Short-Arm Casting Effective in Type A2 Fractures in the Distal Radius
Condition: Distal Radius Fracture
MeSH terms: Fractures, Bone; Radius Fractures; Wrist Fractures
Study type: Interventional

Summary: 
      Distal radius fracture (DRF) is among the most common fractures of the long bones, which
      comprise one sixth of all fractures. Due to its high prevalence, effect on patients' everyday
      life, and cost on national health resources, its proper management is very important. The
      investigators performed this prospective randomized clinical trial on 100 patients with DRFs.
      50 patients were treated in each group either by short or long arm cast. Patients were
      visited during the 6th and 18th weeks after the reduction regarding loss of reduction and
      possible complications.
    

Detailed description: 
      After obtaining institutional review board (IRB) approval, the investigators performed this
      prospective randomized clinical trial on patients with DRFs admitted in three medical centers
      from September 2010 to February 2011. Patients signed the consent form prior to enrolment.
      the investigators included the patients older than 20 years with closed distal radial physis
      and initial radiographic evidence of extra articular DRF with at least one non-comminuted
      cortex. All fractures were type A2 according to the AO classification. The investigators
      considered fractures with dorsal angulations of more than 20 degrees, radial shortening of
      more than 10 millimeters and extensive cortical comminution as unstable fractures. Patients
      with unstable fractures were excluded from this study. Other exclusion criteria were the
      existence of multiple fractures or open fracture in the affected limb or other limbs,
      cerebral palsy, paresthesia of the affected limb due to the pervious cerebro-vascular
      accidents, previous severe deformity of the affected limb, diabetes and severe osteoporosis.
      Th investigators also excluded patients who had less than two consecutive follow-up visits.
      All eligible patients signed the informed consent. One hundred four patients were eligible to
      be included in this study; The investigators excluded four patients, as they did not tend to
      participate in the process of follow-up. The investigators divided 100 remaining patients
      into reduction with SAC or reduction with LAC groups based on the table of random numbers.

      The investigators performed plain anterior posterior (AP) and lateral radiograph of the
      affected wrist in all patients initially to determine fracture severity. Based on the radial
      height, radial inclination and palmar tilt in initial radiograph, patients were divided into
      two groups. There were no significant differences between the groups regarding the
      pre-operative fracture characteristics. Most of the fractures were reduced under local
      anesthesia but general anesthesia or regional block were performed for selected patients. The
      technique of reduction was by slight traction and counter-traction and manipulation methods.
      In SAC group, the investigators positioned the forearm in neutral rotation and volar-ulnar
      deviation. The investigators applied The cast from the metacarpophalangeal joints dorsally
      and proximal palmar crease volarly, extending to one inch distal to antecubital fossa
      anteriorly and the olecranon posteriorly. Three points and inter osseous molding was
      performed. The investigators did the same technique in the LAC group. Additionally, The
      investigators positioned the elbow in 90 degrees of flexion and extended the plaster to the
      middle of the arm.

      The investigators performed lateral and AP radiographs of the forearm after reduction and
      casting and measured the radiographic parameters (radial height, radial inclination and
      dorsal angulations). In all cases, anatomical reduction was considered a successful
      reduction. Immediately after reduction, patients started active motion of the fingers and
      tried to elevate the limb to the level at or above the heart. The investigators examined all
      patients regarding compartment syndrome. Besides, they informed the patients about
      compartment symptoms too. Many patients were treated in an ambulatory setting and discharged
      after six hours observation, but some patients were hospitalized and then discharged within
      two days after reduction. The investigators checked the alignment radiographically during the
      second week after the reduction. In the suspicious cases for the loss of reduction,
      comparison was done with contra-lateral wrist radiography. The investigators performed
      repeated reduction for those cases with unacceptable displacement. The reduction was
      unacceptable if there was more than five millimeters of displacement or more than five
      degrees of angulations. The surgeons converted LAC to SAC during the fourth week and removed
      casts after six weeks. The patients started active and passive motion of the wrist, elbow and
      fingers as the cast was removed. Patients referred to the clinic during the 6th and 18th
      weeks after the reduction. AP and lateral plain radiography of the wrist were performed in
      each visit. The investigators evaluated the patients regarding loss of reduction, malunion,
      nonunion, carpal tunnel syndrome, compartment syndrome, limitation in elbow and forearm range
      of motion (ROM), number of wounds and blisters, patient's satisfaction and stability of the
      distal radioulnar joint. In cases with unstable distal radioulnar joint during the 6th week
      visit, casting was continued for three more weeks in forearm supination position. In these
      cases forearm ROM was examined during the 9th and 18th weeks. The investigators considered
      the instability of distal radioulnar joint (DRUJ) when there was tenderness on DRUJ and pain
      on its mobility. For assessing the forearm pronation and supination, the patient tried to
      range the forearm by holding a pen in the fist with the elbow at 90 degrees flexed and
      adducted. Limits of ROM were abnormal if there was more than 10 degrees of difference
      comparing with the unaffected side.

      The investigators scored patients' satisfaction by using the Visual Analog Scale (VAS) at
      18th week follow-up. VAS consists of ten-point from zero (extremely dissatisfied) to 10
      (extremely satisfied). The independent-Samples t-test and chi square test were used for
      statistical analysis when appropriate. The level of significance was set at P<0.05.
    

Intervention name(s): Casting (long arm); Casting (short arm)
Intervention type(s): Procedure; Procedure
Intervention description(s): Casting using plaster of paris after closed reduction of distal radius fracture
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment