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Three Part Question

In [adults with Colles fractures] is [closed manipulation and immobilisation in a cast better than immobilisation alone] at [improving functional outcome]?

Clinical Scenario

A 60yr old lady presents to A and E complaining of wrist pain following a mechanical fall. X rays reveal a Colles fracture. You wonder if manipulation of the fracture will actually improve her functional outcome?

Search Strategy

Medline 1996 to present and EMBASE 1996 to present via Dialog Datastar, The Cochrane database of systematic reviews and The Cochrane central register of controlled trials via Wiley Interscience, performed 23.02.08.
Medline; [Colles-fractures.de. OR radius-fractures.de.] AND [manipulation OR reduction OR treatment] limited to clinical trials, English and human.
EMBASE; [Colles-fractures.de. OR radius-fractures.de.] AND [fracture-external-fixation OR fracture immobilization OR splinting OR manipulation OR reduction OR treatment] limited to clinical trials, English and human.
Cochrane; [Colles fracture OR radius fracture] AND treatment.

Search Outcome

Medline; 132 titles found, titles and abstracts screened to reveal 1 trial of relevance.
EMBASE; 159 titles found, titles and abstracts screened, no additional relevant trials found.
Cochrane; 39 cochrane reviews, 221 trials. Titles and abstracts screened. No additional relevant trials found, 1 relevant review found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
A.J. Kelly, D.Warwick, T.P.K. Crichlow and G.C. Bannister 1997 UK	• Pts > 65 yrs of age with • fractures of the distal radius • 10°-30° dorsal angulation • <5mm radial shortening • no previous ipsilateral forearm fractures Randomised to receive MUA the immobilisation in a dorsoradial backslab, OR immobilisation alone	PRCT	Modified Gartland and Wesley score assessing pain, movement, complications, deformity	improvement from 9.6 (range 2-12) to 5.81 (range, 1-12) for MUA vs.	Small no. of cases, only 15 in each group. No sample size estimate performed. Outcome assessment not blinded. No description of outcome assessor.
			Grip strength	Mean of 49% of expected for MUA vs. 56% of expected for no MUA.
			Algodystrophy	Stiffness
			Cosmesis	Normal appearance in 11/15 post MUA vs. normal appearance in 9/15 without MUA.
HHG Handoll, R Madlock April 2003 UK	Manipulation vs. no manipulation of patients with distal radial fractures.	Systematic review	The only trial cited to answer this question is the above trial. No other trials of relevance found.		As above

Comment(s)

The above trial was not of significant size, nor proven to be of significant power to truly identify if there is a clinical difference in outcome between patients who have their Colles' fracture manipulated and those who do not.

Clinical Bottom Line

There is no evidence to support cessation of manipulation on displaced Colles' fractures which is widely accepted as the norm across UK Emergency Departments

References

1. A.J. Kelly, D.Warwick, T.P.K. Crichlow, G.C. Bannister Is manipulation of moderately displaced Colles' fracture worthwhile? A prospective randomised trial. Injury May 1997, Vol 28, no.4 p.283-287
2. HHG Handoll, R Madlock Conservative interventions for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews 2003, issue 2.