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(Review)
Handoll HHG, Madhok R, Dodds C
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 1
http://www.thecochranelibrary.com
Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1 HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26 AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30 CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50 DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 1 Pain. . . 58
Analysis 1.2. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 2 Pain and
preferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Analysis 1.3. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 3 Re-
manipulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.4. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 4 Post reduction
anatomical measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Analysis 1.5. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 5 Poor quality of
reduction and anatomical scores. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 1.6. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 6 Later
redislocation/re-reduction of fracture. . . . . . . . . . . . . . . . . . . . . . . . . . 63
Analysis 1.7. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 7 Operator
judgement of effectiveness of procedure (linear analogue scale). . . . . . . . . . . . . . . . . . 64
Analysis 1.8. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 8 Timing of
procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.9. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 9 Adverse
effects/Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 1.10. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 10 Poor
functional score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Analysis 2.1. Comparison 2 Nerve block (at elbow) versus haematoma block, Outcome 1 Pain (moderate or severe) during
procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Analysis 2.2. Comparison 2 Nerve block (at elbow) versus haematoma block, Outcome 2 Poor wrist relaxation during
procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Analysis 3.1. Comparison 3 Intravenous sedation versus haematoma block, Outcome 1 Pain during reduction: visual
analogue scale (0: no pain to 10: excruciating pain). . . . . . . . . . . . . . . . . . . . . . 68
Analysis 3.2. Comparison 3 Intravenous sedation versus haematoma block, Outcome 2 Pain during reduction: VAS score >
3 for procedure (0: no pain; 10: excruciating pain). . . . . . . . . . . . . . . . . . . . . . 68
Analysis 3.3. Comparison 3 Intravenous sedation versus haematoma block, Outcome 3 Time for fracture reduction. . 69
Analysis 3.4. Comparison 3 Intravenous sedation versus haematoma block, Outcome 4 Radiological result at 8 weeks. 70
Analysis 3.5. Comparison 3 Intravenous sedation versus haematoma block, Outcome 5 Adverse effects. . . . . . 71
Analysis 3.6. Comparison 3 Intravenous sedation versus haematoma block, Outcome 6 Substantial rest pain at 8 weeks. 72
Analysis 3.7. Comparison 3 Intravenous sedation versus haematoma block, Outcome 7 Substantial stiffness at 8 weeks. 72
Analysis 4.1. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 1 Radial length
shortening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 4.2. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 2 Residual dorsal
deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 4.3. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 3 Timing of procedure. 74
i Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.1. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 1 Reactions during reduction of
fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Analysis 5.2. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 2 Quality of initial
reduction/redisplaced at 6 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis 5.3. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 3 Adverse effects. . . . . . 77
Analysis 5.4. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 4 Patient apprehension if given same
method of anaesthesia again. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 6.1. Comparison 6 General IV anaesthesia versus haematoma block + sedation (midazolam), Outcome 1 Radial
length shortening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Analysis 6.2. Comparison 6 General IV anaesthesia versus haematoma block + sedation (midazolam), Outcome 2 Residual
dorsal deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Analysis 6.3. Comparison 6 General IV anaesthesia versus haematoma block + sedation (midazolam), Outcome 3 Timing
of procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Analysis 7.1. Comparison 7 Location of IVRA injection site: antecubital fossa versus hand dorsum, Outcome 1 Procedural
problems and adverse effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Analysis 8.1. Comparison 8 Application of an additional tourniquet during IVRA, Outcome 1 Time to clinical anaesthesia
(minutes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Analysis 9.1. Comparison 9 Brachial plexus block technique: proximal cranial needle (PCN) versus Winnie and Collins
(W+C), Outcome 1 Adverse effects (whole group). . . . . . . . . . . . . . . . . . . . . . 82
Analysis 10.1. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 1 Failed reduction/re-manipulation. . 83
Analysis 10.2. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 2 Additional analgesic required. . . 84
Analysis 10.3. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 3 Unacceptable reduced position of
fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Analysis 10.4. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 4 Duration of tourniquet application
(minutes) - whole group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis 10.5. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 5 Timing of sensorial and motor blockade -
whole group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis 10.6. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 6 Adverse effects/Complications. . . 86
Analysis 11.1. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 1 Tourniquet time (minutes). . 87
Analysis 11.2. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 2 Time to rst analgesia (minutes). 88
Analysis 11.3. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 3 Number of painkillers (co-
dydramol) in 24 hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 11.4. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 4 Pain: numerical rating scale (0: no
pain to 10: worst imaginable) in 24 hours. . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 11.5. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 5 Moderate or severe pain in rst 24
hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 12.1. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 1 Radial length
shortening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 12.2. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 2 Residual dorsal
deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 12.3. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 3 Timing of procedure. 93
Analysis 13.1. Comparison 13 Hyaluronidase (enzyme) supplement to haematoma block, Outcome 1 Unsuccessful
manipulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis 14.1. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 1 Sensory blockade at 10 minutes
(VAS: 0 (complete) to 100 (none)). . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis 14.2. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 2 Sensory blockade at 30 minutes
(VAS: 0 (complete) to 100 (none)). . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Analysis 14.3. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 3 Duration of motor blockade
(minutes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Analysis 15.1. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 1 Pain during procedure. . . . . 97
Analysis 15.2. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 2 Unacceptable/poor result. . . . 98
Analysis 15.3. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 3 Adverse effects. . . . . . . 99
99 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ii Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
101 WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101 HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101 CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iii Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Anaesthesia for treating distal radial fracture in adults
Helen HG Handoll
1
, Rajan Madhok
2
, Chris Dodds
3
1
Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, Middlesbor-
ough, UK.
2
Cochrane Bone, Joint and Muscle Trauma Group, University of Manchester, Manchester, UK.
3
Sleep Disorders Clinic,
James Cook University Hospital, Middlesbrough, UK
Contact address: Helen HG Handoll, Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social
Care, University of Teesside, School of Health and Social Care, Middlesborough, Tees Valley, TS1 3BA, UK. h.handoll@tees.ac.uk.
H.Handoll@ed.ac.uk.
Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 5 January 2004.
Citation: Handoll HHG, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database of Systematic
Reviews 2002, Issue 3. Art. No.: CD003320. DOI: 10.1002/14651858.CD003320.
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Anaesthesia is usually
provided during manipulation of displaced fractures or during surgical treatment.
Objectives
To examine and summarise the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous
regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug
adjuncts used during the management of distal radial fractures in adults.
Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003), the Cochrane Central Register
of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966 to November week 2 2003), EMBASE (1988 to 2003
week 49), CINAHL (1982 to December week 1 2003), the UK National Research Register (Issue 4, 2003), Current Controlled Trials
(October 2003) and reference lists of articles. We also handsearched conference abstracts from various orthopaedic meetings.
Selection criteria
Randomised or quasi-randomised clinical trials evaluating relevant interventions for these injuries (see Objectives). We excluded
pharmacological trials comparing drug dosages and, with one exception, different drugs in the same class. Also excluded were trials
reporting only pharmacokinetic and/or physiological outcomes.
Data collection and analysis
All trials meeting the selection criteria were independently assessed by the three reviewers for methodological quality. Data were extracted
independently by two reviewers. Quantitative data are presented using relative risks or mean differences together with 95 per cent
condence limits. Only very limited pooling of results from comparable trials was possible.
1 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
The 18 included studies involved at least 1200, mainly female and older, patients with fractures of the distal radius. All studies had
serious methodological limitations, notably in the frequent failure to assess clinically important and longer-term outcomes.
Five trials provided evidence that, when compared with haematoma block, IVRAprovided better analgesia during fracture manipulation
and enabled better and easier reduction of the fracture, with some indication of a reduced risk of later redislocation or need for re-
reduction. In contrast, haematoma block was quicker and easier to perform and less resource intensive.
There was inadequate evidence of the relative effectiveness of different methods of anaesthesia from the following comparisons,
all examined within single trials only: nerve block versus haematoma block; intravenous sedation versus haematoma block; general
anaesthesia versus haematoma block; general anaesthesia versus sedation; and general anaesthesia versus haematoma block and sedation.
None of the three trials evaluating three different physical aspects of anaesthesia (injection site of, or extra tourniquet, for IVRA; and
technique for brachial plexus block) provided conclusive evidence for the effectiveness and safety of the novel technique.
Six trials examined the use of drug adjuncts. The addition of two different muscle relaxants and one analgesic was tested for IVRA;
one sedative and hyaluronidase for haematoma block; and clonidine for brachial plexus block. All trials evaluating adjuncts failed to
provide evidence on eventual clinical outcome.
A seriously awed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of
treatment by different doctors on patient outcome.
Authors conclusions
There was insufcient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia,
different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some
indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction.
Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which
includes consideration of anaesthesia options, is the way forward.
P L A I N L A N G U A G E S U M M A R Y
Anaesthesia for treating distal radial fracture in adults
Wrist fractures (breaks) are very common, especially in women with osteoporosis. Bone fragments may need to be put back into place.
Anaesthesia is used to prevent pain during treatment and several methods are in common use. General anaesthesia involves a loss of
consciousness. Regional anaesthesia involves an injection (either into a vein or into tissue surrounding nerves) to numb the injured arm.
Local anaesthesia is an injection directly into the fracture site. Sedation usually involves a drug to allay anxiety and promote sleepiness.
The review found there was not enough evidence from randomised trials to decide which is the best method.
B A C K G R O U N D
Fractures of the distal radius are one of the most common fractures
inmany predominantly white and older populations (Sahlin 1990;
Singer 1998). It has beenestimated that a 50 year old white woman
in the USA or Northern Europe has a 15 per cent lifetime risk of
a distal radius fracture; whereas a white man of the same age has
a lifetime risk of a little over two per cent (Cummings 1985). A
recent prospective survey, conducted in six centres in the UK, of
Colles fracture in patients aged 35 years and above, reported the
overall annual incidence of this fracture to be 9/10,000 in men
and 37/10,000 in women (ONeill 2001). Distal radial fractures
are usually treated on an outpatient basis, with around 20 per
cent of patients (mainly older people) requiring hospital admission
(Cummings 1985; ONeill 2001).
Most fractures of the distal radius in older people result from
2 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
low-energy trauma, such as a fall from standing height or less. In
younger adults, these injuries are usually sustained through high-
energy trauma, such as a trafc accident. The pattern of incidence
reects the bone loss from osteoporosis in older people as well as
an increased number of falls by older women (Nguyen 2001).
These fractures are generally closed and usually involve displace-
ment of fracture fragments. They may be either extra-articular
(leaving the articular surface of the distal radius intact) or intra-
articular (the articular surface is disrupted). Numerous classi-
cations have been devised to dene and group different fracture
patterns (Chitnavis 1999). Simple classications based on clinical
appearance, and often named after those who described them, re-
main in common use. In particular, Colles fracture is still the
terminology used for a fracture in which there is an obvious and
typical clinical deformity - of dorsal displacement, dorsal angula-
tion, dorsal comminution (small fragments of bone), and radial
shortening.
The majority of distal radial fractures are treated conservatively
(non-operatively). This usually involves reduction under anaes-
thesia of the fracture if displaced, and forearm immobilisation in
a plaster cast or brace for around six weeks. Questions over the use
and timing of fracture reduction and of conservative methods used
to stabilise the reduced fracture are covered in a separate Cochrane
review (Handoll 2003a). A separate review of methods of closed
reduction, some of which were trialled without anaesthesia, is now
available (Handoll 2003c). Also available is a Cochrane review of
surgical treatment, which usually involves either closed or open
reduction followed by external or internal xation and a similar
period of immobilisation (Handoll 2003b).
A variety of options are available for anaesthesia:
Haematoma block where a local anaesthetic is injected
into the fracture site.
Intravenous regional anaesthesia (IVRA) involving
intravenous infusion of a local anaesthetic into the arm after
draining the venous system and applying a tourniquet/cuff at
greater than arterial blood pressure. This is commonly referred to
as a Biers or Bier block, after the originator of this general
method for limb anaesthesia.
Regional nerve blocks such as radial, median, and ulnar
nerve blocks at the elbow or in the axilla (armpit).
Brachial plexus nerve blocks using the following approaches
(locations for injection): interscalene, supraclavicular, or
infraclavicular; and without or with catheter implantation (to
enable a top-up). (These are also regional nerve blocks but
comprise a distinct category.)
Sedation. In our protocol we called this conscious
sedation. While this expression is widely used in the literature, it
has been pointed out that the term conscious sedation is a
misnomer as well as being vague and confusing (Green 2002;
Shipton 2002). Revised anaesthesia care standards in the USA
have replaced conscious sedation with moderate sedation/
analgesia (JCAHO 2001). The latter denes moderate sedation
as A drug-induced depression of consciousness during which
patients respond purposefully to verbal commands, either alone
or accompanied by light tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually
maintained. The expression monitored intravenous anaesthetic
care is also used (Shipton 2002). In this review sedation
primarily refers to planned moderate sedation.
General anaesthesia by total intravenous anaesthesia or use
of inhalation anaesthetics, with orotracheal intubation or
oropharyngeal intubation (e.g. laryngeal mask airway) as
necessary.
Each of these methods has potential complications and may also
result in inadequate anaesthesia (loss of sensation), analgesia (pain
relief ) and/or muscle relaxation, which could compromise the
treatment process and results. Adverse drug reactions could also
result from any of the agents used. Concerns over the toxicity of
local anaesthetics have been raised (Quinton 1988a) and the se-
rious dangers of leakage of anaesthetic from a poorly contained
Biers block, perhaps resulting froma rupturedcuff, are well known
(Burke 1988; Heath 1982). There are also potential side effects
from tourniquet use (Wakai 2001); specically, any additional
swelling of the forearm on release of the tourniquet may result in
a tighter plaster cast and associated nger stiffness. Local damage,
including haematoma, blood vessel rupture and damage, and var-
ious neuropathies, may ensue from regional nerve blocks. Incor-
rect administration of a nerve block may also result in the serious
consequences of an unintended subarachnoid injection, epidural
block, intravascular injection, phrenic nerve block (diaphragm)
and, in particular for a supraclavicular block, a pneumothorax
(lung collapse). Potential complications of general anaesthesia in-
clude difculties in maintaining or establishing an open airway,
intra-operative hypotension or hypertension, aspiration of gastric
contents, post-operative nausea and vomiting, respiratory depres-
sion, and damage to teeth or upper airways.
Factors affecting the choice of anaesthesia include patient co-mor-
bidity and suitability, patient preferences, local expertise includ-
ing the availability of anaesthetists, treatment methods including
reduction technique (e.g. manual manipulation, nger trap trac-
tion) and whether immediate surgery is anticipated for a failed
reduction, the throughput of patients, and local facilities.
O B J E C T I V E S
This review aimed to identify and assess the evidence from ran-
domised and quasi-randomised trials evaluating the main methods
3 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
of anaesthesia, and associated physical techniques, used during the
management of distal radial fractures in adults. Where possible,
we made a distinction between conservative and surgical manage-
ment, and between the treatment of initially displaced fractures
versus redisplaced or secondarily displaced fractures.
We aimed to test the following null hypotheses.
1. There is no difference in outcome between the main types of
anaesthesia (haematoma block, intravenous regional anaesthesia
(IVRA), regional nerve blocks using various approaches to the
brachial plexus, sedation, and general anaesthesia).
2. There is no difference in outcome between different physical
techniques for the above methods. This includes the position of
the injection site for local anaesthesia (haematoma block), IVRA
and nerve blocks, and total intravenous versus inhalation general
anaesthesia.
3. There is no difference in outcome between the use of drug
adjuncts/supplements such as muscle relaxants.
Where possible and appropriate, we planned separate analyses of
the outcome of conservative and operative treatment, of initial
and secondary treatment, of males and females, of different age
groups (younger adults, older adults), of types of fracture, of co-
morbidities, and of prior functional and mental status. The type
of treatment, including reduction technique, and clinician expe-
rience and speciality were also noted.
M E T H O D S
Criteria for considering studies for this review
Types of studies
We considered any randomised or quasi-randomised (use of a
method of allocating participants to a treatment that is not strictly
random; e.g. by date of birth, hospital record number, alternation)
clinical trials of interventions, as listed above, used for treating
distal radial fractures.
Types of participants
Patients of either sex who had completed skeletal growth and who
were receiving conservative or surgical treatment for a fracture of
the distal radius.
The characteristics of the participants included in the trials were
noted with an emphasis on gender, age, type of fracture, functional
and mental status, and co-morbidities.
Types of interventions
All randomised and quasi-randomised trials comparing different
types and physical techniques of anaesthesia used for treating distal
radial fractures. Also included are trials examining the use of drug
adjuncts/supplements, such as muscle relaxants.
With one exception, we excluded pharmacological trials compar-
ing different drugs in the same class, or drug dosages.
Types of outcome measures
a. Failed/inadequate anaesthesia. This is based on explicit reports
of anaesthesia inadequacy or failure, and/or the needto use another
methodand/or additional procedures, curtailment or modication
of treatment (e.g. of closed reduction), patient complaint of pain
and patient dissatisfaction.
b. Anatomical restoration. Quality of initial reduction, nal malu-
nion and cosmetic deformity.
c. Adverse effects directly attributed to anaesthetic drugs and tech-
niques; complications resulting directly from the administration
of anaesthesia (including cardiac and respiratory arrest).
d. Clinical outcomes. Residual soft tissue swelling, early and late
complications associated with distal radial fractures and/or their
treatment, including reex sympathetic dystrophy (RSD) or com-
plex regional pain syndrome type 1.
e. Functional outcomes. Range of movement (wrist, forearm and
shoulder mobility), pain, grip strength, and activities of daily liv-
ing including return to previous employment; use of patient func-
tional assessment instruments such as Short Form-36 (SF-36), the
Disability of the Arm, Shoulder, and Hand questionnaire (DASH)
and the Patient-Rated Wrist Evaluation (PRWE) (MacDermid
2000).
f. Resource use. Hospital admission, anaesthetist involvement and
other costs.
Trials reporting only pharmacokinetic and/or physiological out-
comes were excluded.
Search methods for identication of studies
We searched the Cochrane Bone, Joint and Muscle Trauma Group
specialised register (November 2003), the Cochrane Central Reg-
ister of Controlled Trials (The Cochrane Library Issue 4, 2003),
MEDLINE (1966 to November week 2 2003), EMBASE (1988
to 2003 week 49) and CINAHL (1982 to December week 1
2003). We also searched Current Controlled Trials at http://
www.controlled-trials.com (accessed October 2003) and the UK
National Research Register at http://www.update-software.com/
national/ (up to Issue 4, 2003 ) for ongoing and recently com-
pleted trials. We handsearched the British Volume of the Journal
of Bone and Joint Surgery supplements (1996 onwards), abstracts
of the American Society for Surgery of the Hand annual meet-
ings (2000 to 2003: http:/www.assh.org/ASSH) and abstracts of
the American Orthopaedic Trauma Association annual meetings
4 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(upto2003: http://www.ota.org/education/amabstracts.htm). We
also scrutinised weekly downloads of Fracture articles in new
issues of 17 journals (Acta Orthop Scand; AmJ Orthop; Arch Or-
thop Trauma Surg; Clin J Sport Med; Clin Orthop; Emerg Med
Clin North Am; Foot Ankle Int; Injury; J Accid Emerg Med; J Am
Acad Orthop Surg; J Arthroplasty; J Bone Joint Surg Am; J Bone
Joint Surg Br; J Foot Ankle Surg; J Orthop Trauma; J Trauma; Or-
thopedics) from AMEDEO (http://www.amedeo.com). No lan-
guage restrictions were applied.
The following search strategies were used:
The search strategy for The Cochrane Library is shown in Appendix
1. This search was used to nd all trials of interventions for distal
radial fractures, not just those comparing anaesthesia methods.
In MEDLINE (OVID WEB) the search strategy (see Appendix 2)
was combined with all three levels of the optimal search strategy
for randomised trials (Clarke 2003).
The search strategy used for EMBASE (OVID WEB) is shown in
Appendix 3.
Data collection and analysis
Potentially eligible trials were assessed for inclusion by all three re-
viewers. Any disagreement was resolved through discussion. Titles
of journals, names of authors or supporting institutions were not
masked at any stage. The methodological quality of included stud-
ies was assessed independently by at least two reviewers. All three
reviewers considered any discrepancies and disagreement was re-
solved by discussion; consistency checks were made by HH. Data
were extracted, using a pre-piloted data extraction form, by two
reviewers (CD & HH) with arbitration, if necessary, by the third
reviewer (RM).
Trialists were contacted for additional details of key items of trial
methodology or data.
Quality assessment tool
A modication of the Cochrane Bone, Joint and Muscle Trauma
Group quality assessment tool (see Group details) was used in the
evaluation of the included studies. The scoring scheme for 12 as-
pects of trial validity, plus brief notes of coding guidelines for some
items, is shown in Table 1. Though the scores of the individual
items were summed, this was to gain an overall impression rather
than for quantitative purposes.
Table 1. Methodological quality assessment scheme
Items Scores Notes
1. Was the assigned treatment adequately
concealed prior to allocation?
3 = method did not allow disclosure of as-
signment.
1 = small but possible chance of disclosure
of assignment or unclear.
0 = quasi-randomised or open list/tables.
Cochrane code (see Handbook): Clearly
Yes = A; Not sure = B; Clearly No = C.
2. Were the outcomes of patients who with-
drewdescribed and included in the analysis
(intention to treat)?
3 = withdrawals well described and ac-
counted for in analysis.
1 = withdrawals described and analysis not
possible, or probably no withdrawals.
0 = no mention, inadequate mention, or
obvious differences and no adjustment.
3. Were the outcome assessors blinded to
treatment status?
3 = effective action taken to blind assessors.
1 = small or moderate chance of unblinding
of assessors, or some blinding of outcomes
attempted.
0 = not mentioned or not possible.
4. Were important baseline characteristics
reported and comparable?
3 = good comparability of groups, or con-
founding adjusted for in analysis.
1 = confounding small, mentioned but not
adjusted for, or comparability reported in
text without conrmatory data.
0 = large potential for confounding, or not
The principal confounders considered were
gender, age, type of fracture, type of treat-
ment, existing co-morbidities (cardiac dis-
ease, arthritis), prior functional and mental
status, and existing complications.
5 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Methodological quality assessment scheme (Continued)
discussed.
5. Were the patients blind to assignment
status after allocation?
3 = effective action taken to blind patients.
1 = small or moderate chance of unblinding
of patients.
0 = not possible, or not mentioned (unless
double-blind), or possible but not done.
6. Were the treatment providers blind to
assignment status?
3=effective actiontakentoblindtreatment
providers.
1 = small or moderate chance of unblinding
of treatment providers.
0 = not possible, or not mentioned (unless
double-blind), or possible but not done.
7. Were care programmes, other than the
trial options, identical?
3 = care programmes clearly identical.
1 = clear but trivial differences, or some
evidence of comparability.
0 = not mentioned or clear and important
differences in care programmes.
Examples of clinically important differ-
ences in other interventions were: differ-
ences in reduction method, subsequent
treatment (surgery, plaster cast), clinician
experience and speciality.
8. Were the inclusion and exclusion criteria
for entry clearly dened?
3 = clearly dened (including type of treat-
ment).
1 = inadequately dened.
0 = not dened.
9. Were the interventions clearly dened
(including who provided the care)?
3 = clearly dened interventions are ap-
plied with a standardised protocol and care
providers identied.
1 = clearly dened interventions are applied
but the application protocol is not stan-
dardised or care providers identied.
0 = intervention and/or application proto-
col are poorly or not dened.
10. Were the outcome measures used
clearly dened?
3 = clearly dened.
1 = inadequately dened.
0 = not dened.
11. Were the accuracy and precision, with
consideration of observer variation, of the
outcome measures adequate (and were
these clinically useful?) - including active
follow-up?
3 = optimal.
1 = adequate.
0 = not dened, not adequate.
12. Was the timing (e.g. durationof surveil-
lance) clinically appropriate?
3 = optimal. (> 1 year)
1 = adequate. (3 months - 1 year)
0 = not dened, not adequate. (< 3 months)
6 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data analysis
Where available and appropriate, quantitative data for outcomes
listed in the inclusion criteria are presented in the analysis tables.
Relative risks and 95 per cent condence limits were calculated
for dichotomous outcomes, and mean differences and 95 per cent
condence limits calculated for continuous outcomes. Results of
comparable groups of trials were pooled using the xed effects
model and 95 per cent condence limits. Heterogeneity between
comparable trials was tested using a standard chi-squared test and
considered to be statistically signicant at p < 0.1. Where there
was signicant heterogeneity in the results of individual trials,
we viewed the results of the random effects model and presented
these, whenconsidered appropriate, instead of those fromthe xed
effects model. No subgroup analyses were undertaken; if they had
been, any tests of interaction calculated to determine if the results
for subgroups are signicantly different would have been based
on Peto odds ratio results. Sensitivity analyses examining various
aspects of trial and review methodology, including the effects of
missing data and study quality were also considered but rarely
possible.
R E S U L T S
Description of studies
See: Characteristics of includedstudies; Characteristics of excluded
studies.
The updating of search from June 2003 to November 2003 re-
sulted in the identication of no new trials in the second update
of this review.
In all, of 36 eligible studies, 18 are included and 18 are excluded
(see Characteristics of Excluded Studies Table).
All of the included studies were fully reported in medical journals;
Singh 1992 was published in an online journal. We received ad-
ditional information from the trialists of seven included trials; in-
cluding separate results for patients withdistal radial fractures from
three mixed population trials (Erlacher 2001; Esmaoglu 1995;
Pippa 2000). The trials were initially identied in the following
ways: bibliography checking (1); Current Contents (1); Cochrane
Library (1); EMBASE (1); handsearching or journal browsing (3);
MEDLINE (10) and reference from an external referee of the re-
view protocol (1).
The periods over which individual trials were conducted spanned
over three decades, from the early 1970s (Bultitude 1972) on-
wards. With the exception of Kendall 1997, which was conducted
in two accident and emergency departments, trials took place at
single centres in eight countries (Austria (1 trial); Denmark (1);
Finland (1); India (1); Italy (1); Sweden (1); Turkey (1); UK(11)).
English translations were obtained for trials reported in Danish
(Walther-Larsen 1988) and Turkish (Esmaoglu 1995).
The 18 included studies involved at least 1200, mainly female and
older, patients with fractures of the distal radius. There was a min-
imum of 1186 randomised patients with these injuries. A further
10 non-randomised patients were included in one trial (Bultitude
1972). There may have been another patient included in Funk
1997. The number of randomised patients in Wardrope 1985 was
not explicitly stated but was probably the same as deduced from a
table in the article. There were an estimated 20 patients with distal
radial fracture not included in Hollingworth 1982. This amounts
to an estimated maximum of 1217 patients overall.
With the exception of two trials (Pippa 2000; Singh 1992), most
trials presenting data onpatient gender recruited more female than
male patients; the proportion ranged from 65 per cent (Erlacher
2001) to 97 per cent (London 1996). Where provided, median
or mean ages of trial populations ranged between 31.5 years (
Esmaoglu 1995) and 70.5 years (Eastwood 1986). The youngest
patient (9 years) appeared in Bultitude 1972 and the oldest (91
years) inFunk 1997. Lower age limits were set by seventrials (Cobb
1985: 15years; Funk 1997: 16years; Hollingworth 1982: 16years;
Jones 1996: 12 years; Kendall 1997: 16 years; Walther-Larsen
1988: 14 years; Wardrope 1985: 45 years). Although childrenwere
included in some trials, it was clear that the majority of patients
were skeletally mature. An upper limit of 54 years was applied in
McGlone 1988.
Fracture type was generally broadly dened as distal radial, Colles,
or wrist fracture. A fracture classication scheme was speci-
ed in three trials: Olders classication scheme was applied in
Abbaszadegan 1990 and Walther-Larsen 1988; and Frykmans in
Abbaszadegan 1990 and Kendall 1997. Two trials specied radi-
ological criteria for trial inclusion; Kendall 1997 gave criteria for
minimum deformity and Abbaszadegan 1990 stated a maximum
for radial shortening. Anaesthesia was for manipulation/reduction
in 16 trials; subsequent plaster cast immobilisation was clearly
evident in 10 of these, and likely in the other six. Anaesthesia
was for surgery in all patients in two trials (Erlacher 2001; Pippa
2000) and perhaps for some of the distal radial fracture patients in
Hollingworth 1982. Four trials included patients requiring anaes-
thesia for other injuries or upper limb surgery: separate data for
patients with distal radial fractures have been provided by the tri-
alists of three trials (Erlacher 2001; Esmaoglu 1995; Pippa 2000);
and are on request for the fourth trial (Hollingworth 1982). A
minority of patients (approximately 10%) in Hollingworth 1982
underwent an operation or manipulation of hand injuries, other
forearm fractures or elbow dislocation.
Further details of the individual studies are provided in the Char-
acteristics of Included Studies Table.
The following is a brief description of the interventions compared
in the 18 trials. One trial (Funk 1997) appears in three compar-
isons (1d, 1f and 3c) as it compared general anaesthesia versus
haematoma block versus haematoma plus a sedative.
1. Main types of anaesthesia
1a. Intravenous regional anaesthesia (IVRA) versus
7 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
haematoma block (local anaesthesia)
Five trials (Abbaszadegan 1990; Cobb 1985; Kendall 1997;
Walther-Larsen 1988; Wardrope 1985) made this comparison
in 478 patients. Prilocaine was used for both methods in
Abbaszadegan 1990, and for IVRA in Cobb 1985, Kendall
1997 and Wardrope 1985; mepivacaine was used for IVRA in
Walther-Larsen 1988; lignocaine was used for the haematoma
block in the latter four trials. Lignocaine was either alkalinised or
neutral in Kendall 1997; this comparison is not included in this
review.
1b. Nerve block versus haematoma block
One trial (Haasio 1990) compared nerve block at the elbowregion
with haematoma block in 35 patients. Prilocaine was used for both
techniques.
1c. Sedation versus haematoma block
One trial (Singh 1992) compared an intravenous injection of pen-
tazocine combined with diazepam for sedation versus haematoma
block in 67 patients. Lignocaine (Xylocaine) was used for the
haematoma block.
1d. General anaesthesia versus haematoma block
Intravenous general anaesthesia was compared with haematoma
block in 40 of the 58 or 59 patients in Funk 1997. Propofol was
used for general anaesthesia and lignocaine for the haematoma
block.
1e. General anaesthesia versus sedation
One vintage trial (Bultitude 1972) compared general inhalation
anaesthesia with intravenous diazepam in 71 patients. The barbi-
turate and inhalation agents for general anaesthesia were not iden-
tied. Readers should note that the dosage of diazepam (generally
20mg) would be now considered dangerously high for adminis-
tration to elderly patients.
1f. General anaesthesia versus haematoma block with sedation
Intravenous general anaesthesia using propofol was compared with
haematoma block and sedation in 40 of the 58 or 59 patients
of Funk 1997. Lignocaine was used for haematoma block and
intravenous midazolam for sedation.
2. Physical techniques of anaesthesia
2a. Site of IVRA (Biers block) injection
One trial (Blyth 1995) compared the injection of prilocaine into
the antecubital fossa (elbow dip) with injection into the more
traditional dorsum (back) of the hand site for a Biers block in 100
patients.
2b. Use of an additional tourniquet for IVRA
One trial (Eastwood 1986), involving 50 patients, tested the ap-
plication of an extra tourniquet immediately proximal to the frac-
ture site during IVRA.
2c. Technique for brachial plexus block
One trial (Pippa 2000) compared a new subclavian perivascular
technique, the proximal cranial needle approach, with the Winnie
and Collins technique involving a supraclavicular approach. Seven
of the 60 patients in this trial underwent surgery for distal radial
fracture.
3. Drug adjuncts or supplements
3a. Muscle relaxant
Two trials (Esmaoglu 1995; McGlone 1988), involving a total of
76 patients, evaluated the addition of a muscle relaxant to IVRA.
Vecuronium was tested in Esmaoglu 1995; all patients received
intravenous lignocaine. Atracurium was tested in McGlone 1988;
prilocaine was used for IVRA in this trial. Seventeen patients in
Esmaoglu 1995 had distal radial fractures; the other 23 patients
had unspecied forearm fractures.
3b. Analgesic
One trial (Jones 1996) tested the addition of an analgesic, tenoxi-
cam, to prilocaine for IVRA in 45 patients. Tenoxicam was in-
serted into either the site of the Biers block or into the equivalent
site on the unaffected arm. Though the site for supplementary
analgesia is not covered in this review, the results for this compar-
ison are presented in the analyses.
3c. Sedative
The addition of intravenous midazolam sedation to haematoma
block was tested in 38 of the 58 or 59 patients in Funk 1997.
Lignocaine was used for the haematoma block.
3d. Enzyme
One trial (London 1996), involving 33 patients, tested the use
of an enzyme, hyaluronidase, with haematoma block. Lignocaine
was used for the haematoma block.
3e. Clonidine
One trial (Erlacher 2001) tested the addition of clonidine to one
of three local anaesthetics (mepivacaine, ropivacaine and bupi-
vacaine) for axillary perivascular brachial plexus block using the
Winnie method. Fifty-seven of the 120 patients in this trial un-
derwent surgery for distal radial fracture. The comparison of the
three different anaesthetics is not included in this review.
4. Extra comparison
Our intentionwas not to include comparisons of drugs inthe same
class. However, we made an exception for one trial (Hollingworth
1982) that compared bupivacaine with prilocaine for IVRAin 200
patients, at least 142 of whom had a distal radial fracture. We in-
cluded this trial for three main reasons: a) it reported orthopaedic
outcomes, b) it appeared to provide some insight into the poten-
tial effects on patient outcome of different operators, and c) it
tested a formerly standard intervention (bupivacaine for IVRA).
It is recognised that the characteristics of drugs in the same drug
class can differ importantly; for instance, bupivacaine has a longer
duration of action than prilocaine. While the differences between
these two drugs are pertinent here, they alone were not sufcient
to determine inclusion. Readers should note that bupivacaine is
no longer used for IVRA in the UK due to safety concerns (BNF
2000).
8 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Risk of bias in included studies
The methodological quality scores based on trial reports were vari-
able. Lack of conrmation of the concealment of allocation and
deciencies in the assessment of outcome, including only short-
term follow-up, were common reasons for lower quality scores. A
summary of the individual aspects of trial quality follows the ta-
ble of the scores for individual trials presented below. Information
specic to the rst three items of the quality score is given in the
methods section of the Characteristics of Included Studies Table.
1 2 3 4 5 6 7 8 9 10 11 12 Total Study ID
1 0 0 0 0 0 1 1 1 1 1 1 7 Abbaszadegan 1990
1 3 0 1 0 0 3 0 3 1 0 0 12 Blyth 1995
0 0 1 0 0 0 0 0 1 1 1 0 4 Bultitude 1972
1 0 0 0 0 0 0 3 1 1 0 0 6 Cobb 1985
1 1 0 0 0 0 3 0 3 1 0 0 9 Eastwood 1986
1 3 1 1 3 3 1 1 1 3 1 0 19 Erlacher 2001
0 1 0 0 0 0 0 3 3 3 1 0 11 Esmaoglu 1995
1 0 1 1 0 0 1 1 1 3 3 0 12 Funk 1997
1 3 0 0 0 0 1 1 3 3 1 0 13 Haasio 1990
3 0 3 0 3 3 0 1 1 3 0 0 17 Hollingworth 1982
1 3 1 3 3 3 3 3 3 3 1 0 27 Jones 1996
0 0 0 3 0 0 3 1 3 3 3 0 16 Kendall 1997
1 1 3 1 3 3 3 0 1 1 0 0 17 London 1996
1 3 3 1 1 3 3 0 3 3 1 0 22 McGlone 1988
0 3 1 0 0 0 1 1 3 3 1 0 13 Pippa 2000
3 3 3 3 3 0 3 3 3 3 1 0 28 Singh 1992
1 3 1 1 0 0 0 3 1 3 1 1 15 Walther-Larsen 1988
0 0 0 1 0 0 0 3 3 3 1 0 11 Wardrope 1985
Allocation was clearly concealed (item 1) in two trials (
Hollingworth 1982; Singh 1992). Some potential for disclosure
of allocation was considered for two trials (Erlacher 2001; Funk
1997) using computer generated randomisation lists and two tri-
als (Eastwood 1986; McGlone 1988) using envelopes. Seven trials
(Abbaszadegan 1990; Blyth1995; Cobb 1985; Haasio 1990; Jones
1996; London 1996; Walther-Larsen 1988) provided no details of
their method of randomisation. Allocation was not concealed in
Kendall 1997, where anopenlist of randomisednumbers was used,
nor in the three trials using quasi-randomised methods based on
either dates of birth (Pippa 2000) or alternation (Bultitude 1972;
Wardrope 1985). Concealment of allocation was also considered
unlikely in Esmaoglu 1995; further clarication of the method of
randomisation has been sought for this trial.
Intention to treat analysis (item 2) was considered very likely in
eight studies (Blyth 1995; Erlacher 2001; Haasio 1990; Jones
1996; McGlone 1988; Pippa 2000; Singh 1992; Walther-Larsen
1988). Reasons for a reduced score for this item were the inclu-
sion of patients from a non-randomised pilot study (Bultitude
1972), discrepancies in the data (Funk 1997; Wardrope 1985),
and no or insufcient information on post-randomisation ex-
clusions or loss to follow-up (Abbaszadegan 1990; Cobb 1985;
Eastwood 1986; Esmaoglu 1995; Hollingworth 1982; Kendall
1997; London 1996).
Blinding of outcome assessors (item 3) where possible was clearly
established in four studies (Hollingworth 1982; London 1996;
McGlone 1988; Singh 1992). For six studies (Bultitude 1972;
Erlacher 2001; Funk 1997; Jones 1996; Pippa 2000; Walther-
Larsen 1988) there was either a lack of information to establish
assessor blinding or only some of the assessors were blinded. Aside
from Esmaoglu 1995, all the studies scoring zero for this item
tested physical methods.
Three trials (Jones 1996; Kendall 1997; Singh 1992) provided suf-
cient information to indicate comparability between the treat-
ment groups in key baseline characteristics such as gender, age
and fracture type (item 4). Eight trials did not score for this item;
either through failure to provide baseline data for all randomised
patients, or failure to present any or sufcient information to con-
rm baseline comparability of important confounders.
Blinding of both patients and treatment providers (items 5 and
6) was considered effective in four drug trials (Erlacher 2001;
Hollingworth 1982; Jones 1996; London 1996). Blinding was ex-
plicitly stated for treatment providers in McGlone 1988; whilst
the lower score reects that there was no report of whether patients
were also blinded, we consider that this is likely. Patient blind-
ing took place in Singh 1992 where two methods of anaesthesia
were compared; Singh et al. reected that this approach would be
less achievable in most other cultures. Blinding of patients and
providers was often not practical for trials that compared different
anaesthetic techniques.
Comparability of care programmes (item7), comprising interven-
tions other than the trial interventions, could not be conrmed in
any trial but was considered likely in seven (Blyth 1995; Eastwood
1986; Jones 1996; Kendall 1997; London 1996; McGlone 1988;
Singh 1992). The criteria for judging comparability varied accord-
ing to the length of follow-up; for instance, the duration of plas-
ter cast immobilisation was not considered relevant when patients
were only followed up to the end of the manipulation. Information
on the technique used for fracture manipulation was provided in
only three trials (Eastwood 1986; Kendall 1997; McGlone 1988);
for these, and for some of the other trials, we may have assumed
incorrectly that the operators used the same methods. There was
no or inadequate information to assess care programme compara-
bility in the six trials that scored zero for this item.
Six trials (Cobb 1985; Esmaoglu 1995; Jones 1996; Singh 1992;
Walther-Larsen 1988; Wardrope 1985) provided sufcient trial
inclusion and exclusion criteria to dene the study population
(item8). In assessing this itemwe put more emphasis on exclusion
criteria that included contraindications and less on the radiological
criteria used to determine when a fracture required reduction; only
Kendall 1997 provided the latter. Studies where the only stated
criterion was wrist or distal radial fractures requiring manipulation
did not score for this item.
Ten trials provided a good description of the interventions used
(item 9); this included sufcient information to identify the disci-
pline of the care providers (see Characteristics of Included Studies
9 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table).
The denition (item 10) of outcome measurement was clear
enough to give a good idea of what was recorded in the major-
ity of the studies, but only two trials (Funk 1997; Kendall 1997)
were rated as having good quality outcome measurement that in-
cluded active follow-up (item11). Five studies (Blyth 1995; Cobb
1985; Eastwood 1986; Hollingworth 1982; London 1996) failed
to score for item 11; the loss of 25 out of 200 questionnaires was
considered an important failing in Hollingworth 1982. Of note is
that the comprehensiveness, aptness or overall validity of outcome
assessment was not scored in item11; hence many trials scored for
this item despite their limited measurement of outcome, as long
as assessment was clearly active and systematic.
The length of overall follow-up (item12) was exceedingly short in
most trials. Of the four trials (Abbaszadegan 1990; Bultitude 1972;
Singh 1992; Walther-Larsen 1988) that followed up patients post-
immobilisation, just two (Abbaszadegan 1990; Walther-Larsen
1988), each with six months follow-up, scored for this item.
Effects of interventions
1. Main types of anaesthesia
1a. Intravenous regional anaesthesia (IVRA) versus
haematoma block
All ve trials (Abbaszadegan 1990; Cobb 1985; Kendall 1997;
Walther-Larsen 1988; Wardrope 1985) testing this comparison
found that the IVRA patients experienced signicantly less pain
during fracture manipulation. Data for two trials (Cobb 1985;
Wardrope 1985) are presented in the analyses; no pooling was
possible due to incompatible outcome measures. Kendall 1997 re-
ported that the pain associated with the administration of anaes-
thesia was also signicantly less in the IVRA group. Two trials
(Cobb 1985; Kendall 1997) reported that pain soon after the pro-
cedure was similar in both groups and Cobb 1985 found no dif-
ference in the duration of post-operative analgesia (see analyses).
Similar numbers of patients in the two groups of Wardrope 1985
stated that they would have preferred general anaesthesia.
Four trials (Abbaszadegan 1990; Kendall 1997; Walther-Larsen
1988; Wardrope 1985) found that IVRA enabled better and easier
reduction of the fracture; Cobb 1985 reported that an inadequate
reduction was rare and not related to the method of anaesthesia.
Pooled results fromthree studies showthat signicantly fewer frac-
tures needed to be remanipulated during IVRA(11/140 versus 33/
131; relative risk (RR) 0.30, 95% condence interval (CI) 0.16 to
0.57; p = 0.0002). In the IVRA group, statistically better anatom-
ical post-reduction measurements were declared for dorsal angu-
lation in Abbaszadegan 1990 and Kendall 1997, and reported,
with conrmatory data, for ulnar angulation and radial length
(mean difference 1.8mm, 95%CI 0.6 to 3.0mm) in Wardrope
1985. Based on categories devised by Older et al. (Older 1965),
there was a tendency in Walther-Larsen 1988 for fewer people in
the IVRA group to have a poor result after reduction, or a poor
anatomical result at ve weeks (see analyses). Pooled results from
three studies show some tendency for fewer later redislocations or
re-reductions with IVRA (2/118 versus 8/110; RR 0.32, 95%CI
0.09 to 1.13).
Nostudy reporteda failure of anaesthesia; either initself, or leading
to a premature curtailment in the procedure, or use of another
method of anaesthesia. Based on an undened linear analogue
scale, Cobb 1985 reported that the casualty ofcers impression of
a greater effectiveness of IVRA was usually more generous than,
but still in agreement with, that of the patients (see analyses).
Cobb 1985 foundthat haematoma block was more popular among
the accident service staff who considered that it was simpler and
quicker to perform and would avoid some of the risks associated
with IVRA.
Both Cobb 1985 and Kendall 1997 found that IVRA took
around 22 minutes longer to prepare or to begin compared with
haematoma block. There was no signicant difference in the tim-
ing of the subsequent procedure in either trial, but an additional
41 minutes for tourniquet release and observation was reported in
Cobb 1985. Kendall 1997 reported no statistically signicant dif-
ference between the two groups in the overall time in the accident
and emergency department; Wardrope 1985 also claimed to have
found no difference. Walther-Larsen 1988 stated that IVRA was
more time consuming.
Four trials reported no or no signicant adverse effects (infection
or systemic complications) from anaesthesia; these were not men-
tioned in Abbaszadegan 1990. Other complications, such as me-
dian nerve compression, were few and occurred in similar num-
bers in the two anaesthesia groups (see analyses).
Functional outcomes were only reported by the two trials pre-
senting longer-term results (Abbaszadegan 1990; Walther-Larsen
1988). The trialist responsible for the medium term follow-up
study of Kendall 1997 indicated that the number of patients avail-
able at three months follow-up were insufcient to draw mean-
ingful conclusions on the nal function and anatomical position.
Abbaszadegan 1990 presented contradictory results in the text
compared with the tables for pain, but claimed that both groups
had similar pain and range of motion at six months. Only grip
strength was reported to be signicantly stronger for the IVRA
group at six months in Abbaszadegan 1990 (percentage of oppo-
site arm: 65% versus 53%; reported p = 0.01). Walther-Larsen
1988 found no statistically signicant difference in the functional
grades (Older 1965) of the two groups (see analyses).
No cost data were provided. Cobb 1985 reported that additional
staff time (mean 41 minutes/patient) was required for IVRA and
Kendall 1997 noted that two doctors were required to apply IVRA
whereas just one was required for haematoma block.
1b. Nerve block versus haematoma block
Haasio 1990 compared nerve block at the elbow region with
haematoma block in 35 patients. Slightly more patients endured
moderate (6 versus 4) or severe (3 versus 2) pain during manipu-
lation in the nerve block group but the difference was not statisti-
10 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
cally different (9/16 versus 6/19; RR 1.78, 95%CI 0.81 to 3.93).
The results of pin-prick analgesia at 15 minutes were reported to
be better (reported p < 0.05) for the median and ulnar nerves in
the nerve block group. Full motor blockade in three nerves (radial,
median, ulnar) only occurred in one patient in the nerve block
group and in one or two nerves in four others of the same group;
no instances of full motor block were found in the haematoma
group. Just one patient, belonging to the haematoma block group,
was considered by the surgeon to have an insufciently relaxed
wrist to ease manipulation; there was no mention of re-manipu-
lation. Despite ve patients experiencing severe pain, all patients
were reported as being satised with their treatment. There were
no cases of systemic toxicity.
1c. Sedation versus haematoma block
Singh 1992 compared intravenous sedation with haematoma
block in 67 patients. The exclusion from the reported analyses
of the results of one sedation group patient in whom intravenous
injection at the fracture site had failed (site chosen for blinding
purposes) was stated not to inuence the overall results. Patients
in the sedation group experienced signicantly more pain during
reduction of their fractures (mean difference in visual analogue
scores (0: no pain to 10: excruciating pain): 5.6, 95%CI 4.5 to
6.6). Only one patient in the sedation group registered a score un-
der three, compared with 25 in the haematoma group (RR 4.00,
95%CI 2.18 to 7.33). The time taken to reduce fractures was
greater for patients in the sedation group (patients for whom frac-
ture reduction took at least one minute: 32/33 versus 25/33; RR
1.28, 95%CI 1.05 to 1.57). Whether this reects operator bias
where a gentler reduction technique was intentionally applied in
the haematoma group could not be answered, but there were no
signicant differences in the number of cases of reduction failure
or cases of deformity sufcient to bother patients between the
two groups by eight weeks follow-up (see analyses). There were no
cases of non-union or signicant adverse effects. Similar numbers
of patients in the two groups had substantial rest pain and stiff-
ness (assumed to be of the wrist) at eight weeks: see analyses.
1d. General anaesthesia versus haematoma block
Intravenous general anaesthesia was compared with haematoma
block in 40 patients in Funk 1997. A request for clarication on
the number of patients entered and analysed in the trial has been
made; where unavailable, the numbers presented in the analyses
represent best guesses. No patients receiving general anaesthesia
experienced pain during manipulation of their fractures, whereas
patients in the haematoma block group experienced signicant
pain (mean pain visual analogue scores (0: no pain to 10: worst
imaginable): 0 versus 3.7). After manipulation, however, the gen-
eral anaesthesia group experienced signicantly greater pain com-
pared with the haematoma block group (mean pain scores: 5.8
versus 1.5; reported p < 0.01). There were no statistically signif-
icant differences in the numbers with radial shortening or with
residual dorsal deformity (see analyses). Patients allocated gen-
eral anaesthesia waited on average ve hours longer for manipu-
lation (mean difference 300 minutes, 95%CI 67 to 533 minutes;
p = 0.01), including over one hour waiting for the arrival of staff
(mean difference 73 minutes, 95%CI 46 to 100 minutes). The
time for anaesthesia and manipulation was twice as long in the
general anaesthesia group (mean difference 10.2 minutes, 95%CI
4.2 to 16.2 minutes; p = 0.0009); Funk 1997 suggested that early
manipulations in the haematoma block group may have resulted
in the extra pain during manipulation in this group. Recovery
time was not recorded. There were no complications. Funk 1997
reported that the cost of administering a general anaesthetic was
more than three times that of a haematoma block (15.56 ver-
sus 4.09); mainly attributable to the requirement for anaesthesia
specialists.
1e. General anaesthesia versus sedation
Bultitude 1972 compared general inhalation anaesthesia with in-
travenous diazepam in 71 patients. As well as being a quasi-ran-
domised study, the results from 10 patients given diazepam but
who were not in the study could not be separated out. Thus, while
we have presented the results of this study, the strong risk of sys-
tematic bias needs to be noted. Though most of the patients given
sedative reacted in some way (groaning etc), only three of these
actually recalled the reduction, two of whom recalled slight pain.
No patient attempted to withdraw their arm during reduction of
their fracture; but reduction was delayed due to a vigorous reaction
in one patient given general anaesthesia. One elderly female pa-
tient given diazepam sustained a precipitous fall in systolic blood
pressure and respiratory rate fromwhich she recovered. Two other
elderly females receiving diazepam were temporarily unrousable -
the diazepam dosage (20mg) used in this trial for elderly people
would now be viewed as dangerous. There were no statistically
signicant differences in adverse effects: see analyses. Just one re-
duction, in the general anaesthesia group, was considered bad
on inspection of post-reduction lms (four lms were missing).
By six weeks, similar proportions of fractures had redisplaced (RR
0.97, 95%CI 0.62 to 1.50). Two general anaesthesia and four di-
azepam patients indicated that they would be apprehensive if they
were given the same method of anaesthesia in future.
1f. General anaesthesia versus haematoma block with sedation
Intravenous general anaesthesia was compared with haematoma
block and midazolam sedation in 40 patients in Funk 1997. As
explained earlier (see 1d), where denominators are unavailable for
this trial, the numbers presented in the analyses represent best
guesses. No patients receiving general anaesthesia experienced
pain during manipulation of their fractures, while patients re-
ceiving haematoma block with sedation experienced, on average,
slight pain only (mean pain visual analogue scores (0: no pain to
10: worst imaginable): 0 versus 0.9). After manipulation, the gen-
eral anaesthesia group experienced signicantly greater pain com-
pared with the haematoma block with sedation group (mean pain
scores: 5.8 versus 1.6; reported p < 0.01). There were no statisti-
cally signicant differences in the numbers with radial shortening
or with residual dorsal deformity, although these tended to favour
11 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
the haematoma block with sedation group (see analyses). Patients
allocated general anaesthesia waited on average four hours longer
for manipulation (mean difference 240 minutes, 95%CI -11 to
491 minutes; p = 0.06, not signicant), including over an hours
wait for the arrival of staff (mean difference 76 minutes, 95%CI
47 to 105 minutes). The time for anaesthesia and manipulation
was twice as long in the general anaesthesia group (mean difference
10.7 minutes, 95%CI 4.3 to 17.1 minutes; p = 0.001). Recovery
time was not recorded but was described as longer in the sedation
group. There were no complications. Funk 1997 reported that the
cost of administering a general anaesthetic was three times that of
a haematoma block with sedation (15.56 versus 5.18); mainly
attributable to the requirement for anaesthesia specialists.
2. Physical techniques of anaesthesia
2a. Site of IVRA (Biers block) injection
Blyth 1995 compared IVRA injection into the antecubital fossa
with injection into the dorsum of the hand in 100 patients. No
statistically signicant differences were reported for pain during
IVRAat either the fracture site (visual analogue scale (0: no pain to
10: worst imaginable) mean values: 3.45 versus 2.66) or at the cuff
(mean values: 3.30 versus 3.16). The two groups were reported
to be similar in the number of manipulations, usually one, per
patient. The surgeons recorded more procedural problems in the
hand group in terms of failed cannulations, and injection site
bleeding or haematoma leading to difculties in the application of
a plaster (0/50 versus 10/50; RR0.05, 95%CI 0.0 to 0.8; p = 0.03).
There were no major complications, including signs of systematic
toxicity, noted. Longer-term outcome was not recorded.
2b. Use of an additional tourniquet for IVRA
Eastwood 1986 investigated the application of an extra tourni-
quet immediately proximal to the fracture site during IVRA in
50 patients. Only one outcome was reported in the trial report:
the time to achieve clinical anaesthesia (pin prick test) in the ad-
ditional tourniquet group was about half as long as that for the
control group (mean difference -4.2 minutes, 95%CI -5.2 to -3.1
minutes). Contact with one of the trialists revealed that there were
no recorded adverse effects.
2c. Technique for brachial plexus block
Pippa 2000 compared the proximal cranial needle approach
(PCN) with the Winnie and Collins technique (W+C). Seven of
the 60 patients in this trial underwent surgery for distal radial
fracture. All seven patients were rated as having either excellent or
good anaesthesia after 20 minutes. The one serious complication
in these seven patients was a subclavian artery puncture in one
patient of the W+C group. In the whole trial population, serious
complications occurred only in the W+C group: phrenic nerve
block with respiratory failure (6/30 versus 0/30); subclavian artery
puncture (9/30 versus 0/30); there were no cases of pneumothorax
(see analyses).
3. Drug adjuncts or supplements
3a. Muscle relaxant
Two trials (Esmaoglu 1995; McGlone 1988) evaluated the addi-
tion of a muscle relaxant to IVRA in a total of 76 patients. There
were no anaesthesia failures, in that there was no recourse to gen-
eral anaesthesia, in Esmaoglu 1995; but the fractures of two con-
trol patients could not be initially reduced in McGlone 1988. One
control group patient with a distal radial fracture received an ad-
ditional analgesic in Esmaoglu 1995 and overall a non-statistically
signicant tendency for less pain and discomfort in the muscle re-
laxant group was reported for this trial. Better analgesia during re-
duction was also found for the muscle relaxant group in McGlone
1988 (mean pain scores (0: painless to 10: worst imaginable): 0.6
versus 1.8; reported p <0.05). Easier reductionof fractures, as mea-
sured on a visual analogue scale (0: impossible to 10: very easy),
in the muscle relaxant group was also noted in McGlone 1988
(mean 8.4 versus 6; reported p < 0.025). Two patients, both in the
control group, had an unacceptable anatomical result in McGlone
1988; no anatomical outcomes were reported in Esmaoglu 1995.
No statistically signicant difference was found in the overall
tourniquet time for the whole trial population in Esmaoglu 1995
(see analyses). Esmaoglu 1995 found that sensorial and motor
blockade were faster in the muscle relaxant group by around one
and 10 minutes respectively (see analyses). The recovery time from
the motor block was 10 minutes longer in the muscle relaxant
group in Esmaoglu 1995 (see analyses) and, dened in terms of
return to ne movement, around 20 minutes longer (mean time
25.8 versus 4.8 minutes; reported p< 0.001) in McGlone 1988.
Adverse effects of anaesthesia were fewand transient (see analyses).
No long-term or functional outcomes were recorded in these two
trials.
3b. Analgesic
Jones 1996 examined supplementary analgesia where tenoxicam
was injected either into the IVRA injection site or into the oppo-
site arm or not at all in 45 patients. The results for the three com-
parisons in this trial are presented in the analysis tables. Aside from
tourniquet time, which was similar in all three groups, there was
no mentionof outcomes during anaesthesia or orthopaedic results;
the focus of the trial was on post-reduction analgesia. Tenoxicam
has a relatively long half-life that allows a once-daily administra-
tion; the choice of a 24 hour follow-up may reect this. Inject-
ing tenoxicam into the affected arm at the same time as the lo-
cal anaesthetic (prilocaine) provided better analgesia than either
no tenoxicam or injecting tenoxicam into the opposite arm (see
analyses): patients waited longer before taking extra analgesics and
took statistically signicantly fewer analgesics over 24 hours; they
also had a signicantly lower mean pain score, with fewer patients
assessing their pain as moderate (none of the trial patients had
severe pain). The injection of tenoxicam into the unaffected arm
was relatively ineffective in providing analgesia. No adverse effects
were reported by any of the trial patients.
3c. Sedative
The addition of intravenous midazolam sedation to haematoma
block was tested in 38 patients in Funk 1997. As explained above
(see 1d), where denominators are unavailable for this trial, the
12 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
numbers presented in the analyses represent best guesses. Patients
receiving midazolamexperiencedsignicantly less painduring ma-
nipulation of their fractures (mean pain visual analogue scores
(0: no pain to 10: worst imaginable): 0.9 versus 3.7; reported p
<0.01). The pain scores in the two groups were similar after frac-
ture manipulation (mean pain scores: 1.6 versus 1.5). There were
no statistically signicant differences in the numbers with radial
shortening or with residual dorsal deformity (see analyses). There
were no statistically signicant differences between the two groups
in either of the two measures of waiting time (see analyses), and
the mean times for anaesthesia and manipulation were similar in
the two groups. Recovery time was not recorded but was observed
to be longer in the sedation group. There were no complications.
The cost per person of supplementary sedation was about one
pound sterling more (5.18 versus 4.09).
3d. Enzyme
London 1996 tested the use of hyaluronidase for enhancing
haematoma block in 33 patients. One patient in the enzyme group
was excluded due to an unsuccessful manipulation (cause not
stated) and another because they did not understand visual ana-
logue scales. London 1996 reported that there were no signicant
differences (reported p > 0.05) between the two groups in any of
the three measures of subjectively assessed pain. There were no
side effects noted.
3e. Clonidine
Erlacher 2001 tested the addition of clonidine to either mepiva-
caine, ropivacaine or bupivacaine for axillary brachial plexus block
in 57 patients undergoing surgery for distal radial fracture. The
results in the analysis tables are presented for each of the three
local anaesthetics, as well as overall. The onset of sensory blockade
was not statistically signicantly different between the clonidine
and control groups when the results from the three comparisons
were pooled: mean visual analogue scale (0: complete blockade
to 100: no blockade) scores for sensory blockade at 10 minutes
(weighted mean difference (WMD) in score 6.5, 95%CI -2.4 to
15.5) and at 30 minutes (WMD 1.2, 95%CI -1.0 to 3.36). But,
the onset of sensory blockade was statistically signicantly slower
when clonidine was added to bupivacaine (see analyses). When
the results of the three comparisons were pooled, motor blockade
was signicantly prolonged in patients given clonidine (WMD
199 minutes, 95%CI 167 to 231 minutes). These results, how-
ever, are signicantly heterogeneous for the three anaesthetics; the
addition of clonidine to ropivacaine appeared to have little effect
on the duration of motor blockade (see analyses). There were no
side effects (specically: hypotension, nausea, vomiting) recorded.
4. Extra comparison
Hollingworth 1982 compared bupivacaine with prilocaine for
Biers block (IVRA) in 200 patients with forearm injuries. Sep-
arate results for the 142, or more, patients with fractures of the
distal radius are not currently available but have been requested.
Outcome assessment was by questionnaire, and only 175 of these
were retrieved. There were no statistically signicant differences
between the two groups in the incidence of great pain as assessed
by the doctor or patient (see analyses). No bupivacaine patient
versus nine prilocaine patients had a poor (remanipulation/aban-
doned procedure) result (RR 0.05, 95%CI 0.0 to 0.92; P = 0.04).
However, similar numbers in the two groups had a poor or un-
acceptable result (49/85 versus 47/88; RR 1.08, 95%CI 0.83 to
1.41). A worst case analysis, where it is assumed that the patients
missing from the analysis in the bupivacaine group had a poor
result whereas those in the prilocaine group did not, shows the
non robust nature of the results for poor result (15/100 versus 9/
100; RR 1.67, 95%CI 0.77 to 3.63). No major side effects were
recorded in Hollingworth 1982. There was a non signicant ten-
dency for slightly more side effects (notably tinnitus and feeling
funny) in patients given bupivacaine (20/85 versus 12/90; RR
1.76, 95%CI 0.92 to 3.39). Hollingworth 1982 examined the
variability in performance of the 20 doctors who administered
IVRA in the trial. The poor performances of two doctors, explic-
itly in relation to pain assessed by the patients, were highlighted.
Hollingworth 1982 reported that the ndings of the trial were not
signicantly affected by the variation in the performance of the
doctors but provided no conrmatory evidence.
D I S C U S S I O N
Most of the comparisons addressed by the 18 included trials are rel-
evant to current practice, at least in some parts of the world. Safety
concerns mean that bupivacaine for Biers block (Hollingworth
1982) and the high dosage of diazepam used in Bultitude 1972
for sedation are no longer sanctioned; at any rate not in the UK
(BNF 2000). In agreement with comments received at editorial
review, we also question the acceptability of intravenous sedation
using drugs with little or no analgesic effect such as diazepam and
midazolam without supplementary analgesia (Shipton 2002).
Small trial sizes of 50 or fewer patients in each intervention group,
awed methodology and deciencies in the assessment of outcome
hamper the ability of individual trials to address their own ques-
tions, let alone the objectives of this review. Althoughsome pooling
was possible for the two comparisons (IVRA versus haematoma
block; muscle relaxant adjunct for IVRA), the number of patients
remains low. Trial methodology was inadequately reported in most
trials but, even with feedback from some of the trialists involved,
the possibility of systematic bias resulting in awed evidence can-
not be ruled out. Notable is the failure to ensure or conrm the
concealment of allocation in all but two trials. Another issue is
that of confounding, where factors other than the interventions
under investigation inuence the trial results. Examples of con-
founders are imbalances in baseline characteristics, such as fracture
type, of patients, and differences in care programmes including
reduction methods, their timing (as considered in Singh 1992)
and the expertise of, and/or delivery of health care by, the health
13 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
professionals involved (as reported in Hollingworth 1982). Our
methodological quality scheme did not score the comprehensive-
ness of outcome assessment in individual trials; instead we looked
at the potential for ascertainment bias due to a lack of blinding of
outcome assessors, and the quality of measurement of the actual
outcomes recorded. Nonetheless, the included trials did not pro-
vide a full, or sufcient, picture of the relative effects of the in-
terventions under investigation. This deciency was usually asso-
ciated with an inadequate length of follow-up. Some trials such as
Eastwood 1986, which primarily reported on the time to achieve
clinical anaesthesia, were particularly limited. While it is tempting
to focus on very short termoutcomes, such as pain during manip-
ulation, for evaluating anaesthetic interventions, it is important
to collect long-term outcomes given that inadequate anaesthesia
could have long-term consequences; for instance, resulting from
inadequate reduction. Some side effects may also have longer-term
implications. (The confounding effects of differences in subse-
quent treatment hamper the interpretation of long-term follow-
up results; thus measures are needed to ensure comparability of
care programmes other than the trial interventions.) Trials that
fail to record the success of the procedure, usually reduction, for
which anaesthesia is required are certainly incomplete and poten-
tially misleading.
Our prime focus is on examining clinical outcomes. However, in-
formation on resource use and costs that would enable a cost-effec-
tiveness analysis is alsodesirable; andparticularly useful whenthere
is no strong evidence for important differences in the effective-
ness of interventions. Though some information on care providers
and timing was available from other trials, only one trial (Funk
1997) provided some cost data: namely, the average total proce-
dural costs for the three interventions under test. The entry for
this trial in the NHS Economic Evaluation Database (NHS EED
2003) points out several deciencies relating to the cost evaluation
in this trial. These include the absence of information on the trial
dates and price year, insufcient information on the methods used
for calculating costs, and no consideration of the generalisability
to other settings or countries. It is noteworthy that the NHS EED
reviewer(s) commented that it was impossible to state whether
all relevant costs were included in the analysis. Trials examining
costs and resource use should aim for a complete assessment of
costs, covering the whole treatment period.
Finally, the interpretation and application of trial ndings is lim-
ited where, as is often the case with the trials included in this re-
view, there are inadequate details of the intended and actual trial
population and interventions.
These general points need to be considered when interpreting the
results of individual comparisons. To aid the reader, a table sum-
marising the types of outcome data available for the interventions
tested within randomised controlled trials plus some comments
is available (Table 2). These comments are expanded on in this
discussion.
Table 2. Summary table of outcomes available for interventions studied within RCTS
Interven-
tion
Compara-
tor
Procedure <-----------
--------
-------------
-------
----------
Available
outcomes-
-----
-------------
-------
-------------
------>
Com-
ments
MAIN
TYPES
(compar-
ison num-
ber in re-
view)
Ad-
equacy of
anaesthesia
Anatomi-
cal restora-
tion of
fracture
Adverse ef-
fects asso-
ciated with
interven-
tion
Clinical
outcomes
Functional
outcomes
Resource
use
Haematoma
block
IVRA (1a.) Manipula-
tion
Yes Yes Yes Yes Yes Yes Insuf-
cient
evidence
overall, but
some evi-
dence that
haematoma
block,
whilst
quicker
and eas-
ier to
14 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
perform,
provided
poorer
analgesia
and less
satisfac-
tory reduc-
tion than
IVRA.
Haematoma
block
Nerve
block (el-
bow) (1b.)
Manipula-
tion
Yes No Yes No No No Insuf-
cient evi-
dence to
determine
effective-
ness of
haematoma
block
compared
with nerve
block.
Haematoma
block
Se-
dation (di-
azepam)
(1c.)
Manipula-
tion
Yes Yes Yes No Yes No Insuf-
cient
evidence
available
to establish
whether
haematoma
block is
better than
sedation.
Some evi-
dence that
haematoma
block gives
better
analgesia
during
fracture
reduction,
but op-
erators
may have
applied
a gentler
reduction
technique.
15 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
Haematoma
block
General
(IV) (1d.)
Manipula-
tion
Yes Yes Yes No No Yes Insuf-
cient
evidence
available
and lack
of details
on method
of general
anaes-
thesia.
Some evi-
dence that
haematoma
block gave
poorer
pain relief
during
procedure
but was
quicker
and
cheaper to
perform.
IVRA
Haematoma
block (1a.)
Manipula-
tion
Yes Yes Yes Yes Yes Yes Insuf-
cient
evidence
but some
evidence
that IVRA,
whilst
more
labour
intensive,
provided
better
analge-
sia and
enabled
better and
more sat-
isfactory
reduction
than
haematoma
block.
16 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
Nerve
block (el-
bow)
Haematoma
block (1b.)
Manipula-
tion
Yes No Yes No No No Insuf-
cient evi-
dence to
determine
effective-
ness of
haematoma
block
compared
with nerve
block.
Se-
dation (di-
azepam)
Haematoma
block (1c.)
Manipula-
tion
Yes Yes Yes No Yes No Insuf-
cient
evidence
available
to establish
whether
sedation is
better than
haematoma
block.
Some evi-
dence that
sedation
provided
less pain
relief
during
fracture
reduction,
but op-
erators
may have
applied
a more
forceful
reduction
technique.
Se-
dation (di-
azepam)
General
(inhala-
tion)
anaesthesia
(1e.)
Manipula-
tion
Yes Yes Yes Yes No No Insuf-
cient and
awed evi-
dence
from dated
trial. Inap-
propri-
ately high
17 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
dosage of
di-
azepam for
elderly pa-
tients.
Haematoma
block with
sedation
(midazo-
lam)
General
(IV) anaes-
thesia (1f.)
Manipula-
tion
Yes Yes Yes No No Yes Insuf-
cient
evidence
available
and lack
of details
on method
of general
anaes-
thesia.
Some evi-
dence that
haematoma
block with
sedation
was rea-
sonably
effective
in provid-
ing pain
relief and
cheaper to
perform.
Sedation
resulted
in a pro-
longed
recovery
time (see
below).
General
(IV) anaes-
thesia
Haematoma
block (1d.)
Manipula-
tion
Yes Yes Yes No No Yes Insuf-
cient evi-
dence
available
and lack of
details on
method of
gen-
eral anaes-
thesia.
Some evi-
18 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
dence that
gen-
eral anaes-
thesia gave
better pain
relief dur-
ing pro-
cedure but
involved
longer
waits and
higher pro-
cedural
costs.
General
(inhala-
tion)
anaesthesia
Se-
dation (di-
azepam)
(1e.)
Manipula-
tion
Yes Yes Yes Yes No No Insuf-
cient and
seriously
awed evi-
dence
from dated
trial. Inap-
propri-
ately high
dosage of
di-
azepam for
elderly pa-
tients.
General
anaesthesia Haematoma
block with
sedation
(midazo-
lam) (1f.)
Manipula-
tion
Yes Yes Yes No No Yes Insuf-
cient
evidence
available
and lack
of details
on method
of general
anaes-
thesia.
Some evi-
dence that
general
anaesthesia
was only
marginally
better at
19 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
providing
pain re-
lief and
involved
higher
procedural
costs.
However,
sedation
resulted
in a pro-
longed
recovery
time (see
below).
PHYSI-
CAL
TECH-
NIQUES
Compara-
tor
Procedure Ad-
equacy of
anaesthesia
Anatomi-
cal restora-
tion of
fracture
Adverse ef-
fects asso-
ciated with
interven-
tion
Clinical
outcomes
Functional
outcomes
Resource
use
Com-
ments
Antecu-
bital
fossa injec-
tionsite for
IVRA
Dorsum of
hand in-
jection site
(2a.)
Manipula-
tion
Yes No Yes No No No Insuf-
cient
evidence
to say if
alterative
injection
site is
safe or
effective.
Injec-
tion site
bleeding/
haematoma
causing
problems
with plas-
ter cast ap-
plication
were only
recorded
in the
control
group.
Interest-
20 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
ingly, these
outcomes
were not
reported
in other
IVRA
trials using
the usual
injection
site.
Extra
tournique
proxi-
mal tofrac-
ture site
Usual
for IVRA
(2b.)
Manipula-
tion
Yes No No No No No Insuf-
cient evi-
dence
to evaluate
use of extra
tournique
for IVRA.
Only one
outcome -
time
to achieve
clin-
ical anaes-
thesia - was
reported.
Proxi-
mal cranial
needle ap-
proach for
brachial
plexus
block
Winnie
and
Collins ap-
proach us-
ing supra-
clavicular
approach
(2c.)
Surgery Yes No Yes No No No Note
should
be taken
of the
potential
for serious
compli-
cations
(phrenic
nerve
block with
respiratory
failure,
accidental
puncture
of subcla-
vian artery,
pneu-
mothorax)
of this
21 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
method.
Should
this
method of
anaesthesia
be consid-
ered, then
the new
approach
appears
safer but
this needs
conrma-
tion.
DRUG
AD-
JUNCTS
Supple-
ment to:
Procedure Ad-
equacy of
anaesthesia
Anatomi-
cal restora-
tion of
fracture
Adverse ef-
fects asso-
ciated with
interven-
tion
Clinical
outcomes
Functional
outcomes
Resource
use
Com-
ments
Muscle
relaxant
(atracurium;
vecuro-
nium)
IVRA (3a.) Manipula-
tion
Yes Yes Yes No No No Insuf-
cient evi-
dence
overall,
how-
ever, some
limited
evidence in
favour of
muscle re-
laxant dur-
ing proce-
dure. But
also, tran-
sient side-
effects and
prolonged
motor
blockade.
Analgesic
(tenoxi-
cam)
IVRA
(3b.)
Manipula-
tion
No No Yes Yes No No Insuf-
cient ev-
idence in-
cluding no
evalu-
ation of ef-
fects on ef-
fec-
22 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
tiveness of
anaesthe-
sia. How-
ever, some
ev-
idence that
tenoxicam
injecteddi-
rectly into
the IVRA
injec-
tion site re-
lieved pain
in the rst
24 hours.
Seda-
tive (mida-
zolam)
Haematoma
block (3c.)
Manipula-
tion
Yes Yes Yes No No Yes Insuf-
cient
evidence
available
to draw
conclu-
sions. The
addition
of mida-
zolam to
haematoma
block may
enhance
pain relief
during
manip-
ulation,
but the
implica-
tions and
extent of
the longer
recovery
times re-
ported for
patients
given
sedation
are not
known.
Enzyme
(hyalu-
ranidase)
Haematoma
block (3d.)
Manipula-
tion
Yes Yes Yes No No No Insuf-
cient
23 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Summary table of outcomes available for interventions studied within RCTS (Continued)
evidence
available to
draw con-
clusions.
Given the
localised
nature
of the
fracture
site and
procedure,
and the
potential
for allergic
reactions,
the use of
hyaluronidase
is ques-
tionable.
Clonidine Axillary
brachial
plexus
block (3e.)
Surgery Yes No Yes No No No Insuf-
cient evi-
dence,
how-
ever, some
evidence
that cloni-
dine may
delay sen-
sory block-
ade and
pro-
long motor
blockade.
ANAES-
THETIC
AGENT
Though
one excep-
tion
was made
(4.), com-
parisons
of different
anaesthet-
ics are not
covered in
this review
24 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1. Main types of anaesthesia
Asearch for surveys of anaesthesia practice for these fractures iden-
tied two studies conducted in the UK. Responses were obtained
from 86 accident and emergency (A&E) departments to a ques-
tionnaire on the methods of anaesthesia used in the manipulation
of Colles fractures in 1994 (Kendall 1995). These revealed that
Biers block (IVRA) was given to one third of patients, haematoma
block to another third, general anaesthetic to 24 per cent and in-
travenous sedation to seven per cent. Five years previously, a study
of 54 UK centres showed that general anaesthesia was given to 44
per cent of patients, IVRA to 33 per cent, intravenous sedation to
13 per cent and haematoma block to just seven per cent (Hunter
1989). The swing to haematoma block, primarily at the expense
of general anaesthesia, was associated with a reduction in the in-
volvement of anaesthetists and reduction in numbers of patients
requiring fasting and/or hospital admission. More A&E doctors
also performed IVRA. Kendall et al. also found that monitoring
(ECG, blood pressure and oxygen saturation) was carried out in a
third of patients given haematoma blocks compared with 85 per
cent of Biers blocks and all those given general anaesthesia or in-
travenous sedation. Though these surveys reveal trends in current
practice in just one country, this review aimed to examine the ev-
idence supporting the various choices for anaesthesia worldwide.
There was evidence from ve trials comparing IVRA with
haematoma block that IVRAprovidedbetter analgesia during frac-
ture manipulation and enabled better and easier reduction of the
fracture. There was some indication of superior post-reduction
anatomical measurements and a reduced risk of later redisloca-
tion or re-reduction. Neither method was associated with anaes-
thesia failure or signicant adverse effects. There was some evi-
dence that haematoma block was quicker and easier to perform
and less resource intensive. One study found enhanced long-term
grip strength in the IVRA group. Overall, there was not enough
evidence here to conrm a clinical superiority of IVRA, or to es-
tablish the relative safety of the two methods. But, there is some
indication that haematoma block provides poorer analgesia and
can compromise reduction.
One trial that compared nerve block (this method is relatively
rare for these fractures and did not appear in Kendalls UK sur-
vey (Kendall 1995)) with haematoma block found no statistically
signicant differences in pain during manipulation; there was one
case of insufcient muscle relaxation. These limited results provide
no basis to judge the relative effectiveness of the two methods.
One well conducted trial comparing intravenous sedation with
haematoma block found that patients in the sedation group expe-
rienced signicantly more pain during reduction of their fractures.
No signicant differences in the reduction failure, deformity,
rest pain or stiffness were evident at eight weeks. The time taken
for fracture manipulation was greater in the sedation group and
there is a possibility of some confounding due to doctors doing a
different, perhaps gentler, manipulation in the haematoma block
group. The numbers were too few and outcomes measures too
vague to examine this or to detect long termdifferences. Also rele-
vant is that this trial was carried out in a developing country with
scarce resources and involved a relatively young trial population.
The choices available will differ in other circumstances and for
other populations.
Inadequate information on methodology, interventions and pa-
tient numbers, mean that the results of a trial comparing intra-
venous general anaesthesia with haematoma block must be viewed
very cautiously. However, it is plausible that general anaesthesia
gives better pain relief during manipulation but involves longer
waits and takes longer, with higher procedural costs compared
with haematoma block. There was some indication that there was
more pain post manipulation after general anaesthesia. Overall,
there were too few patients to determine if the lack of statistically
signicant differences in radiological outcomes was a true result,
as well as an absence of evidence on eventual clinical outcome.
As noted previously, the evidence froma dated, quasi-randomised
study comparing general inhalation anaesthesia versus sedation
with diazepam is likely to be seriously biased, and the dosage of
diazepam is excessive for elderly persons. Nonetheless some of
the observations from this study still appear to have merit. For
instance, the serious event after diazepam in one elderly woman
given sedation, the contrast between the reactions observed dur-
ing fracture manipulation and recall in sedated patients, and the
enumeration of redisplaced fractures at six weeks.
The same reservations listed for the above comparison of general
anaesthesia versus haematoma block apply to the comparison of
general anaesthesia versus haematoma block with sedation. The
absence of quantitative data on recovery times means that it is
not possible to comment on the clinical and administrative con-
sequences of the longer recovery time for patients given supple-
mentary sedation.
2. Physical techniques of anaesthesia
A trial comparing two different injection sites for IVRA found
more procedural problems during plaster cast application when
the more traditional injection site, into the dorsum of the hand,
was used. However, the small sample size, the lack of blinding
and the incomplete assessment of outcome mean that the lack
of difference between the two injection sites in other reported
outcomes cannot be considered conclusive evidence that injection
into the antecubital fossa is a safe and effective alternative.
The inadequate assessment of outcome in a study (Eastwood
1986) of the use of an extra tourniquet for IVRA has already been
mentioned.
Although the one trial examining two techniques for brachial
plexus block was small and involved only seven patients under-
going surgery for distal radial fractures, the excess in the number
of serious complications associated with the Winnie and Collins
technique in this trial is notable; both on its own and in the con-
text of an absence of serious complications for the proximal cranial
needle approach. Since the successful application of regional nerve
blocks is particularly dependent on the skill and experience of the
operator, the promising results for the new approach need to be
25 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
tested by other anaesthetists.
3. Drug adjuncts or supplements
The addition of two different muscle relaxants and one anal-
gesic was tested for IVRA, one sedative and hyaluronidase for
haematoma block and clonidine for brachial plexus block. All trials
evaluating adjuncts were too small and failed to provide evidence
on eventual clinical outcome.
Two trials provided some limited and preliminary evidence in
favour of a muscle relaxant adjunct to IVRA in terms of analgesia
and ease of fracture reduction. Muscle relaxant prolonged recov-
ery time from motor blockade and was associated with transient
double-vision in some patients.
There was limited evidence from one small trial that injection of
tenoxicam directly into the IVRA injection site improved post-
reduction analgesia in the rst 24 hours. Other relevant outcomes,
such as effectiveness of anaesthesia, were not reported.
The reservations listed for the above comparison of general versus
haematoma block also apply to the examination within the same
trial of the additionof sedationtohaematoma block. Sedationwith
midazolam may give better pain relief during manipulation but
there were too few patients to determine if the lack of statistically
signicant differences in radiological outcomes was a true result,
and a lack of information to judge the importance of the longer
recovery times for patients given sedation.
Given the localised nature of the fracture site and manipula-
tion, the rationale for the use of hyaluronidase for enhancing
haematoma block through the breakdown of local connective tis-
sue is fairly unconvincing especially in view of the potential for
allergic reactions. However, the trial evaluating this option did not
provide the robust evidence required to settle the question.
One trial provided some limited evidence of the effect on neural
blockade of supplementary clonidine for axillary brachial plexus
block in patients undergoing surgery or distal radial fracture.
While the effects on neural blockade varied according to the
anaesthetic used (bupivacaine, mepivacaine, ropivacaine), cloni-
dine does not appear to enhance and may delay the speed of sen-
sory blockade, and may unnecessarily prolong motor blockade for
the relatively short operations for these injuries. Whether cloni-
dine affected the onset of motor blockade was not reported.
4. Extra comparison
At study selection, we considered that the inclusion of a trial com-
paring bupivacaine with prilocaine for IVRA was merited due to
a) the more comprehensive assessment of clinical outcomes, espe-
cially orthopaedic outcomes; b) the recording of patient outcomes
for the different care providers in this trial; and c) the special rel-
evance of the comparison for IVRA. Though prilocaine was pro-
posed as rst-line medication due to low toxicity, both drugs
are listed as being suitable for IVRA for upper limb trauma in
a recent publication (Mollmann 2000). However, bupivacaine is
not approved for IVRA in the UK (BNF 2000). There was some
concern expressed at editorial review that making this exception,
to our general ban on comparisons of drugs within the same class,
could lay us open to charges of selection bias. We counter this by
stressing that this is an exception and that we consider our reasons
for including it remain valid. Two alternatives would have been to
a) exclude the trial but summarise its ndings in the Discussion
and b) formulate an additional hypothesis based on important
differences in the characteristics of these two drugs. We decided
against these as neither was satisfactory; either resulting in the loss
of the valuable insights gained through the systematic processing
and full presentation of the trial, or engendering further hypothe-
ses based on other differences in characteristics of other drugs in
the same class.
In the event, we found that Hollingworth 1982 had serious
methodological aws and that the evidence was not robust.
Nonetheless, there was some indication that the pain experienced
by patients could depend to some extent on the doctor reducing
the fracture.
A U T H O R S C O N C L U S I O N S
Implications for practice
There was insufcient robust evidence from comparisons tested
within randomised trials to establish the relative effectiveness of
different methods of anaesthesia or of different techniques of in-
dividual methods, or to judge the use of different drug adjuncts
in the treatment of distal radial fractures.
Though there was not enough evidence to conrm a clinical su-
periority of IVRA, nor to establish the relative safety of IVRA to
haematoma block, there is some indication that haematoma block
provides poorer analgesia and can compromise reduction. Clini-
cians need to be mindful of this in view of the potential attrac-
tiveness of haematoma block in terms of technical ease and lower
cost of administration.
Implications for research
Research onanaesthetic interventions needs to be set inthe context
of the overall management of these fractures. There are many
unresolved issues such as:
When is fracture manipulation required and what is the
best method for doing this?
When, to what extent, by what means and for how long is
immobilisation required?
When is surgery indicated and what method should be
used?
Patient characteristics and preferences, fracture type, and local ex-
pertise and resources inuence treatment choices and must be con-
sidered. We suggest an integrated programme of research, which
includes considerationof anaesthesia options, for the management
of these fractures is the way forward.
26 Anaesthesia for treating distal radial fracture in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
For researchers contemplating specic research on anaesthesia op-
tions for these fractures, we suggest that priority should be given
to large scale, preferably, multi-centre randomised comparisons of
the main methods (haematoma block, IVRA, general anaesthesia,
and intravenous sedation (with analgesia)) in common use. In ad-
dition, any new promising developments in anaesthesia must be
rigorously evaluated before general implementation. Such devel-
opments include combinations of the main methods (e.g. intra-
venous sedation plus analgesia with a haematoma block or elbow
block), an expansion in the use of regional nerve blocks especially
in the light of improved techniques for delivery, and multimodal
analgesia (Shipton 2002). Other developments at the pharmaco-
logical level include the use of single enantiomers (Burke 2002).
For example, there is some preliminary evidence that levobupi-
vacaine, the levo or S-enantiomer of bupivacaine, has less cardiac
toxicity than bupivacaine (Burke 2002; Whiteside 2001). Any tri-
als testing anaesthesia options should abide by the methodolog-
ical criteria for a well-conducted and well-reported randomised
trial (Altman 2001). As well as anaesthesia outcomes, trials should
record the effectiveness of the orthopaedic procedure being per-
formed under anaesthesia, and subsequent clinical outcomes for at
least six months, as well as patient satisfactionandall relevant costs.
Stratication by key patient characteristics and by care provider
should be considered.
A C K N O W L E D G E M E N T S
We thank Lesley Gillespie for her help with the search strategy and
trial retrieval. We thank the following for feedback at the editorial
and external review of the protocol: Ted Shipton, Lesley Gillespie,
Bill Gillespie, Peter Herbison, Finn Molke Bjorgbjerg, Leeann
Morton and Janet Wale. We thank the following for feedback and
help at the editorial and external review of the review and review
updates: Mike Bennett, Bill Gillespie, Peter Herbison, Finn Molke
Bjorgbjerg, Kate Rowntree, Ted Shipton, Marc Swiontkowski and
Janet Wale. We thank Hilda Bastianfor her help with the Synopsis.
We are grateful to the following for providing further informa-
tion on their trials: Patricia Allen, C Bhattacharjee, Owen Brady,
Marcus Cope, Aliye Esmaoglu, Lennard Funk, Nick James, Ja-
son Kendall, Christopher Khoo, Raymond McGlone, P Pippa and
Keith Porter.
R E F E R E N C E S
References to studies included in this review
Abbaszadegan 1990 {published data only}
Abbaszadegan H, Jonsson U. Regional anesthesia preferable for
Colles fracture. Controlled comparison with local anesthesia. Acta
Orthopaedica Scandinavica 1990;61(4):3489.
Blyth 1995 {published data only}
Blyth MJG, Kinninmonth AWG, Asante DK. Biers block: A
change of injection site. Journal of Trauma 1995;39(4):7268.
Bultitude 1972 {published data only}
Bultitude MI, Wellwood JM, Hollingsworth RP. Intravenous
diazepam: Its use in the reduction of fractures of the lower end of
the radius. Injury 1972;3(4):24953.
Cobb 1985 {published data only}
Cobb AG, Houghton GR. Comparison of local anaesthetic
inltration and intravenous regional anaesthesia in patients with
Colles fracture [Abstract]. Journal of Bone & Joint Surgery. British
Volume 1985;67(5):845.