1

DRF project. Appendix 5: Evidence from RCTs,included in the five Cochrane reviews,associated with the provisional list of 18 top priority research areas(Table 8)

No. / Question
Comparison(s) tested within the RCT(s) /

Evidence from RCTs

Interpretation
1 / Q4 When is reduction (non surgical or surgical) required?
Reduction versus no reduction; followed by plaster immobilisation / 1 RCT, 30 participants (elderly, 65 years old) with moderately displaced fractures
Unknown effectiveness
2 / Q5 Is immobilisation of the injured wrist for any duration necessary for undisplaced (or minimally displaced) fractures?
Elastic bandage / crepe bandage versus plaster cast / 2 RCTs, 177 participants (older) with undisplaced [and uncomplicated] fractures.
Unknown effectiveness
3 / Q7.7 How long should the wrist be immobilised? (undisplaced / minimally displaced fractures)
  1. 3-4 weeks versus 5-6 weeks
  1. 1-2 weeks versus 4-5 weeks
  1. 1 week versus 3 weeks
/
  1. 4 RCTs, 331 participants
Unknown effectiveness
  1. 1 RCT, 55 participants
Unknown effectiveness
  1. 2 RCTs, 114 participants
Unknown effectiveness
4 / Q7.11 What rehabilitation interventions should be given at this stage (post immobilisation)?
  1. Provision of routine therapy versus no provision
  1. Referral for routine physiotherapy versus home exercise sheet and instruction at outpatients by orthopaedic surgeon

c.Passive mobilisation versus no passive mobilisation

  1. Intermittent pneumatic compression prior to occupational therapy versus occupational therapy alone
  1. Forearm immersion in whirlpool prior to physiotherapy versus wrapping of forearm in 2 towels
/
  1. 3 RCTs, 226 participants; ?+2+56 undisplaced fractures
Unknown effectiveness
  1. 1 RCT, 18 participants: most or all with displaced fractures
Unknown effectiveness
  1. 2 RCTs, 70 participants: most if not all had displaced fractures including 13 treated with pins and plaster cast
Unknown effectiveness
  1. 1 RCT, 43 participants: most if not all had displaced fractures
Unknown effectiveness
  1. 1 RCT, 24 participants: 6 with undisplaced fractures
Unknown effectiveness

Cont’d over

No. / Question
Comparison(s) tested within the RCT(s) /

Evidence from RCTs

Interpretation
5 / Q8 When is surgery indicated for definitive treatment (at start)?
  1. Percutaneous pinning versus plaster cast alone
  1. External fixation versus plaster cast alone
  1. Open reduction and internal fixation (ORIF) versus plaster cast alone
  1. Bone scaffolding (graft / substitute) versus plaster cast alone
  1. Triangular ligament repair (+ usually ulnar styloid fragment fixation) versus plaster cast alone
/
  1. 5 RCTs, 363 participants
Across fracture pinning ‘likely to be beneficial’ but circumstances not established. Unknown effectiveness: Kapandji pinning.
  1. 13 RCTs, 859 participants; 133 redisplaced fractures
External fixation is “likely to be beneficial” but indications (e.g. fracture type) for treatment, and the type, technique and timing of external fixation are not resolved.
  1. 1 RCT, 62 participants
Unknown effectiveness
  1. 4 RCTs, 488 participants; 109 redisplaced
Unknown effectiveness (Norian SRS bone substitute)
  1. 1 RCT, 41 participants
Unknown effectiveness
6 / Q9.6 What is the preferred immediate treatment option if reduction is immediately unsuccessful? / No evidence
7 / Q13.2 What type of immobilisation is required for reduced initially displaced fractures?

a.Modified cast allowing greater wrist mobility versus usual plaster cast

b.Dorsal splint versus circular plaster cast

c.Modified sugar-tong plaster cast blocking forearm rotation versus below-elbow cast

d.Above-elbow cast (in neutral / pronation) versus below-elbow cast / back slab

  1. Brace (various) versus cast (various)
  1. Type of casting material: QuickCast (shrinkable polymer) versus fibreglass tape cast; Hexelite (thermoplastic) bandage versus plaster cast; Polyurethane cast with "zipper" versus plaster cast.
/
  1. 1 RCT, 90 participants
Unknown effectiveness
  1. 2 RCTs,  300 participants; some  40 minimally displaced
Unknown effectiveness
  1. 1 RCT, 126 participants
Unknown effectiveness
  1. 2 RCTs, 227 participants; some minimally displaced
Unknown effectiveness
  1. 9 RCTs,  1370 participants; some minimally or undisplaced fractures
Unknown effectiveness
  1. 3 RCTs, 135 participants (10 treated surgically); <100 displaced
Unknown effectiveness
8 / Q13.5 What rehabilitation interventions should be given at this stage (during immobilisation)?
Provision of occupational therapy soon after plaster cast versus no provision / 1 RCT, 40 participants
Unknown effectiveness

Cont’d over

No. / Question
Comparison(s) tested within the RCT(s) /

Evidence from RCTs

Interpretation
9 / Q13.7 How long should the wrist be immobilised for reduced fractures?
3-4 weeks versus 5-6 weeks / 3 RCTs, 298 participants
Unknown effectiveness
10 / Q13.11What rehabilitation interventions should be given at this stage (post-immobilisation)?
  1. Provision of routine therapy versus no provision
  1. Referral for routine physiotherapy versus home exercise sheet and instruction at outpatients by orthopaedic surgeon

c.Passive mobilisation versus no passive mobilisation

  1. Ultrasound (5 minutes) versus sham ultrasound
  1. Intermittent pneumatic compression prior to occupational therapy versus occupational therapy alone
  1. Forearm immersion in whirlpool prior to physiotherapy versus wrapping of forearm in 2 towels
/
  1. 3 RCTs, 226 participants; ?+30+40 displaced fractures
Unknown effectiveness
  1. 1 RCT, 18 participants: most or all with displaced fractures
Unknown effectiveness
  1. 2 RCTs, 70 participants: most if not all had displaced fractures including 13 treated with pins and plaster cast
Unknown effectiveness
  1. 1 RCT, 38 participants
Unknown effectiveness
  1. 1 RCT, 43 participants: most probably had displaced fractures
Unknown effectiveness
  1. 1 RCT, 24 participants: 18 with displaced fractures
Unknown effectiveness
11 / Q14 What method(s) of surgery (could be a combination) are preferable for typical circumstances (fracture types)?
  1. Percutaneous pinning versus external fixation
  1. Medullary pinning versus external fixation
  1. Open reduction and internal fixation (ORIF) versus external fixation
  1. Bone scaffolding (graft / substitute) versus external fixation
  1. ORIF versus arthroscopic reduction and percutaneous pinning
  1. ORIF with external fixation versus arthroscopic reduction and percutaneous pinning
  1. Arthroscopic reduction, percutaneous pinning and external fixation versus ORIF
/
  1. 2 RCTs, 156 participants
Unknown effectiveness
  1. 1 RCT, 100 participants
Unknown effectiveness
  1. 1 RCT, 57 participants
Unknown effectiveness
  1. 4 RCTs, 395 participants
Unknown effectiveness
  1. 1 RCT, 37 participants
Unknown effectiveness
  1. 1 RCT, 34 participants
Unknown effectiveness
  1. 1 RCT, 96 participants
Unknown effectiveness

Cont’d over

No. / Question
Comparison(s) tested within the RCT(s) /

Evidence from RCTs

Interpretation
12 / Q18.1 What method(s) of external fixation is / are preferable?
  1. Pins and plaster external fixation versus external fixator
  1. Non-bridging (of wrist joint) versus bridging external fixation
/
  1. 2 RCTs, 149 participants
Unknown effectiveness
  1. 2 RCTs, 80 participants
Non-bridging external fixation ‘likely to be beneficial’ when able to place distal pin securely. (Evidence for predominantly redisplaced fractures.)
13 / Q19.1 What method(s) of internal fixation is / are preferable?

Pi-plate versus 2 ¼ tube plates

/ 1 RCT, 65 participants
Pi-plate “unlikely to be beneficial” in present form for smaller radii due to operational difficulties in fitting the plate.
14 / Q19.2 Is triangular ligament repair necessary (internal fixation)? / No evidence
15 / Q20.1 What materials for filling bony defects are acceptable? / No evidence
16 / Q21.3 When should (re-)reduction be done for re-displaced / secondarily displaced fractures? / No evidence
17 / Q23.2 What are good (practical and effective) ways of (routinely) deliveringrehabilitative interventions?
Exercises either supervised by a physiotherapist or upon instruction by surgeon / 1 RCT, 135 participants
Unknown effectiveness
18 / Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention? For example, should patients be screened for osteoporosis? / No evidence (from RCTs with the5reviews)