Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. Conservative management of minimally displaced isolated fractures of the ulnar shaft. Two procedures for Kirschner wire osteosynthesis of distal radial fractures. A randomized trial. The non-operative management of radial head fractures: a randomized trial of three treatments. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Seven-year outcome following Colles' type distal radial fracture. A comparison of two treatment methods. Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures. Trans-styloid fixation of fractures of the distal radius. A prospective randomized comparison between 6- and 1-week postoperative immobilization in 60 fractures.
We performed a prospective, randomised study on 57 patients older than 60 years of age with unstable, extra-articular fractures of the distal radius to compare the outcome of immobilisation in a cast alone with that using supplementary, percutaneous pinning. Patients treated by percutaneous wires had a statistically significant improvement in dorsal angulation (mean 7 degrees), radial length (mean 3 mm) and radial inclination (mean 3 mm) at one year. However, there was no significant difference in functional outcome in terms of pain, range of movement, grip strength, activities of daily living and the SF-36 score except for an improved range of movement in ulnar deviation in the percutaneous wire group. One patient developed a pin-track infection which required removal of the wires at two weeks. We conclude that percutaneous pinning of unstable, extra-articular fractures of the distal radius provides only a marginal improvement in the radiological parameters compared with immobilisation in a cast alone. This does not correlate with an improved functional outcome in a low-demand, elderly population. The purpose of this prospective study was to compare three different ways of conservative management of isolated fractures of the ulnar shaft: immediate mobilisation, below-elbow plaster cast and above-elbow plaster cast immobilisation. Over a 24-month period, 102 minimally displaced isolated fractures of the distal two-thirds of the ulnar shaft were treated on an outpatient basis. Thirty-two fractures were immobilised with an above-elbow plaster cast for 3 weeks and a below-elbow plaster cast for an additional 3 weeks. Thirty-six fractures were immobilised with a below-elbow plaster cast for 6 weeks. The remaining 34 fractures were managed with immediate mobilisation. Radiological healing, range of motion of the wrist, and pain were assessed. Results were good and were comparable in terms of healing, time to healing, pain and range of motion of the wrist. The treatment of displaced Colles-type fractures of the distal part of the radius remains a challenge. Two procedures for closed reduction and Kirschner wire osteosynthesis of these fractures were compared in a prospective randomized study.
                One hundred consecutive patients with a Colles fracture of the distal part of the radius (AO classification 23-A2, 23-A3, or 23-C1) were treated over an eighteen-month period. One group was managed with the conventional method, described by Willenegger and Guggenbuhl in 1959, in which two Kirschner wires are introduced into the styloid process of the radius. The other group was treated with the Kapandji method, as modified by Fritz et al., in which two Kirschner wires are inserted into the fracture gap and a third is placed through the styloid process. Postoperative care was standardized for both groups and carried out according to a strict procedure. Forty patients who had been operated on according to the modified Kapandji method and forty-one treated with the Willenegger technique were available for follow-up, for a follow-up rate of 81%. The follow-up assessment was performed with a modified version of the Martini score.
                The median time to follow-up was ten months (range, six to twenty months). The results as assessed with the Martini score were, on the average, good to very good for the patients treated with the Kapandji method and satisfactory to good for the patients treated with the conventional Kirschner wire fixation. The duration of radiographic exposure was significantly shorter with the Kapandji method than with the Willenegger technique.
                Conventional Kirschner wire fixation remains a good method of osteosynthesis for the treatment of displaced fractures of the distal part of the radius. We found both the functional and radiographic outcomes of the Kapandji method to be significantly better than those of the Willenegger technique.
                Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence. Ninety-eight consecutive patients with Mason type 1 and 2 radial head fractures were randomized into three treatment groups to compare early mobilization with immobilization in flexion and extension. Eighty-one patients were reviewed on average 25 months following fracture and assessed for pain, disability and range of movement. Loss of full extension was the most frequent restriction of movement and was found in 17 patients. Two patients had restricted flexion without limited extension. Patients immobilized in a flexion cast had a significantly reduced range of movement compared with patients immobilized in extension (P = 0.02). Nineteen patients had residual pain and again the flexion group fared worse than the extension group (P = 0.06). Results from early mobilization in a sling were not significantly different from the other two groups. Treatment of radial head fractures in flexion casts should be avoided. Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. In this study 90 adult cases of acute displaced intra-articular fractures of the lower end of the radius were classified according to Frykman's and AO classifications after obtaining radiographs in antero-posterior and lateral planes. These were randomly treated by one of three methods: (1) closed reduction and plaster immobilisation, (2) external fixation and (3) open reduction and internal fixation, and were followed for an average of 4 yr. In the final functional assessment (Sarmiento) the results were (1) plaster 43% good and excellent, 50% fair and 7% poor, (2) external fixator 80% good and excellent, 20% fair and poor results, (3) open reduction and internal fixation 63% good and excellent, 26% fair, 11% poor. We recommend that displaced severely comminuted intra-articular fractures should be treated with an external fixator. Eighty-five patients were reviewed 7 years after prospective randomization to bridging external fixation or plaster immobilization for treatment of a Colles' type distal radial fracture. The Gartland and Werley score showed that most patients in each group had an excellent or good outcome and patient satisfaction was comparable and high in both groups. The fixator group had significantly less radial shortening (P<0.05). Despite a high level of radiographic malunion (50%) overall function, range of movement and activities of daily living were not limited. Twenty-five per cent of patients had minor radiological signs of post-traumatic arthritis although only one patient was symptomatic. We conclude that, in the long term, external fixation of distal radius fractures does not confer an improved outcome when compared to plaster immobilization. We report a prospective trial of 66 patients with intraarticular fractures of the calcaneum. All fractures were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better results than the displaced fractures. There was no significant difference in outcome between the operatively and the conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury, which is of use in assessing prognosis for both clinical and medicolegal purposes. Distal radial fractures are common, and many methods of treatment have been reported but there are no studies that compare the different treatment methods. This randomized prospective study demonstrated no advantage in using an external fixator to immobilize reduced distal radial fractures over closed reduction and plaster cast immobilization in patients less than 60 years of age. The external fixator group had a significant complication rate. We performed a prospective randomized study on 60 patients with dorsally displaced extra-articular or noncomminuted intraarticular fractures of the distal radius. All 60 fractures were treated by closed reduction and Kirchner wire trans-styloid fixation. 30 patients had 1 weeks' postoperative immobilization and 30 patients had 6 weeks' immobilization. All patients had a clinical and radiographic review at 6 weeks and at 1 year after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, frontal radial deviation, ulnar variance, and radial shortening were assessed radiographically. Rates of complications were the same in both groups. At follow-up, pain was similar in both groups and range of motion and grip strength were somewhat better after early mobilization--in comparison with the opposite wrist--but this was statistically significant only for ulnar deviation. The postoperative radiographic reductions were similar in both groups, with no differences in loss of reduction after bone healing. Therefore, in Colles' fractures, trans-styloid fixation with two K-wires seems to give a stable osteosynthesis, which does not need additional immobilization with a plaster cast.
There remains insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Patient preferences and circumstances, and the risk of complications should also be considered.
Prioritising research questions to clarify the most appropriate conservative treatment for this common fracture is warranted. Researchers should differentiate between extra-articular and intra-articular, and non-displaced and displaced fractures, ascertain patient preferences, and agree a core outcome data set.