• 
• 

Three Part Question

In [adults with a displaced distal radius fracture], does [the use of ultrasound during closed fracture reduction] result in [less repeat reductions andless open reductions with internal fixation (ORIF)]

Clinical Scenario

A 53 year old woman presents to the Emergency Department after falling on her right outstretched arm. On arrival her wrist appears to be swollen. X-ray examination reveals a displaced distal radius fracture. While performing Böhlers anesthesia, you wonder if US-guided closed reduction would increase the likelihood of reduction adequacy, thereby avoiding the need of repeat reduction or open reduction and internal fixation [ORIF].

Search Strategy

Date last searched was June 22th 2018.

Pubmed/MEDLINE: ("Radius Fractures"[Mesh] OR Radius Fracture*[tiab] OR (("Wrist"[Mesh] OR "Wrist Joint"[Mesh] OR "Wrist Injuries"[Mesh] OR "Forearm"[Mesh] OR wrist*[tiab] OR forearm*[tiab]) AND ("Fractures, Bone"[Mesh] OR fracture*[tiab]))) AND distal[tiab] AND ("Ultrasonography"[Mesh:NoExp] OR Ultrasonograph*[tiab] OR Echograph*[tiab] OR Ultrasound*[tiab] OR PoCUS[tiab]) AND ("Closed Fracture Reduction"[Mesh] OR closed fracture reduction*[tiab] OR closed reduction*[tiab] OR CRDRF[tiab] OR ORIF[tiab] OR (open reduction[tiab] AND internal fixation[tiab]))
AND Ultrasound-guided[Title] AND reduction[Title] AND distal[Title] AND radius[Title] AND fractures[Title].

Embase: distal:ab,ti AND ('radius fracture'/exp OR 'radius fracture*':ab,ti OR (('wrist'/exp OR 'wrist injury'/exp OR 'forearm'/exp OR wrist:ab,ti OR forearm:ab,ti) AND ('fracture'/exp OR fracture:ab,ti))) AND ('echography'/exp OR echograph*:ab,ti OR ultrasonograph*:ab,ti OR ultrasound*:ab,ti OR pocus:ab,ti) AND (‘closed fracture reduction*’:ab,ti OR 'closed reduction*':ab,ti OR crdrf:ab,ti OR 'closed reduction (procedure)'/exp OR orif:ab,ti OR ('open reduction':ab,ti AND 'internal fixation':ab,ti))

Cochrane: ("radius fracture":ti,ab,kw or "radial fracture":ti,ab,kw or ((wrist:ti,ab,kw or forearm:ti,ab,kw) and fracture:ti,ab,kw)) and distal:ti,ab,kw and (ultrasonograph:ti,ab,kw or echograph:ti,ab,kw or ultrasound:ti,ab,kw or pocus:ti,ab,kw) and ("closed fracture reduction":ti,ab,kw or "closed reduction":ti,ab,kw or ORIF:ti,ab,kw or ("open reduction" and "internal fixation":ti,ab,kw))




One additional record was identified through cross-referencing.

Search Outcome

A total of 54 articles were found of which 44 were excluded based on: exact duplicates (n=17), title and abstract (n=27). Out of 10 eligible full-text articles, 8 were excluded (for reasons; not the right outcomes(n=5), study performed in the pediatric population(n=1) and no full-text study available (conference abstracts) (n=2)). In total, 2 articles could be included (see table 1).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sabzghabaei et al 2016 Iran	N=130 patients with a distal radius fracture with dorsal angulation divided in 2 equal groups of US-guided and blind (non US- guided) reduction	Prospective case control study (Level B, class IIb	Significantly less repeated attempts in the US group. Significantly less ORIFs the US group	9.2% in the US group vs. 24.6% in non US group; (n=6 vs. n=16, P = .019). 10,8% in the US group vs. 27.7% in the non US group; (n=7 vs. n=18, P = .014)	Non randomized study
Ang et al. 2010 Singapore	N=62 patients with a distal radius fracture underwent US-guided reduction. The retrospective control group (N=120) had a non US-guided reduction	Prospective cohort compared with retrospective controls (Level B, IIb)	Tendency to less repeated attempts in the US group. Significantly less ORIFs the US group	1.6% in the US group vs. 8.8% in the control group; (n=1 vs. n=9, P = .056). 4.9% in the US group vs. 16.7% in the control group; (n=3 vs n=17, P = .02)	Small sample size- Possible inclusion bias depending on the ED crowding Retrospective control group

Comment(s)

One of the included studies shows a decrease in the number of repeat reductions when US was used during reduction of displaced distal radius fractures, while both studies show a decrease in the number of ORIFs performed. This suggests US may be a beneficial tool to use during distal radius fracture reduction. A disadvantage for the implementation for US-guided reduction may be the need for ED resources, including US and staff. The included studies both had small sample sizes. Further randomized prospective research is needed to substantiate the usefulness of US-guided reduction for a displaced distal radius fracture, and should include use of resources and time spend on the ED as additional parameters.

Clinical Bottom Line

The effect of US-guided closed reduction of displaced distal radius fractures on adequacy of fracture reduction as measured by the number of repeat reductions performed was found to be inconclusive (heterogeneity of study results). However, US-guided reduction was found to reduce the likelihood of ORIF compared to non-US-guided closed reduction. Although the level of evidence was low (level B, classIIb), US- guided reduction could therefore be considered as it will cause no harm to the patient.

References

1. Sabzghabaei A, Shojaee M, Arhami Dolatabadi A, Manouchehrifar M, Asadi M Ultrasound-Guided Reduction of Distal Radius Fractures Emerg (Tehran) 2016 Summer;4(3):132-135
2. Ang SH, Lee SW, Lam KY. Ultrasound-guided reduction of distal radius fractures. Am J Emerg Med 2010 Nov;28(9):1002-1008