Closed Reduction of Colles Fractures: Comparison of Manual Manipulation and Finger-Trap Traction A PROSPECTIVE, RANDOMIZED STUDY

Transcription

1 354 COPYRIGHT 2002 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Closed Reduction of Colles Fractures: Comparison of Manual Manipulation and Finger-Trap Traction A PROSPECTIVE, RANDOMIZED STUDY BY S.A. EARNSHAW, DM, FRCS, A. ALADIN, MRCS, S. SURENDRAN, FRCS, AND C.G. MORAN, MD, FRCS Investigation performed at the Department of Orthopaedic Surgery, Queen s Medical Centre, Nottingham, United Kingdom Background: An optimal outcome of closed treatment of a Colles fracture may depend on accurate reduction and adequate immobilization. It has been suggested that the use of finger-trap traction results in a better reduction and a lower rate of redisplacement than manual manipulation does, but to our knowledge these concepts have never been evaluated scientifically. We compared these two methods in a prospective, randomized controlled trial. Methods: Two hundred and twenty-three patients with 225 displaced Colles-type fractures were randomized to treatment with closed reduction with either finger-trap traction (112 patients) or manual manipulation (111 patients). The fractures were assessed radiographically by measurement of the radial angle, dorsal tilt, and radial shortening before reduction, immediately after reduction, and at one and five weeks after reduction. Results: The groups were comparable with regard to age, sex, side of injury, fracture grade, and amount of displacement at presentation. No significant differences were found between the alignment of the fractures in the two treatment groups at any time. With dorsal tilt of <10 and radial shortening of <5 mm considered acceptable, the two techniques both produced an 87% rate of satisfactory reductions. However, the percentages of fractures in an acceptable alignment were only 57% and 50% at one week after finger-trap traction and manual manipulation, respectively, and only 27% and 32% at five weeks. The failure rates did not differ significantly between the two groups. Conclusions: The two methods of fracture reduction did not differ with regard to the eventual position of the fracture or the rate of failure. Although closed reduction was successful for the majority of fractures, most redisplaced substantially during the period of cast immobilization. A commentary is available with the electronic versions of this article, on our web site ( and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). Colles fracture is a common injury affecting 17% of women over the age of fifty years 1. These fractures are typically displaced and angulated dorsally and radially, with shortening of the distal part of the radius. If they are allowed to unite in poor anatomical alignment, a poor functional outcome is more likely 2,3. Common practice is to attempt a closed reduction to restore fracture alignment. In the United Kingdom, fractures are usually reduced by manual manipulation with countertraction provided by an assistant 4,5. Ideally, a second assistant applies the plaster while the first continues to apply countertraction at the elbow to maintain the reduction, but it is not uncommon for only one assistant to be available. Potential problems with this technique include the placement of the wrist in excessive flexion, which may increase the dorsal angular forces on the distal fragment and increase the risk of displacement 6. In addition, excessive manipulation may comminute the cancellous bone of the distal part of the radius, causing greater instability. In the United States, Colles fractures are often reduced with use of finger traps with 10 to 15 lb (4.5 to 6.8 kg) of countertraction applied to the upper arm 6,7. It has been suggested that this method is easier to perform and reduces the risk of redisplacement 6. However, this technique has never been compared with conventional manual manipulative reduction in a controlled trial, to our knowledge. The aim of this study was to compare the results of conventional manipulation with those of finger-trap traction for the closed reduction of Colles fractures on the basis of radiographic outcome measures in a prospective, randomized trial.

2 355 TABLE I Baseline Characteristics Finger-Trap Traction Manual Manipulation No. of patients Difference Between Groups Age* (yr) 60.2 ± ± 17.5 Not significant Female gender (%) Not significant Left side (%) Not significant Frykman 8 type (%) I Not significant II Not significant III Not significant IV Not significant V Not significant VI Not significant VII Not significant VIII Not significant Dorsal tilt* (deg) 23.6 ± ± 10.8 Not significant Radial angulation* (deg) 15.7 ± ± 6.6 Not significant Radial shortening* (mm) 5.5 ± ± 5.5 Not significant *The values are given as the mean and standard deviation. Materials and Methods Patients wo hundred and twenty-three patients with 225 acute T dorsally displaced fractures of the distal part of the radius who presented to our hospital between August 1997 and October 1998 were recruited into this study. All fractures were diagnosed on the basis of standard posteroanterior and lateral radiographs of the affected wrist. Patients with an undisplaced fracture (<10 of dorsal angulation and <5 mm of radial shortening), open fracture, or palmarly angulated fracture and those who were unable to give written informed consent were excluded from the study. Patients with marked comminution or displacement of the articular surfaces were considered for primary external or internal fixation and were also excluded from the study. Our ethical committee approved the study, and all patients gave written informed consent. Basic demographic data, including age, gender, occupation, hand dominance, and mechanism of injury, were collected for all patients. Methods With use of sealed envelopes, patients were randomly allocated either to conventional manual manipulative reduction or to reduction with finger-trap traction. Randomization was stratified according to patient age into four groups: less than forty-five years, forty-five to fifty-nine years, sixty to seventyfour years, and seventy-five years and older. All patients had regional anesthesia with a Bier block with injection of 40 ml of 1% prilocaine into a peripheral vein, and a tourniquet around the upper arm was inflated to a pressure 100 mm Hg above systolic brachial arterial pressure. Patients randomized to manual manipulation had the fracture manipulated by the on-call Senior House Officer in Orthopaedic Surgery (equivalent to a first or second-year resident in the United States), and countertraction was applied to the elbow by the plaster-room nurse. Traction was applied along the axis of the limb to disimpact the fracture, and the wrist was then fully deviated ulnarly and flexed to approximately 15. The fracture was then reduced by manual pressure on the dorsoradial aspect of the distal fragment, and reduction was confirmed by portable fluoroscopy. Patients randomized to reduction with finger-trap traction had finger traps applied to the thumb, index, and long fingers by the on-call Senior House Officer in Orthopaedic Surgery. The forearm was suspended vertically from an intravenous stand with the elbow flexed to 90, and 10 to 15 lb (4.5 to 6.8 kg) of traction weights were suspended from the upper arm. After five minutes of traction, reduction was assessed with portable fluoroscopy, and manual pressure was applied to the distal fragment, as necessary, to complete the reduction. The surgeon performing the reduction graded its overall difficulty on a 10-cm visual analog scale. Posteroanterior and lateral radiographs of the affected wrist were made after reduction, and a below-the-elbow Collestype plaster-of-paris cast was applied. The cast was split immediately and then overwrapped at a subsequent evaluation at the fracture clinic, usually after one week. Patients in both groups were given clear instructions about the care of the plas-

3 356 Fig. 1 Dorsal angulation at each time interval. MM = manual manipulation, and FTT = finger-trap traction. ter cast and were encouraged to perform a gentle finger, elbow, and shoulder exercise program until the cast was removed. Within three days after the reduction, the patients were seen by an orthopaedic surgeon in the fracture clinic to assess the adequacy of the reduction and immobilization. They were then seen at one and five weeks following the reduction. All casts were worn for five weeks. Posteroanterior and lateral radiographs were made of the affected wrist at the one-week evaluation and were made of both wrists at five weeks. When a fracture was considered to have redisplaced into an unacceptable position at one week, the patient was admitted to the hospital for surgical treatment. Two observers (S.S. and A.A.), who were blinded to the method of reduction, assessed all radiographs. Fractures were graded according to the Frykman system 8 to allow subgroup analysis by fracture grade. Radial angulation, dorsal tilt, and radial shortening (compared with those on the uninjured side) were measured on each radiograph as described by van der Linden and Ericson 9. The presence of carpal malalignment was assessed as described by McQueen et al. 10. Statistical Analysis The baseline characteristics and the radiographic measurements of the two groups were compared with use of unpaired t tests or Mann-Whitney U tests as appropriate. Survivorship analysis was used to compare the rates of failure of closed treatment, with failure defined as either loss of an acceptable reduction (defined as <10 of dorsal tilt and <5 mm of radial shortening) or surgical intervention. This analysis was then repeated with use of the more strict criteria for acceptable reduction of dorsal tilt to neutral and <2 mm of radial shortening. Results wo hundred and twenty-three patients were recruited; 172 T(77%) were female. Their ages ranged from fifteen to ninety-two years (median, sixty-five years). In 198 patients (89%), the fracture was the result of a simple fall. The remainder of the fractures were due to a sports injury (fourteen), an industrial accident (two), or another mechanism (nine). One hundred and twenty-nine (58%) of the patients had a fracture of the left wrist, and 127 (57%) had a fracture of the nondominant upper limb. One male and one female patient, both treated with manual manipulation, had a bilateral fracture. One hundred and twelve patients (with 112 fractures) were randomized to treatment with finger-trap traction, and 111 patients (with 113 fractures) were randomized to treatment with manual manipulation. The two groups did not differ significantly with regard to their demographic and fracture characteristics (Table I). There was also no significant difference between the two groups with regard to the mean rating (and standard deviation) of the difficulty of the reduction (3.6 ± 2.2 compared with 3.8 ± 2.3 cm, p = 0.591) as measured on the visual analog scale. When the patients were stratified according to age, we Fig. 2 Radial shortening at each time interval. MM = manual manipulation, and FTT = finger-trap traction.

4 357 Fig. 3 Percentage of fractures in a radiographically acceptable position at each postreduction time interval. MM = manual manipulation, and FTT = finger-trap traction. found that there were significantly fewer female patients in the youngest two age-groups (p < 0.001). There were no other significant differences in the baseline data between the agegroups (see Appendix). The radial angle, dorsal tilt, and degree of radial shortening were found not to differ between the two groups at presentation or following reduction (p > 0.05). The majority of fractures in both groups gradually redisplaced during the period of plaster cast immobilization, and the radiographic positions of the fractures in the two groups did not differ significantly at one or five weeks after the reduction. The improvement in the radiographic position between the time of presentation and five weeks after the reduction also did not differ between the two groups. The radiographic positions of the fractures in the two groups are illustrated in Figures 1 and 2. Overall, of the 225 fractures, 195 (87% [95% confidence interval, 82% to 91%]) were successfully reduced into an acceptable position according to the criteria of <10 of dorsal angulation and <5 mm of radial shortening. The rate of successful reduction was 87% in both the manual manipulation group (ninety-eight of 113) and the finger-trap group (ninetyseven of 112) (p = 0.41). At one week, fifty-six (50%) of the 113 fractures in the manual manipulation group and fortyeight (43%) of the 112 in the finger-trap group had redisplaced with 10 of dorsal angulation or 5 mm of radial shortening (p = 0.16). By five weeks, fifty-six (25%) of the 225 fractures had been treated with surgical intervention because of failed closed treatment and only sixty-five (29% [95% confidence interval, 21% to 38%]) remained in a satisfactory position. Survivorship analysis revealed no significant difference (p = 0.56) between the two groups with regard to the rate of failure at any stage of treatment (Fig. 3). When the more strict criteria for success of neutral dorsal tilt and <2 mm of radial shortening were applied, reduction was again found to be successful for 195 (87% [95% confidence interval, 82% to 91%]) of the 225 fractures. According to these criteria, however, only twenty (9% [95% confidence interval, 4% to 13%]) of the fractures remained in an acceptable position by five weeks. Again, there were no significant differences between the two treatment groups. Discussion t is widely believed that accurate reduction and adequate Iimmobilization of Colles fractures produces superior radiographic and functional outcomes 11. Various methods of reduction and immobilization have been described 4-7. Although manual manipulation is widely used, it has been suggested that reduction with finger-trap traction achieves a better reduction and a lower rate of subsequent redisplacement 6. This is thought to be due to avoidance of excessive wrist flexion and of further comminution of the fracture site. Finger-trap traction can be applied without the need for an assistant, and it allows for easier application of the plaster cast. During molding of the plaster, however, the traction tends to pull the wrist straight, making it difficult to achieve ulnar deviation and flexion. This prospective, randomized trial had 90% power to detect differences in mean angular deformities of 3, differences in mean radial shortening of 2 mm, and differences in the failure rate of 10%. Our data do not support the hypothesis that finger-trap traction is more effective than manual manipulation; we could find no significant differences in reduction or radiographic outcome between the two techniques. Furthermore, we did not find that the use of finger-trap traction was any easier than manual manipulation. Closed reduction was successful for the majority of fractures. However, there was loss of position in most of the fractures, and by five weeks after the manipulation only 29% had not redisplaced with at least 10 of dorsal angulation or 5 mm of radial shortening. Many of these failures occurred after the one-week follow-up evaluation. These redisplacement rates were similar to those reported previously The relationship between the radiographic and functional outcomes of treatment of Colles fractures remains controversial, with little consistency of findings. Some investigators have found dorsal angulation to adversely affect function 11,13, others have implicated radial shortening 14, and some have found no relationship between radiographic malunion and final functional outcome 15,16. The current study was limited to radiographic outcome; functional outcome will be the subject of future investigation. In conclusion, this prospective, randomized study failed to demonstrate any difference in the radiographic outcomes of

5 358 Colles fractures treated with manual manipulation as opposed to reduction with finger-trap traction. Loss of reduction during the period of cast immobilization is common with both methods. The reduction technique does not appear to influence the radiographic outcome, and surgeons should continue to use the technique in which they have been trained and for which their institution provides the best facilities. Appendix A table showing baseline data subdivided according to patient age is available with the electronic versions of this article, on our web site at (go to the article citation and click on Supplementary Material ) and on our quarterly CD-ROM (call our subscription department, at , to order the CD-ROM). S.A. Earnshaw, DM, FRCS A. Aladin, MRCS S. Surendran, FRCS C.G. Moran, MD, FRCS Department of Orthopaedic Surgery, Queen s Medical Centre, Nottingham NG7 2UH, United Kingdom. address for S.A. Earnshaw: steven.earnshaw@talk21.com The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. References 1. Cummings SR, Kelsey JL, Nevitt MC, O Dowd KJ. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev. 1985;7: Wadsworth TG. Colles fracture. BMJ. 1990;301: Kopylov P, Johnell O, Redlund-Johnell I, Bengner U. Fractures of the distal end of the radius in young adults: a 30-year follow-up. J Hand Surg [Br]. 1993;18: Charnley J. The closed treatment of common fractures. 3rd ed. Edinburgh: E. and S. Livingstone; The Colles fracture; p McRae R. Practical fracture treatment. 3rd edition. New York: Churchill Livingstone; The wrist and hand. Colles fracture; p Cooney WP 3rd, Linscheid RL, Dobyns JH. Fractures and dislocations of the wrist. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green s fractures in adults. 4th ed, volume 1. Philadelphia: Lippincott-Raven; p Crenshaw AH Jr. Fractures of the shoulder girdle, arm, and forearm. In: Canale ST, editor. Campbell s operative orthopaedics. 9th ed, volume 3. St. Louis: Mosby; p Frykman GK. Fracture of the distal radius including sequelae shoulderhand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967;Suppl 108: van der Linden W, Ericson R. Colles fracture. How should its displacement be measured and how should it be immobilized? J Bone Joint Surg Am. 1981;63: McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomized comparison of four methods of treatment. J Bone Joint Surg Br. 1996;78: Porter M, Stockley I. Fracture of the distal radius. Intermediate and end results in relation to radiological parameters. Clin Orthop. 1987;220: Altissimi M, Mancini GB, Azzara A, Ciaffoloni E. Early and late displacement of fractures of the distal radius. The prediction of instability. Int Orthop. 1994;18: Gartland JJ Jr, Werley CW. Evaluation of healed Colles fractures. J Bone Joint Surg Am. 1951;33: Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles fracture. A prospective review. J Bone Joint Surg Br. 1987;69: Cassebaum WH. Colles fracture. A study of end results. JAMA. 1950;143: Stewart HD, Innes AR, Burke FD. Factors affecting the outcome of Colles fracture: an anatomical and functional study. Injury. 1985;16: