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.
閱讀完整摘要
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.
目的
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.
搜尋策略
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.
選擇標準
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.
資料收集與分析
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 confidence limits. Only very limited pooling of results from comparable trials was possible.
主要結果
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, IVRA provided 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 flawed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of treatment by different doctors on patient outcome.
作者結論
There was insufficient 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.
