A Cochrane review [withdrawn from publication] included 44 studies with a total of 3 193 subjects. Surgical methods were usually associated with better anatomical appearance after fracture healing, but there was inadequate evidence to confirm that these had resulted in better functional and clinical outcomes for the patients.
Another Cochrane review (abstract , review ) comparing external fixation with conservative treatment (plaster cast immobilisation) for distal radial fractures included 15 heterogenous studies with a total of 1 022 adult subjects. There was considerable variation in patient characteristics and interventions. External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment: 7/356 vs 51/338, RR 0.17, 95% CI 0.09 to 0.32; 9 trials) and prevented late collapse and malunion compared with plaster cast immobilisation. There was insufficient evidence to confirm a superior overall functional or clinical result for the external fixation group. External fixation was associated with a high number of complications, such as pin-track infection, but many of these were minor. There was insufficient evidence to establish a difference between the two groups in serious complications such as reflex sympathetic dystrophy (RR 1.31, 95% CI 0.74 to 2.32).
Another Cochrane review (abstract , review ) included 9 studies with a total of 510 subjects. Two trials comparing a bridging (of the wrist) external fixator versus pins and plaster external fixation found no significant differences in function or deformity. One trial found tendencies for more serious complications but less subsequent discomfort and deformity in the fixator group. Three trials compared non-bridging versus bridging fixation. Of the two trials testing uni-planar non-bridging fixation, one found no significant differences in functional or clinical outcomes; the other found non-bridging fixation significantly improved grip strength, wrist flexion and anatomical outcome. The third trial found no significant findings in favour of multi-planar non-bridging fixation of complex intra-articular fractures. One trial using a bridging external fixator found that deploying an extra external fixator pin to fix the 'floating' distal fragment gave superior functional and anatomical results. Two trials compared dynamic versus static external fixation. One trial found no significant effects from early dynamism of an external fixator. The poor quality of the other trial undermines its findings of poorer functional and anatomical outcomes for dynamic fixation.
Another Cochrane review (abstract , review ) included 10 studies with a total of 874 subjects. Four trials (239 participants) found implantation of bone scaffolding compared with plaster cast alone; and two found it improved function. Reported complications of bone scaffolding were transient discomfort resulting from extraosseous deposits; with surgical removal of one intra-articular deposit. One trial (323 participants) comparing bone substitute versus plaster cast or external fixation found no difference in functional or anatomical outcomes at one year. Statistically significant complications in the respective groups were extraosseous deposits and pin track infection. One trial (48 participants with external fixation) found that autogenous bone graft did not significantly change outcome. There was one serious donor-site complication. One trial (21 participants) found some indication of worse outcomes for hydroxyapatite bone cement compared with Kapandji's intrafocal pinning. Three trials (180 participants) found bone scaffolding gave no significant difference in functional outcomes but some indication of better anatomical outcomes compared with external fixation. Most reported complications were associated with external fixation; extraosseous deposits occurred in one trial. One trial (93 participants with dorsal plate fixation) found autografts slightly improved wrist function compared with allogenic bone material but with an excess of donor site complications.
Comment: The quality of evidence is downgraded by inconsistency (variability in results across studies, heterogeneity in interventions and outcomes).