Closed Reduction and Immobilization of Displaced Distal Radius Fractures

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.

Main Question

What is the most effective technique for closed reduction and immobilization in the treatment of DRFs?

Current Opinion

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