for closed reduction of DRFs on the basis of radiographic outcome. Two hundred and 23 patients with 225 displaced DRFs were randomized to treatment groups of closed reduction with either finger-trap traction (112 patients) or manual manipulation (111 patients). Dorsal angulation, radial shortening, and radial angulation were reported to have no differences between the two groups either at initial presentation or after reduction. No significant difference in VAS scores between the two groups were found. When the dorsal tilt less than 10 degrees and radial shortening less than 5 mm are considered as acceptable, both techniques resulted in 87% of satisfactory reductions. However, the percentages of fracture that showed an acceptable alignment were only 57% and 50% at 1 week and only 27% and 32% at 5 weeks in the finger-trap traction and manual manipulation groups, respectively. The failure rates did not differ significantly between the two groups.
A recent systematic review and metaanalysis reported that closed reduction using finger-trap traction seems better than manual manipulation in restoring radial length, whereas a manual reduction technique seems better in restoring dorsal tilt ( Figs. 2 and 3 ). However, finger-trap reduction seemed to provide less pain and fewer complications.
Dailey et al. conducted a prospective randomized controlled study on the effectiveness of mini C-Arm fluoroscopy for closed reduction of DRFs. Standard reductions were performed in 34, and fluoroscopically aided reductions in 29 patients. No significant differences in postreduction radial height, radial inclination, ulnar variance, and volar tilt were observed. The overall reduction attempts and subjective difficulty of fracture reduction increased when fluoroscopy was performed. The rate of initial operative management did not differ between the groups.
Kazum et al. also compared the radiological outcomes of adult closed DRF reductions with and without fluoroscopy. In this retrospective study, 90 and 84 patients underwent reduction with and without fluoroscopy, respectively. According to the accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of the patients in the reduction without fluoroscopy group and for 56% of the patients in the fluoroscopy-assisted reduction group ( P = .44). In addition, no significant difference in any postreduction radiographic parameters or alignment of unstable fractures was observed between the groups.
Kodama et al. compared ultrasonography-assisted closed reduction between a retrospective cohort of blind and fluoroscopy-assisted reduction and a blind reduction control group. The ultrasonography-guided group consisted of 43 patients, and the control group consisted of 57 patients, including 35 who underwent fluoroscopic reduction and 22 who underwent reduction unaided by imaging. They found no significant displacement differences between the radiographic and ultrasonographic measurements. Ultrasonography-guided reduction took longer than the other two methods. The criteria for successful reduction were defined as radial shortening of less than 1 mm and the volar tilt of 0 degree or greater in postreduction radiographs. The success rates were similar between the ultrasonography and fluoroscopy groups (95% and 94%, respectively). However, fluoroscopy-assisted reduction had a higher success rate than blinded closed reduction (94% vs 68%), but both reduction methods provided similar radiographic results. They suggest that both ultrasonographic and fluoroscopic assistance can aid in the reduction of DRFs.
Comparison Between Hematoma Block and Procedural Sedation
Fathi et al. compared the efficacy and safety of ultrasonography-guided hematoma block with those of procedural sedation and analgesia in patients with acute DRF reduction pain control. This randomized clinical trial demonstrated that pain scores did not differ significantly before and during reduction, and at 5 and 15 min after reduction in the procedural sedation and analgesia, and ultrasonography-guided hematoma block groups. Overall satisfaction levels of the patients and physicians were similar between the two groups.
Singh et al. also performed a randomized controlled study and reported that the pain scores during reduction in the hematoma block group were significantly lower than those in the sedation group.
Bear et al. conducted a prospective study for DRF reduction in children. They reported no significant difference in pre- and postreduction angulations between the hematoma block and sedation groups, and reductions maintained satisfactory alignment. The overall satisfaction was excellent, and pain/discomfort was minimal in both groups. However, the length of stay in the emergency department was significantly shorter for the hematoma block group.
A recent systematic review and metaanalysis reported that postreduction pain severity was lower for hematoma block than procedural sedation and analgesia (95% confidence interval [CI], 1.170–0.029; P = .039), although there was no difference in pain severity during reduction between these two groups (95% CI, 1.101–1.812; P = .632). Most of the reported side effects include nausea, vomiting, and respiratory distress in adult patients treated with procedural sedation and analgesia. The incidence rates of the reported side effects did not significantly differ between the groups of pediatric patients.
Immobilization After Reduction
The sugar-tong splint is a long-arm plaster construct that prevents pronation and supination while allowing some flexion and extension at the elbow. It is commonly used in the acute setting of DRFs; however, the sugar-tong splint is a heavy and cumbersome splint that typically requires patients to use an arm sling. Bong et al. performed a prospective randomized study to compare the sugar-tong splint with the short-arm splint in terms of patient satisfaction and the ability to maintain reduction of DRFs. They found that 16 out of 38(%) fractures immobilized with the short-arm splint, and 17 out of 47(%) fractures immobilized with a sugar-tong splint were displaced, indicating no significant difference. When the splint constructs were evaluated based on fracture stability, no significant differences were found between the splints in terms of the ability to maintain fracture reduction in both stable and unstable displaced fractures. The patients in the short-arm splint group had significantly better DASH scores than those in the sugar-tong group at 1 week.
Park et al. also conducted a prospective randomized multicenter study to compare short- and long-arm plaster casts for the treatment of stable distal radius fractures in patients aged older than 55 years. There were no significant differences in radiological parameters between the groups, except for volar tilt. Volar tilt is superior for the patients in the long arm cast group at each follow-up. However, the mean score for disability caused by plaster cast immobilization and the incidence rate of shoulder pain were significantly higher in the patients who had a long plaster cast.
Chess et al. demonstrated a cast index to determine the quality of the molding of the cast to the normal contours of the child’s forearm. The index was determined by dividing the sagittal width of the cast by the coronal width of the cast at the fracture site and was shown to be 0.7 for a cast used on the distal part of a normal forearm of a child. They reported that 10% of the fractures in their series had reduction loss which were related to poor cast-molding as demonstrated by the cast index. These results suggest that short arm casts, if applied with appropriate molding, can be effective in the treatment of fractures of the distal third of the forearm in children.
Webb et al. performed prospective randomized study to compare short and long arm casts for displaced fractures in the distal third of the forearm in children and demonstrated there were no significant differences between the two groups with regard to the change in displacement, angulation, or deviation during the treatment. However, fractures that lost reduction in the cast had significantly higher cast indices, indicating poor cast molding. Thus, either a long or a short arm cast can be used, but proper molding of either is mandatory.
Repeated attempts of closed reduction of DRFs are occasionally performed in the emergency department or outpatient clinical setting to optimize fracture alignment and avoid surgery. However, additional manipulation of the fracture may increase dorsal comminution and lead to loss of reduction in the cast. Schermann et al. found that repeated reduction attempts worsen dorsal comminution, however, they improve immediate fracture alignment. Only 5.2% of patients who underwent two reduction attempts had acceptable final alignment without requiring any surgery. Another study investigated whether re-manipulation of DRFs 1–2 weeks after the initial closed reduction was beneficial, at the time of the first follow-up. They found that repeated reduction attempts improved dorsal angulation in only 32% of the patients, all of whom were aged less than 60 years. This suggests that re-manipulation and optimal molded casting is best reserved for experienced teams in selected patients, such as those with minimal comminution, those who fail to get appropriate reduction due to inadequate anesthesia or those who have relative contraindications to surgery. In experienced hands, satisfactory rates of maintained reduction can be achieved in order to avoid surgery.
When the decision is made to operate, based on the initial fracture radiographs, controversy exists whether the fracture should be reduced before surgery. Reduction can relieve soft tissue tension, reduced pressure on the median nerve and might reduce discomfort. However, the hypothetical risks of soft tissue problems, median neuropathy related to deformity, and increased pain remain controversial as routinely manipulating the reduction provides discomfort to the patient and takes considerable time and resources for medical personnel without evident benefit. ANY EVIDENCE ON CASES WITH SIGNS OF ACUTE CARPAL TUNNEL SYNDROME? ASSUME THEY SHOULD BE REDUCED ASAP? (Although it is generally agreed that closed reduction should be performed in patient who had skin tenting or acute carpal tunnel syndrome due to distal radius fractures, no clear consensus exists about the appropriate indication for closed reduction.)
Based on the study by Fan et al. who retrospectively evaluated 128 patients with unstable DRFs, there were no significant differences between the patients who did and did not undergo closed reduction in terms of surgery time, complication rate, and functional outcomes. Teunis et al. performed a retrospective cohort study to assess unreduced fractures before surgery in the cases without any wound, skin tenting, or neuropathy. They reported no significant differences in rates of adverse events or number of subsequent surgeries within the first year after surgery between the reduced and unreduced fractures before surgery. Jung et al. also performed retrospective comparative study between the acceptable reduction and nonacceptable reduction group. They reported that there were no significant differences in the preoperative pain VAS score, mean length of stay, operation time, and postoperative complications between the groups. In addition, radiologic parameters and the DASH score at a 1-year follow-up were also not significantly different between the groups.
No universally agreed consensus has been reached on the optimal technique and anesthetic approach for closed reduction of DRFs as various methods seem equally effective. In addition, the reduction technique does not appear to influence radiological outcomes. Patient characteristics and preferences, fracture type, local expertise, and resources influence treatment choices. Thus, there is sufficient argument to support that surgeons should continue to use the technique that they have been trained on and perform best in their institution with local facilities. Evidence regarding the benefit of routine repeated or preoperative reduction in patients with DRFs is insufficient. A future prospective randomized study is necessary to investigate the need for repeated or preoperative reduction in terms of radiological or surgical outcomes and patient comfort.