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Three Part Question

In [those patients who have manipulation of a Colles fracture] does [the position of immobilisation of the wrist in a plaster cast] [affect clinical outcome]?

Clinical Scenario

A 63 year old lady presents to the Accident and Emergency department with pain in her right wrist after a fall onto an outstretched hand. She is extremely tender over her distal radius and has poor range of movement. An x-ray of her wrist confirms a diagnosis of Colles fracture. Whilst in the plaster room, the question is raised of which position is best in order to immobilise her wrist in a plaster cast.

Search Strategy

medline 1950 to current, using Dialog Datastar interface
(immobilisation.TI,AB. AND LG=EN AND HUMAN=YES) AND (Colles.TI,AB. AND LG=EN AND HUMAN=YES)

Search Outcome

the search yielded 55 papers of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gupta A 1991 India	204 patients age range 18 to 74 with Colles fracture with the wrist immobilised in different positions: palmar flexion (60), neutral position (75) and dorsiflexion (69) after closed reduction.	Prospective cohort study	Anatomical loss of dorsal tilt	Least in displaced, extra-articular fractures with comminution and displaced intra-articular fractures with the wrist immobilised in dorsiflexion. No significant difference between the groups with displaced, extra-articular and uncomminuted fractures	Statistical significance not assessed Population sample is younger than those we see in UK with Colles fracture No mention of associated complications in each group Heterogeneous sample of patients with no mention of previous bone disease Exclusion of undisplaced fractures Inclusion of comminuted and intra-articular fractures which would often be referred to Orthopaedics in the UK Unspecified randomisation process
			Anatomical loss of radial angulation	Almost no difference between the groups
			Anatomical loss of radial length	Greatest in neutral position group and least in dorsiflexion group
			Functional results	Best results noted in wrists immobilised in dorsilflexion
Wahlstrom O 1982 Sweden	42 women over 40 years with closed extra-articular displaced fractures of the wrist reduced and randomly immobilised in pronation (14), midway (12) or supination (16)	Prospective cohort study	Redisplacement of fracture	Lowest in pronation group but ? statistical significance	Small study Only one type of fracture included in study Only women over 40 years included No mention of axial position of wrist i.e. flexion, neutral or extension No assessment of function in follow up of patients
			Fractures needing re-reduction	One from pronation group, one from midway group and three from supination group
			Anatomical result at 4-5 weeks	Best in pronation group i.e. lowest increase in dorsal angulation
Wilson C and Venner R March 1984 UK	41 patients with Colles' fracture reduced and the wrist randomly immoblised in positions of pronation (20) and supination (21) with anatomical assessment and fucntional assessment made at 4 weeks	Prospective cohort study	Anatomical assessment of dorsal tilt	No statistically significant difference	Small study Unspecified randomisation process Both groups held in volar and ulnar deviation - no assessment of other axial positions
			Anatomical assessment of radial deviation	No statistically significant difference
			Functional result	No statistically significant difference
Van der Linden W and Ericson R, 1981, Sweden	250 patients with Colles' fracture randomised into 5 groups with each group being immobilised using different techniques comparing casts and splints and also the position of immobilisation i.e. the Coton Loder position and the neutral position with or without ulnar deviation. Anatomical assessment was made using radiographs at prospective points during follow up	Prospective randomised cohort study	Radiographic anatomical assessment	'hardly any difference' between 5 groups	Unspecified randomisation process Different surgeons used which is another variable No exclusions were made, notably of those who had fractures re-reduced at ten days
			Restriction in range of movement compared with uninjured side at 6 months	No significant difference

Comment(s)

Colles' fracture is the most common fracture seen in the A&E department. Each of the relevant papers address key aspects of clinical outcome and long term management. All of these papers compare different positions of immobilisation of the wrist. There were weaknesses with all the studies such as small sample size, a lack of functional assessment, a lack of statistical significance analysis and lack of applicability to the UK population. These are outlined for each specific paper in the table. Unfortunately, the papers are also all rather dated and very little work has been done into this subject in recent times. The standard and accepted Cotton-Loder position lacks a strong evidence base. Further research is needed in this area.

Clinical Bottom Line

No robust clinical evidence exists to support any particular position of immobilisation. Local guidelines should be followed.

References

1. A Gupta The Treatment of Colles Fracture: Immobilisation with the Wrist Dorsiflexed British Editorial Society of Bone and Joint Surgery 1991; 312-315
2. O Wahlstrom Treatment of Colles' Fracture: a Prospective Comparison of Three Different Positions of Immobilisation Acta Orthopaedia Scandinavia 1982; 225-228
3. C Wilson, R Venner Colles Fracture: Immobilisation in pronation or supination? Journal of the Royal College of Surgeons of Edinburgh 1984; 109-111
4. W Van der Linden and R Ericson. Colles' Fracture: How Should its Displacement be Measured and How Should it be Immobilised? Journal of Bone and Joint Surgery (American version) 1981; 1285-1288