Closed reduction of distal radius fractures: a systematic review and meta-analysis

Comparison of 2 Types of Local Anesthetic Techniques in the Reduction of Distal Radius Fracture: A Prospective Cohort Study

BACKGROUND

The treatment of distal radius fractures may require manipulation of the fracture assisted by finger traction, causing pain both at the fracture site and at the fingers. The usual type of anesthesia used does not anesthetize the fingers.

METHODS

We conducted a prospective cohort study with two groups, hematoma block (HB) and hematoma with associated median nerve block (MHB). Characteristic variables of the patients were collected. The main variable for the analysis was pain, measured using the Visual Analogical Scale (VAS). It was measured prior to the injection (VAS1), during fracture reduction (VAS2), and 30 minutes after the injection (VAS3) in both groups.

RESULTS

The study included a total of 140 fractures (70 anesthetized with HB), 78% were women. There were no significant differences in the variables age, sex, Elixhauser index. and need for surgery between the groups. In the HB group, the VAS means were VAS1 5.23 cm (SD 2.31), VAS2 5.80 cm (SD 2.52), and VAS3 1.89 cm (SD 1.94); while in the MHB group, VAS1 5.13 cm (SD 2.36), VAS2 3.15 cm (SD 1.70), and VAS3 1.09 cm (SD 1.38). Area of greatest pain during fracture reduction in the HB group was finger traction in 78% cases (p < .05), while in the MHB group it was the manipulation of the fracture site in 71% cases (p < .05).

CONCLUSIONS

The study demonstrates that the use of hematoma with associated median nerve block decreases pain perception in patients with distal radius fracture that needs closed reduction, when compared to HB alone.

Assessing the efficacy of manual reduction and novel traction techniques for distal radius fractures: A randomized controlled trial

Background and Aim

One of the leading reasons that patients, particularly older persons, are brought to the orthopedic emergency room is a fracture at the end of the radius. In this study, a new traction method for distal radius fractures was compared with manual reduction.

Methods

The census method was used in this clinical trial to study 45 patients (46 hands) who were referred to Hamedan Besat Hospital in 2021. Patients were randomly assigned to two groups. The manual reduction (pressure and traction by an assistant and a doctor) method was implemented in Group A, and the new traction procedure (pressure and traction by hardware or a device) was performed in Group B. The radiographic results of reduction in both groups were investigated and compared immediately and in the first and 6 weeks after surgery.

Results

The following results were observed in the new and manual groups in the sixth week after surgery: average volar tilt: 4.19 ± 3.79 and 4.08 ± 3.88 (p = 0.926), radial angulation: 2.18 ± 1.27 and 2.21 ± 1.35 (p = 0.934), radial shortening: 10.52 ± 0.65 and 10.56 ± 0.68 (p = 0.828), radial inclination: 22.52 ± 2.46 and 22.71 ± 2.01 (p = 0.787), dorsal angulation: -5.89 ± 0.33 and 5.22 ± -1.91 (p = 1.00), ulnar variance: 1.66 ± 0.90 and 1.67 ± 0.81 (p = 0.958), and average pain score: 2.40 ± 0.68 and 2.47 ± 0.73 (p = 0.737).

Conclusion

The new reduction procedure with hardware in patients with distal radius fractures showed the same effect as the traditional method based on pressure and traction by the assistant and doctor in terms of radiographic changes and pain score of the fracture site.

Peripheral nerve blocks for closed reduction of distal radius fractures-A protocol for a systematic review

BACKGROUND

Current methods of anaesthesia used for closed reduction of distal radial fractures may be insufficient for pain relief and muscle relaxation, potentially compromising reduction quality and patient satisfaction. Peripheral nerve blocks have already been implemented for surgery of wrist fractures and may provide optimal conditions for closed reduction due to complete motor and sensory blockade of the involved nerves. However, existing literature on peripheral nerve blocks for closed reduction is sparse, and no updated systematic review or meta-analysis exists.

AIMS

This protocol is developed according to the PRISMA-P statement. The systematic review and meta-analysis aim to consolidate the literature regarding the effect and harm of peripheral nerve blocks compared with other anaesthesia modalities for closed reduction of distal radius fractures in adults.

METHODS

The two primary outcomes are the proportion of participants needing surgery after closed reduction and pain during closed reduction. We will only include randomised clinical trials. Two review authors will each independently screen literature, extract data, and assess risk of bias with Risk of Bias 2 Tool. Meta-analysis will be carried out with Rstudio. We will also perform a Trial Sequential Analysis. The certainty of evidence will be judged using GRADE guidelines.

DISCUSSION

We will use up-to-date methodology when conducting the systematic review outlined in this protocol. The results may guide clinicians in their decision-making regarding the use of anaesthesia for closed reduction of distal radius fractures in adults.

The hematoma block is not enough as method of anesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in the emergency are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess the pain during closed reduction of distal radius fractures after using the hematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilization during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analog scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the hematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

The hematoma block is only a mild effective method to reduce the wrist pain during closed reduction of distal radius fractures. This technique decreases slightly the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

[Translated article] The haematoma block is not enough as method of anaesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in an emergency department are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess pain during closed reduction of distal radius fractures after using haematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilisation during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analogue scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the haematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

Haematoma block is only a mildly effective method to reduce wrist pain during closed reduction of distal radius fractures. This technique slightly decreases the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

A facile, semi-automatic protocol for the design and production of 3D printed, anatomical customized orthopedic casts for forearm fractures

Closed fractures of distal radius and ulna are one of the most common skeletal injuries, occurring at all ages. Temporary arm immobilization through cast is part of the standard treatments. However, traditional casting procedures are time consuming, operator's skill dependent and do not always guarantee a satisfactory outcome. From a clinical perspective, casts are often considered uncomfortable and can be associated to skin lesions. To overcome these limitations, the recent growth of 3D technologies has enabled new standardized casting procedures: additive manufacturing (AM) is a technique that creates highly customized cast models from anatomical 3D data by using digitally controlled and operated material laying tools. Compared with conventional casts, those produced with AM technique could potentially reduce skin complications and satisfy both mechanical and clinical requirements of functionality, comfort, and aesthetics. The objective of this study is to describe the new practical methodology to produce a 3D printable cast for upper arm immobilization. The parametric modelling tool, employed to develop a semi-automatic design system for generating the printable cast model, reduces the complex process of orthosis design to a few minutes and all the manufacturing operations remain unaffected by CAD skills of the operator. Specific hardware and software tools (3D scanner, modelling software and FDM technology) were chosen to mitigate design and production costs while guaranteeing suitable levels of data accuracy, process efficiency and design versatility. To highlight the effectiveness of the proposed solution, a finite element analysis simulation was performed on models with different geometry, highlighting the mechanical strength of generated structures. The final result is a personalized 3D printed cast with a highly ventilated structure that is lightweight but still maintains a high level of strength and provides hygienic benefits, reducing the risk of cutaneous complications, potentially improving treatment efficacy and increasing patient satisfaction.

Closed reduction of dorsally displaced distal radius fractures in the elderly provided improved final radiographic results

BACKGROUND

Recent guidelines recommend non-operative treatment as primary treatment in elderly patients with displaced distal radius fractures. Most of these fractures are closely reduced. We aimed to evaluate the radiological results of closed reduction and casting of dorsally displaced distal radius fractures in patients 65 years or older.

METHODS

A total of 290 patients treated during the years 2015, 2018 and 2019 in an urban outpatient fracture clinic with complete follow-up at least 5 weeks post-reduction were available for analysis. Closed fracture reduction was performed by manual traction under hematoma block. A circular plaster of Paris cast was used. Radiographs pre- and post-reduction and at final follow-up were analyzed.

RESULTS

Mean age was 77 years (SD 8) and 258 (89%) were women. Dorsal tilt improved from mean 111° (range 83-139) to 89° (71-116) post-reduction and fell back to mean 98° (range 64-131) at final follow-up. Ulnar variance was 2 mm ((-1)-12) pre-reduction, 0 mm ((-3)-5) post-reduction and ended at mean 2 mm (0-8). Radial inclination went from 17° ((-6)-30) to 23° (SD 7-33), and then back to 18° (0-32) at final follow-up. 41 (14%) patients had worse alignment at final follow-up compared to pre-reduction. 48 (17%) obtained a position similar to the starting point, while 201 (69%) improved. Fractures with the volar cortex aligned after reduction retained 0.4 mm (95% Confidence Interval (CI) 0.1 to 0.7; p = 0,022) more radius length during immobilization. In a regression analysis, less ulnar variance in initial radiographs (OR 1.8 (95% CI 1.4 to 2.3) per mm, p < 0.001) and lower age (OR 1.06 (95% CI 1.02 to 1.09) per year, p < 0.003) protected against loss of reduction.

CONCLUSION

Subsequent loss of reduction after initial closed reduction was seen in most distal radius fractures. Reduction improved overall alignment in 2/3 of the patients at final follow-up. An aligned volar cortex seemed to protect partially against loss of radial length.

[Conservative management of distal radius fractures]

Distal radius fractures are the third most frequent fractures in Germany. The decision for conservative treatment and the weighing up of surgical treatment need an exact consideration of the indications based on instability criteria and the extent of possible articular involvement. Indications for an emergency operation must be excluded. In cases of stable fractures or multimorbid patients in a poor general condition conservative treatment is indicated. The principles for a successful treatment are the precise reduction and stable retention in a plaster splint. In the further course, fractures are closely monitored by biplanar radiography. This is necessary to rule out a secondary displacement until the swelling of the soft tissues has subsided and the plaster splint is changed to a circular cast approximately 11 days after the traumatic event. The total duration of immobilization is 4 weeks. Physiotherapy and ergotherapy including adjacent joints, starts after 2 weeks of treatment. This treatment is extended to the wrist after removal of the circular cast.

Adult Distal Radius Fracture Management

Distal radius fractures (DRFs) are some of the most commonly encountered fractures, and the incidence is increasing. Optimal treatment remains controversial. Critical evaluation of the initial imaging is necessary to recognize fracture characteristics and stability. The fracture pattern, injury mechanism, soft-tissue injury, patient characteristics, and surgeon preference are generally taken into consideration when choosing the most appropriate modality. Volar plating has become the workhorse of surgical DRF management but is not without complications. The surgeon should be comfortable using a wide variety of techniques to customize the fixation to the fracture pattern. Recognition of potential dangers and use of intraoperative imaging techniques can mitigate complications. Goals of rehabilitation after the initial treatment of DRF include regaining motion, strength, and ultimately function while managing pain.

Phalangeal Fracture Secondary to Hammering One’s Finger

The authors report the case of a man who smashed his finger while using a hammer, resulting in a fracture-dislocation. The description of this injury type and the emergency management is discussed.

Distal radius fractures: an evidence-based approach to assessment and management

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Closed Unassisted Reduction in Emergency: A Technique for Unassisted Closed Reduction of Colles Fractures Without Equipment

BACKGROUND

Colles fractures are fractures of the distal radius that are often encountered in the emergency department. They result from accidents and sport injuries in the young but are a common outcome of falls in the elderly population. While Colles fractures are frequently expected to heal with good results, improper reduction, malunion, or later displacement are related to poor functional outcomes in the long term. Treatment is usually by closed reduction either manually or using longitudinal traction. The disadvantage of this is the need for either trained assistants or equipment. We propose a technique for closed unassisted reduction without the use of equipment that can be useful in acute settings where there is shortage of assistance and tools.

DISCUSSION

Fifty-two patients with distal radius fractures were treated with closed unassisted reduction in emergency. The steps of the technique are explained in detail and shown in the accompanying videos. The key lies in the placement of the patient, the use of the doctor's thigh as a lever for the reduction, and positioning of the arm to support the reduction using its own weight. All 52 reductions were successful, while the duration of the reduction process was in all cases under 10 min.

CONCLUSIONS

Closed unassisted reduction in emergency for Colles fractures is a reliable and simple technique, its major advantage being that it can be performed quickly by 1 physician without equipment.