Immobilisation Position in the Plaster Cast Management of Colles’ Fracture
Date First Published:
September 8, 2006
Last Updated:
January 23, 2007
Report by:
Dr S Jain, SHO (Hull Royal Infirmary)
Search checked by:
Dr R Perry, Hull Royal Infirmary
Three-Part Question:
In [those patients who have manipulation of a Colles fracture] does [the position of immobilisation of the wrist in a plaster cast] [affect clinical outcome]?
Clinical Scenario:
A 63 year old lady presents to the Accident and Emergency department with pain in her right wrist after a fall onto an outstretched hand. She is extremely tender over her distal radius and has poor range of movement. An x-ray of her wrist confirms a diagnosis of Colles fracture. Whilst in the plaster room, the question is raised of which position is best in order to immobilise her wrist in a plaster cast.
Search Strategy:
medline 1950 to current, using Dialog Datastar interface
Search Details:
(immobilisation.TI,AB. AND LG=EN AND HUMAN=YES) AND (Colles.TI,AB. AND LG=EN AND HUMAN=YES)
Outcome:
the search yielded 55 papers of which 4 were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The Treatment of Colles Fracture: Immobilisation with the Wrist Dorsiflexed A Gupta 1991 India | 204 patients age range 18 to 74 with Colles fracture with the wrist immobilised in different positions: palmar flexion (60), neutral position (75) and dorsiflexion (69) after closed reduction. | Prospective cohort study | Anatomical loss of dorsal tilt | Least in displaced, extra-articular fractures with comminution and displaced intra-articular fractures with the wrist immobilised in dorsiflexion. No significant difference between the groups with displaced, extra-articular and uncomminuted fractures | Statistical significance not assessed Population sample is younger than those we see in UK with Colles fracture No mention of associated complications in each group Heterogeneous sample of patients with no mention of previous bone disease Exclusion of undisplaced fractures Inclusion of comminuted and intra-articular fractures which would often be referred to Orthopaedics in the UK Unspecified randomisation process |
| Anatomical loss of radial angulation | Almost no difference between the groups | ||||
| Anatomical loss of radial length | Greatest in neutral position group and least in dorsiflexion group | ||||
| Functional results | Best results noted in wrists immobilised in dorsilflexion | ||||
| Treatment of Colles' Fracture: a Prospective Comparison of Three Different Positions of Immobilisation O Wahlstrom 1982 Sweden | 42 women over 40 years with closed extra-articular displaced fractures of the wrist reduced and randomly immobilised in pronation (14), midway (12) or supination (16) | Prospective cohort study | Redisplacement of fracture | Lowest in pronation group but ? statistical significance | Small study Only one type of fracture included in study Only women over 40 years included No mention of axial position of wrist i.e. flexion, neutral or extension No assessment of function in follow up of patients |
| Fractures needing re-reduction | One from pronation group, one from midway group and three from supination group | ||||
| Anatomical result at 4-5 weeks | Best in pronation group i.e. lowest increase in dorsal angulation | ||||
| Colles Fracture: Immobilisation in pronation or supination? C Wilson, R Venner Mar-84 UK | 41 patients with Colles' fracture reduced and the wrist randomly immoblised in positions of pronation (20) and supination (21) with anatomical assessment and fucntional assessment made at 4 weeks | Prospective cohort study | Anatomical assessment of dorsal tilt | No statistically significant difference | Small study Unspecified randomisation process Both groups held in volar and ulnar deviation - no assessment of other axial positions |
| Anatomical assessment of radial deviation | No statistically significant difference | ||||
| Functional result | No statistically significant difference | ||||
| Colles' Fracture: How Should its Displacement be Measured and How Should it be Immobilised? W Van der Linden and R Ericson. 1981, Sweden | 250 patients with Colles' fracture randomised into 5 groups with each group being immobilised using different techniques comparing casts and splints and also the position of immobilisation i.e. the Coton Loder position and the neutral position with or without ulnar deviation. Anatomical assessment was made using radiographs at prospective points during follow up | Prospective randomised cohort study | Radiographic anatomical assessment | 'hardly any difference' between 5 groups | Unspecified randomisation process Different surgeons used which is another variable No exclusions were made, notably of those who had fractures re-reduced at ten days |
| Restriction in range of movement compared with uninjured side at 6 months | No significant difference |
Author Commentary:
Colles' fracture is the most common fracture seen in the A&E department. Each of the relevant papers address key aspects of clinical outcome and long term management. All of these papers compare different positions of immobilisation of the wrist. There were weaknesses with all the studies such as small sample size, a lack of functional assessment, a lack of statistical significance analysis and lack of applicability to the UK population. These are outlined for each specific paper in the table. Unfortunately, the papers are also all rather dated and very little work has been done into this subject in recent times. The standard and accepted Cotton-Loder position lacks a strong evidence base. Further research is needed in this area.
Bottom Line:
No robust clinical evidence exists to support any particular position of immobilisation. Local guidelines should be followed.
References:
- A Gupta. The Treatment of Colles Fracture: Immobilisation with the Wrist Dorsiflexed
- O Wahlstrom. Treatment of Colles' Fracture: a Prospective Comparison of Three Different Positions of Immobilisation
- C Wilson, R Venner. Colles Fracture: Immobilisation in pronation or supination?
- W Van der Linden and R Ericson.. Colles' Fracture: How Should its Displacement be Measured and How Should it be Immobilised?