closed manual reduction of distal end radius

Over recent decades, surgical approaches such as open reduction and internal fixation have seen increasing use, but recent studies with one-year follow-up show no significant differences between surgical intervention and closed reduction with cast immobilization in terms of functional outcome. 1, 2 Additionally, complications such as tendon afflictions and further surgery can arise from surgical intervention. 1 Therefore, closed reduction and cast immobilization remains an important treatment option in a majority of cases. However, the optimal method of closed reduction remains to be determined. A very commonly used method of closed reduction is manual traction (MT). An assistant provides counter-traction while the operator provides traction and manipulates the bone fragments into position. 3, 4 Even though it has been the most commonly used method for at least the better part of a century, 3 the evidence of its effectiveness is ambiguous, and by the 1950s it was already being postulated that the method might damage the soft tissues surrounding the fracture. 5 Another method is mechanical reduction by finger-trap traction (FTT) which dispenses with the need for an assistant as the forearm is suspended by finger-traps in the radial fingers. Counter-traction is provided by weights suspended on the arm near the elbow joint. This restores the longitudinal axis without further actions, and the operator can then apply manual dorsal pressure to the fragments, if necessary, to restore the volar tilt of the wrist. 6 Several study authors have recommended this procedure as a more gentle method of reduction. 5, 7, 8 A Cochrane Review from 2003, updated in 2007, found insufficient evidence to recommend one type of reduction over the other.

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There is obvious deformity about the wrist with associated swelling and tenderness. X-ray imaging reveals the following: How do you treat this? This post will review the technique of hematoma block for analgesia as well as the different techniques for reduction of distal radius fractures and application of splint. Cleanse this entire area thoroughly with skin cleanser. The patient sits in this position for 10-15 minutes and is then splinted while still in the finger traps. Involves hyperextension of the wrist to recreate the mechanism of injury followed by volar translation of the distal radial fragment. This is done while an assistant is providing counter-traction at the upper arm with the elbow flexed to 90 degrees. The reduction should be splinted with the hand held in ulnar deviation. Two hundred twenty three patients were randomized with distal radius fractures to undergo finger trap reduction or manual manipulation. Both techniques achieved an 87% successful reduction rate initially. Long term reduction was decreased in both groups with only 57% (finger trap) and 50% (manual manipulation) achieving acceptable alignment after one week. This was not statistically significant. Both techniques appear to be safe and equally efficacious for closed reduction. Cochrane Database of Systematic Reviews 2002; 3, CD003320. Bookmark the permalink. Abstract Distal radius fractures (DRF) are a common injury, especially in the elderly. Displaced fractures can be reduced by closed reduction through several techniques, two of which are compared in this systematic review and meta-analysis. Closed reduction by finger-trap traction (FTT) seems to offer better correction of radial shortening. Additionally, there may be less pain and fewer complications associated with this technique. Closed reduction by manual traction seems to offer better correction of the dorsal tilt. Further research is needed to fully determine the optimal method of closed reduction.

Search The search string was generated with the aid of a scientific librarian: (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) Study selection Management of the search results was carried out in Covidence. 12 Duplicate studies were identified automatically and manually in Covidence. Titles and abstracts of all retrieved studies were individually reviewed for relevant articles by two authors for inclusion. Eligible abstracts were collectively reviewed, and candidate studies were read in full text. Holkenborg et al 7 was only available as an abstract and was included because the corresponding author provided raw radiographic outcomes as well as additional details through correspondence. Data collection process Disagreements between reviewers were resolved through discussion between the two first authors. If a decision was not reached, a third reviewer was advised. One review author entered the extracted data into Excel, and data registration was examined by a second author. Data items The fracture should be classified by either the AO or Frykman classification 13 or provide a specified, reproducible method of measuring the displacement radiographically. Data extraction of included studies was performed using a data-extraction sheet based on type of study, country, baseline characteristics, intervention, comparator, radiographic outcomes as well as pain and success rate. Holkenborg et al 7 were contacted with additional questions, primarily concerning bias. In addition, Mr. Holkenborg kindly provided the radiographic outcomes and other details, though not a full paper.

9 The aim of this article is to perform a systematic review and meta-analysis of the current literature that compares closed reduction by MT to FTT with radiographic measures and pain assessment in the treatment of distal radial fractures in adults. Methods Protocol and registration This systematic review and meta-analysis was planned, conducted, and reported according to the guidelines of the PRISMA statement. 10 A study protocol was registered with the PROSPERO register of systematic reviews prior to data abstraction and analysis with the registration number CRD42016036274. 11 Eligibility criteria We considered studies featuring an adult population with a dislocated distal radial fracture who had undergone closed reduction by either MT or FTT and measured radiographic outcomes. Inclusion criteria: Articles involving distal radius fractures. Articles written in English, French, German or a Scandinavian language. Randomized controlled trials (RCTs), including abstracts. Report of the sought outcome of interest: radiographic evaluation. Exclusion criteria: Articles including patients under 18 years of age. Systematic reviews. Studies with a focus on any type of surgical intervention, such as open reduction and internal fixation (ORIF), pinning and external fixation. Primary outcome: Radiographic measurements of angulation and radial length. Secondary outcomes: Pain during reduction, difficulty of reduction, success rate of reduction. Randomized controlled trials evaluating the use of fluoroscopy during closed reduction on adult patients were also sought, but none were found. Information sources Studies were identified by using electronic databases and by scanning the reference lists of articles.

None of the studies addressed the randomization or allocation concealment in sufficient detail, and only Earnshaw et al 14 reported blinding of the radiographic assessors. Holkenborg et al 7 provided some additional information through email correspondence. Only Kongsholm et al 8 addressed completeness of data within the article. Only Holkenborg et al 7 had a protocol pre-published to assess selective outcome reporting and were available for additional inquiries regarding bias. 19 Table 2. Quality assessment using the Cochrane Collaboration’s tool for assessing risk of bias 16 Sequence generation Allocation concealment Blinding of participants, personnel etc. Incomplete data outcome Selective outcome reporting Other sources of bias Earnshaw et al 14 Unclear Yes Yes Unclear Unclear Unclear Holkenborg et al 7 Unclear Yes Yes Unclear Yes Unclear Kongsholm et al 8 Unclear Unclear Unclear Yes Unclear Unclear Open in a separate window Result of individual studies None of the radiological outcomes differ significantly between groups, apart from the dorsal tilt in Kongsholm et al 8 in favour of FTT ( Table 3 ). In Kongsholm et al 8 there was significantly less pain associated with FTT. Open in a separate window Fig. 3 Forest plot of fracture shortening in patients with a distal radius fracture after reduction with either FTT or MT. Note. FTT, finger-trap traction; MT, manual traction; SD, standard deviation; df, degree of freedom; Fixed, fixed effects model. Discussion From the evidence presented here, there may be a slight but significant advantage in FTT in terms of restoring radial length but MT seems to provide a significantly better dorsal tilt post-reduction. In the pooled data, the differences are quite small: an improvement of 0.43 degrees in dorsal tilt and 0.19 mm improvement in radial length. However, in individual studies, the difference in radial length is as large as 0.65 mm, which is substantial.

In Earnshaw et al, 14 radiographic outcomes were only reported graphically and were measured digitally to approximate numerical values. For the sake of comparison, the radial lengths in Kongsholm et al 8 and Holkenborg et al 7 were converted to radial shortening using the original reference. 15 Any disagreement regarding inclusion of an article was resolved by discussion or input from a third co-author (BV). Each of the above domains were judged as being at low risk of bias, high risk of bias or unclear risk of bias (indicating either a lack of information or uncertainty over the potential for bias). None of the studies contained information about a pre-published protocol, and, apart from Holkenborg et al, 7 it was not possible to locate pre-published protocols through search engines. Risk of bias across studies An assessment of publication bias was attempted through a search on ClinicalTrials.gov. No further studies were identified. Publication bias has been found likely to exist in another study. 17 Additional analyses and synthesis of results Dorsal tilt and shortening were evaluated across studies and were meta-analysed using forest plots (statistical software: Rewman 5.3). Intervention effect was expressed as standard mean difference. Pooled data were assessed for heterogeneity using chi 2 test and I 2 test. FTT, finger-trap traction. Study characteristics All three trials were based in Europe. A total of 483 patients were included ( Table 1 ). Of these, 240 were treated using FTT and 243 using MT. Median ages were comparable between studies although range was not specified in Holkenborg et al 7 and inclusion period was not mentioned in Kongsholm et al. 8 Female gender was highly predominant across studies, although this was lower in Earnshaw et al 14 than the other studies ( Table 1 ). Risk of bias within studies Concerning the risk of bias in the studies, there was generally a lack of information within the articles ( Table 2 ).

Kongsholm et al 8 did not appear to be blinded in their radiographic assessments, which may pose a risk of bias. Concerning bias at review level, all identified research was retrieved. However, it has earlier been concluded that there likely exists a publication bias in the literature on distal radial fractures. 17 Our study is limited by the assumptions we make in gathering the quantitative outcome. Although the measurement of graphical data from Earnshaw et al 14 was performed as accurately as possible (measured by pixel), it is still an approximation of the actual results. In the data from Kongsholm et al 8 and Holkenborg et al 7 radial length was converted to radial shortening using the original reference article, but the validity of this conversion is untested. In conclusion, the studies lack sufficient quality to reliably determine a difference between the two methods. Reduction by FTT seems to have a small significant advantage in restoring radial length, whereas reduction by MT seems to have a significant advantage in realigning dorsal tilt. The advantages are not necessarily clinically significant, and the studies were very heterogenic. Further research is warranted to investigate the best possible method of reduction in terms of radiographic outcome and patient comfort. Footnotes ICMJE Conflict of interest statement: None declared. Funding statement No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC.J Hand Surg Am. Bartl C, Stengel D, Bruckner T, Gebhard F, ORCHID Study Group. The treatment of displaced intra-articular distal radius fractures in elderly patients. Dtsch Arztebl Int. Charnley J.In: The closed treatment of common fractures. 3rd ed. McRae R.In: Practical fracture treatment. 3rd ed. Robbins JV.NY State J Med. Bate JT.Clin Orthop Relat Res. Holkenborg J, Napel S-JT, Kolkman K.

Kongsholm J, Olerud C.Handoll HH, Madhok R.In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews.January. Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med JuneMelbourne, Australia: Veritas Health Innovation. Frykman G.A clinical and experimental study. Acta Orthop Scand. Earnshaw SA, Aladin A, Surendran S, Moran CG.J Bone Joint Surg Am. Solgaard S.J Hand Surg Am. Lakartidningen. MarchJ Orthop Trauma. Abbaszadegan H, Jonsson U, von Sivers K.Acta Orthop Scand. Aro HT, Koivunen T.J Hand Surg Am. Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y.J Hand Surg Am. Immediate post-operative radiographs are seen in Figure A. The patient recovered well initially but presents after 6 months with grip weakness. What complication is most likely to occur in this patient?Four months post-injury, he presents to the office with an inability to extend his thumb. Which of the following injuries is the most likely cause of this finding?Radiographs of the affected wrist are shown in Figure A. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Incompetence of which of the following anatomic structures is the most likely etiology of this finding?The injury is closed and she is neurovascularly intact. There is no median nerve paresthesias. Radiographs are shown in Figures A and B. What is the next best step in management of this patient?He sustains the injury shown in Figure A. The patient undergoes open reduction and internal fixation of the fracture. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. This medication is given in an effort to decrease the incidence of which of the following?He denies any new trauma, and has followed all post-operative activity restrictions.

As several studies have identified radial shortening as the biggest factor of a poor outcome, 21, 22 this indicates that improved reduction by finger-trap traction could potentially reduce the need for surgical intervention. These differences between the two methods seem logical considering the traits of the two methods. In FTT, there is a substantial amount of longitudinal traction for what may be a longer period than in MT. 8 On the other hand, it can be harder to apply dorsal pressure to the fragments during finger-trap reduction, as noted by Earnshaw et al. 14 Even if radiographic outcomes are similar, there are other differences to consider, including pain and potential damage done by the reduction manoeuvre itself. Two of our included studies have measured pain as an outcome. In Kongsholm et al, 8 FTT reduction was significantly less painful than MT, even though this group was without anaesthesia. In a follow-up paper by the same research group, FTT was associated with significantly less neurological impairment, primarily less thumb numbness after 5 weeks. 20 Holkenborg et al 7 showed a significantly better Quick-DASH score in the FTT group as well as a reduced rate of carpal tunnel syndrome and Complex Regional Pain Syndrome. These findings may be indicative of less trauma being inflicted during the actual reduction manoeuvre by FTT and warrants further investigation. However, both Holkenborg et al 7 and Earnshaw et al 14 found reduction by FTT to be more difficult to perform than manual reduction. It is noted in Earnshaw et al 14 that manual reduction is the most commonly used method in the UK, whereas the finger-trap reduction method is often used in the US, and the difficulty in performing FTT may simply be a result of regional experience and preference as both studies are European. Table 4 underlines the heterogeneity in the studies in both method and result.

Though cast type seems to be relatively similar, method of anaesthesia is not comparable between studies at all and the follow-up time and amount of complications differ significantly as well. Kongsholm et al 8, 20 reported on neurological complications defined as paraesthesia, weakness or numbness, which could vary a lot between patients. Furthermore, some of these neurological symptoms were transient and subsided in some patients and occurred in others between 5 weeks and 12 months. Finally, the two included groups also differ in method of anaesthesia. Holkenborg et al 7 used a more validated and reproducible method (Quick-DASH). Though Earnshaw et al 14 do not report specifically on complications, they do report 25% of patients requiring surgery. In Holkenborg et al, 7 10 patients in each group required surgery, corresponding to 15% FTT and 13% MT. The statistically significant complication rate differences in Kongsholm et al 8, 20 do not seem to be reproducible in the other studies, but this is probably due to their definition of neurological impairment being looser. The experience of the operator performing the reduction is impossible to evaluate in Kongsholm et al 8 as they do not specify who performed the reduction. One further study 18 tested a different method where the patient provided traction for the manoeuvre without anaesthesia. There were no significant differences between patient traction and MT in radiographic outcome, and patient traction was associated with significantly more pain. No RCTs evaluating fluoroscopy were found, but Kodama et al 23 compared ultrasound-assisted closed reduction with a retrospective cohort of blind and fluoroscopy-assisted closed reduction control groups. Here, fluoroscopy-assisted reduction had a higher success rate than blinded closed reduction (94% versus 68%), but both reduction methods provided similar radiographic results. There are some limitations to consider.

Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient?Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture?She complains of wrist pain and deformity. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Radiographs are provided in Figure A. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Which of the following interventions should be taken?Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function?What is the most appropriate treatment at this time?During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program?There are no open wounds and the hand is neurovascularly intact. Radiographs are provided in Figures A-C. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist?Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?Adequate maintenance of reduction by non-operative treatment is unsuccesful.

Which plating option provides the most appropriate treatment of this fracture?She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. What is the appropriate surgical treatment at this time?Update your browser for more security, speed and the best experience on this site. A Prospective, Randomized Study - Plaster cast versus external fixation for unstable intraarticular Colles' fractures. - External fixation or plaster for severely displaced comminuted Colles' fractures A prospective study of anatomical and functional results. - Displaced distal radius fractures. A comparative study of early results following external fixation, functional bracing in supination, or dorsal plaster immobilization. - External fixation or plaster cast for severely displaced Colles' fractures. Prospective 1-year study of 46 patients. - Cast or external fixation for fracture of the distal radius. A prospective study of 126 cases. - A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures. Forearm fractures in children. Cast treatment with the elbow extended. Outcome following non operative treatment of displaced distal radius fractures in low demand patients older than 60 years. Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. Predicting Alignment After Closed Reduction and Casting of Distal Radius Fractures Original Text by Clifford R. Wheeless, III, MD. Last updated by Clifford R. Wheeless, III, MD on Friday, April 24, 2015 9:57 am He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. We review technical pearls for successful reduction and splinting, as well as some relative indications for nonoperative management.

With a brief refresher, that shouldn’t be a problem in the ED For those practicing in resource-limited environments there is no choice. Distal radius fractures should not be intimidating. Campared with the complexity of other procedures in emergency medicine, reductions are hard to screw up. Early intervention minimizes risk of expanding hematoma, soft tissue swelling, and muscular spasm which all potentially complicate treatment. When I perform reduction I always document that my involvement represents a more timely intervention, or that I was directed by the orthopedist to perform reduction in order to minimize additional swelling and soft tissue trauma.Highly comminuted intra-articular fractures are unstable in anyone’s hands and will require surgery. Obviously any open fracture requires orthopedic consultation as well as any fractures that potentially involve instability of the carpal bones such as dorsal or volar Barton’s fractures in which the carpal bones displace with the fracture fragment. Other complex fractures warranting orthopedics consultation include any pattern of carpal instability manifest by obvious widening of the scaphoid-lunate or luno-triquetral space, or obvious displacement of the lunate suggesting lunate or peri-lunate dislocation.The most common determinants of care are age, hand dominance, profession, co-morbidities, and activity level. Profession or trade and hand dominance affect tolerance to anything other than anatomic reduction. Older patients with few functional demands can tolerate greater deformity. That said, some older patients, especially those dependent on a cane or walker, may require aggressive interventions to maintain weight bearing through the wrist. Patients with multiple co-morbidities, whether old or young, are less likely to undergo surgical intervention, so achieving near anatomic reductions is more important because reduction is definitive treatment.

Before reducing any fracture, anticipate the ultimate treatment goal. When orthopedics is involved, I try to get a feel if the intention is ultimately to operate or not. Patients who are unlikely to undergo surgical intervention will require near anatomic reduction. Obviously musicians, athletes, and anyone dependent on their wrist to make a living or function require minimal residual deformity. Patients who are poor operative candidates can tolerate some displacement, angulation, or shortening. As a general rule though, treat all distal reductions as if they represent definitive treatment. A good reduction in the ED can possibly spare the patient a surgical intervention. If an orthopedist is on call, this discussion should occur immediately following the reduction so a decision can be made about hospital admission or discharge with followup. If no orthopedist is on call or available, I emphasize to the patient that the best ED treatment has been achieved but additional treatment is needed and an orthopedist should be seen within the next five days.The radio-carpal joint is responsible for flexion and extension, but pronation and supination, perhaps an even more functionally critical movement, is achieved through complex rotational articulation of the distal radial-ulnar joint (DRUJ). Sometimes we fail to look at the dynamics of the injury. An X-ray provides a static moment in time. Injuries to the DRUJ are often missed or under appreciated and can have far worse functional outcomes then injuries to the radio-carpal joint. If you ever have the luxury of mini c-arm during a reduction, take your next distal radius fracture through pronation and supination under live flouro (while the patient is sedated, of course). The dynamic articulations are astounding. Think about how many daily activities involve pronation and supination: opening a door, turning a key, pulling luggage, lifting a bag off the floor.

Shortening of the radius can result in significant disruption of the DRUJ, so achieving appropriate length can be just as important as achieving appropriate alignment. Simply identifying fracture lines that extend into the DRUJ can be an important piece of information that may affect the orthopedist’s threshold to pursue operative intervention. As we have become more comfortable with procedural sedation, the art of hematoma block has been lost. Hematoma blocks can be extremely effective as primary analgesia or an adjunct for patients who cannot tolerate aggressive sedation. It’s typically an easily identified step-off. It’s easy because you just stick the needle in until it hits bone. Often the angle needs to be adjusted a few times before you drop in. The olive oil looking substance is fat. When you see this mixed with dark blood, you’re in the right place. You’re done. One other thing, a little Ativan goes along ways to mellow patients out before and during the procedure. Then break the stick. What happens? The two pieces shorten and overlap under the deforming force of the rubber band. Now try to put the two ends back together, fitting all the jagged edges together while the rubber band is still working against you. You have to fight against the rubber band. This is exactly what happens in any long bone fracture. There are countless muscles whose origin is proximal to the fracture site and insertion is distal. When the spanning muscles spasm, they shorten and deform alignment. The most common muscle culprit in distal radius fractures is the brachioradialis muscle, with the origin above the elbow on the lateral super-condylar ridge and insertion on the radial styloid. Brachioradialism spasm can be somewhat overcome during reduction when the elbow is flexed. You have to fight against this muscle to get the fragment back out to length. The easiest way to achieve traction for distal radius fractures is with finger traps.