Percutaneous pinning for treating distal radial fractures in adults

In older people, a 'broken wrist' (from a fracture at the lower end of one of the two forearm bones) can result from a fall onto an outstretched hand. Treatment usually involves reduction (putting the broken bone back into position) and immobilising the wrist in a plaster cast. Surgery may be considered for more seriously displaced fractures. One type of surgery is percutaneous pinning. This involves the insertion of pins through the skin (percutaneous) to hold the bones in a proper position while they heal. In most pinning methods, wires are placed across the fracture and used to fix the fragments together. In Kapandji pinning, the wires are placed to support the distal (lower end) fragment. This review looked at the evidence from randomised controlled trials testing the use of percutaneous pinning or comparing different aspects of percutaneous pinning.

Thirteen trials, involving 940 generally older adults with potentially or evidently unstable fractures, were included. Because of weak methodology such as using inadequate methods of randomisation and outcome assessment, the possibility of serious bias cannot be ruled out.

Six trials compared percutaneous pinning with plaster cast immobilisation. Pinning involving across-fracture fixation, used in five of these trials, improved anatomical outcome; and in three trials it appeared to improve function too. The complications associated with across-fracture fixation were generally minor. Kapandji pinning, used in the remaining trial, was associated with an excess of complications compared with conservative treatment. Three other trials compared different methods of pinning. Two of these found some evidence of an increased complication rate with Kapandji pinning compared with across-fracture methods. Two trials using two very different pinning techniques compared biodegradable (dissolvable) pins or wires versus metal pins or wires. Both trials found a significant excess of complications associated with the use of the biodegradable material. Two trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One of these trials found the duration of immobilisation after across-fracture pinning did not have a significant effect on outcome. In contrast, more complications occurred in the early mobilisation group after Kapandji pinning in the other trial.

The review concluded that there is some evidence to support the use of percutaneous pinning. However, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.

Authors' conclusions: 

Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.

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Background: 

Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture.

Objectives: 

To evaluate the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

Selection criteria: 

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning.

Data collection and analysis: 

Two authors independently assessed and extracted data from the included trials. Some pooling of data was undertaken for one comparison.

Main results: 

Thirteen trials, involving 940 generally older adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. Factors affecting the applicability of trial evidence included inconsistent fracture classification, variations in outcome assessment and incomplete reporting.

Six heterogeneous trials compared percutaneous pinning with plaster cast immobilisation. Across-fracture pinning, used in five trials, was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group. One quasi-randomised trial found an excess of complications after Kapandji pinning.

Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across-fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation.

Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material.

Two small trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One trial found duration of immobilisation after trans-styloid fixation did not have a significant effect on outcome. More complications occurred in the early mobilisation group after Kapandji pinning in the second trial.