1Orthopaedics and Traumatology Department, Prof. Dr. IGNG Ngoerah General Hospital, Faculty of Medicine Udayana University, Bali, Indonesia
2Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
3Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia
*Corresponding author: Sherly Desnita
Savio, Orthopaedics and Traumatology Department, Prof. Dr. IGNG Ngoerah General
Hospital, Faculty of Medicine Udayana University, Jl. Diponegoro, Dauh Puri
Klod, Denpasar, Bali 80113, Indonesia, E-mail:
sherlydsavio@gmail.com
• Received: July 21, 2024 • Revised: September 14, 2024 • Accepted: September 15, 2024
This is an Open-Access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits
unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Objectives: Conservative treatment for distal radius fractures
typically involves closed reduction and immobilization with a plaster cast.
However, no consensus exists regarding the best method and duration for
immobilization. This study investigated the functional outcomes associated with
different plaster cast application techniques in the treatment of stable distal
radius fractures.
Methods: A systematic search was performed in accordance with PRISMA
guidelines for studies in the last 5 years. The inclusion criteria were
randomized controlled trials that investigated non-operative treatments for
distal radius fractures. We excluded studies with short-term follow-up (less
than 3 months), ongoing trials, those that did not directly address fractures,
and studies involving the use of sugar-tong splints or non-circular
immobilization. The outcomes evaluated included subjective measures
(Disabilities of the Arm, Shoulder and Hand score; Patient-Rated Wrist
Evaluation score; Mayo Wrist Score; and visual analog scale) and objective
outcomes (complication rate and radiological parameters).
Results: We included seven articles from 2017 to 2022. These studies
reported a total of 542 fractures, predominantly in women, with a mean age of
over 50 years. Both short and long arm casts demonstrated similar functional and
radiological outcomes. A longer immobilization period (>3 weeks) should
be considered to prevent re-displacement.
Conclusion: In stable fractures treated conservatively, the use of
both short and long arm casts resulted in comparable functional outcomes in
older patients. Immobilization for at least 3 weeks is recommended, as it
provided similar clinical and radiological outcomes compared to longer periods
of immobilization (level of evidence: 2A).
Distal radius fractures are among the most common fractures encountered in the
emergency room [1]. In the younger
population, these fractures typically result from high-energy trauma, whereas in
older adults, weakened, porous bones make them susceptible to fractures from
minor trauma. For stable distal radius fractures in both groups, the
conservative treatment approach is closed reduction followed by immobilization
using a plaster cast [2]. However, there
is still no clear guideline on the best method and immobilization period to
apply plaster cast.
One of the most debated aspects of plaster cast application involves the length
of the cast (above or below the elbow) and the duration of immobilization. Even
when an acceptable reduction is unattainable, previous studies have demonstrated
that well-established radiological parameters do not necessarily correlate with
a favorable functional outcome in older patients. Conversely, functional outcome
reflects the patient's satisfaction with the treatment and should be the
primary consideration [3].
Objectives
The aim of this study is to investigate the clinical and radiological outcomes of
various non-operative treatments for distal radius fractures, focusing on the
length of the cast and the duration of immobilization. We hypothesize that using
a short arm cast with a shorter period of immobilization will yield clinical and
radiological outcomes comparable to those achieved with a long arm cast and a
longer immobilization period (>4 weeks).
Methods
Ethics statement
This was a literature-based study; thus, neither institutional review board
approval nor informed consent was required.
Study design
This systematic review was performed in accordance with the PRISMA guidelines
[4]. A review protocol was registered
on PROSPERO (registration number: CRD42020212627).
Eligibility criteria
All types of randomized controlled trials (RCTs) published as full articles were
included in this study. The selection of articles was based on the stated
inclusion and exclusion criteria, following the PICO (population, intervention,
comparison, outcome) method as outlined in Supplement 1.
Information sources
We performed a systematic search of English-language literature from the past
five years on PubMed/MEDLINE, Cochrane Central Register of Controlled Trials
(CENTRAL), and ClinicalTrials.gov.
Search strategy
The search terms included, but were not limited to, "distal radius
fracture," “Colles fracture,” “management,”
“treatment,” “casting,”
“immobilization,” and “nonoperative.”
Selection and data collection process
The quality of the included RCTs was assessed by two independent reviewers using
the 13-item 2015 Updated Method Guideline for Systematic Reviews from Cochrane
[5].
Data items
The data were extracted using a standardized data collection form by a research
team, with each selected article being independently screened by two reviewers.
Disagreements between reviewers about whether to include or exclude a study will
be resolved through consensus, and if necessary, by consulting a third
reviewer.
Study risk of bias assessment
A critical appraisal of all potential studies was conducted to assess their
eligibility, utilizing a scoring system adapted from the Joanna Briggs
Institute. The evaluation criteria included study population, exposures,
confounding factors, outcomes, follow-up duration, and statistical analysis.
Effect measures
Data were extracted from study reports and under appropriate conditions for each
test to compare and identify associations.
Synthesis methods
The variables collected included patient age, sex, fracture classification,
interventions used, follow-up, Disabilities of the Arm, Shoulder, and Hand
(DASH) score, Patient-Rated Wrist Evaluation (PRWE) score, the Mayo Wrist Score,
the visual analog scale score, the complication rate, and radiological
parameters (volar tilt, radial inclination, radial length, ulnar variance). The
results were then tabulated into specific tables for drawing conclusions.
Reporting bias assessment
The quality and reliability of potential studies were evaluated by four authors
(MFD, CS, SDS, EK), as well as the published protocols and registrations.
Certainty assessment
No certainty assessment was done.
Results
Study selection
The identification of studies in the primary literature search and the flow
diagram of the selection process, according to PRISMA guidelines, are presented
in Fig. 1.
Fig. 1.
Identification of studies in the primary literature search and the
flow diagram of selection process according to the PRISMA
guideline.
Study characteristics
The initial electronic search across all databases yielded 156 records. Following
a selection process, seven articles were included in the analysis.
Risk of bias in studies
All seven studies were confirmed to be of high quality, each receiving a
"yes" response for more than seven parameters, as shown in Supplement 2.
Results of syntheses
Baseline characteristics
A total of 542 distal radius fractures were analyzed. All studies reported a
higher proportion of female participants over the age of 50. Most of these
fractures were stable, extra-articular fractures with minimal displacement;
however, unstable fractures were also observed. The follow-up period ranged
from 3 to 18 months (Table 1).
The seven RCTs discussed plaster casts in terms of the cast length (short
versus long arm cast; n=3) and the length of the immobilization period
(n=4). Three RCTs concluded that the clinical outcomes were comparable
between short arm casts and long arm casts (Table 2). Long arm casts and short arm casts demonstrated
comparable radiological outcomes, as measured by volar tilt, radial
inclination, radial height, and ulnar variance (Table 3).
SACs were as effective as LACs for
stable distal radius fractures in older patients.
Furthermore, they were more comfortable and introduced fewer
restrictions on daily activities.
Patients treated with SACs had
comparable radiological and functional scores to those
treated with LACs, with fewer complications secondary to
immobilization of the elbow joint.
Similar VAS and Mayo Wrist Scores
between the two groups. The greatest volar tilt angle
occurred after 6 wk of PC. No significant differences in
other radiological parameters between the two groups.
NA
NA
I: 58.46 ±21.24 C:
61.87 ±22.97
VAS pain: I:
2.53±3.06 C: 3.58±2.56 VAS
activity: I: 7.61 ±1.83 C: 7.58
±2.3
NA
DASH, Disabilities of the Arm, Shoulder, and Hand; PRWE,
Patient-Rated Wrist Evaluation; VAS, visual analog scale; SAC,
short arm cast; LAC, long arm cast; NA, not available; PC,
plaster cast; I, intervention; C, control; DRF, distal radius
fracture; DRUJ, distal radioulnar joint; CRPS, complex regional
pain syndrome.
SAC, short arm cast; LAC, long arm cast; NA, not available.
Ten days of immobilization has not been proven effective radiologically, as
it has been associated with redisplacement in terms of radial inclination
and radial height compared to 1 month of immobilization. However, these
findings remain controversial, as one study demonstrated similar outcomes
between 1 week and 4–5 weeks of plaster cast immobilization.
Generally, a minimum of 3 weeks of immobilization in a plaster cast is
sufficient to provide satisfactory clinical and radiological outcomes for up
to 18 months of follow-up.
Reporting biases
All the studies reviewed were sourced from peer-reviewed journals. However, it
was uncertain whether the reports fully disclosed all study outcomes.
Discussion
Interpretation
This study aimed to objectively compare conservative treatment methods for distal
radius fractures. The findings indicated that both long and short arm casts were
equally effective in preventing displacement and achieving satisfactory
functional outcomes. However, an immobilization period of less than three weeks
was associated with poorer radiological outcomes, which could potentially lead
to inferior final functional results.
Comparison with previous studies
Immobilization with casting is the common initial treatment for a distal radius
fracture. Although the final radiographic alignment may not be optimal,
long-term motion and patient-reported outcomes from casting are similar to those
of surgical treatments [1,13,14]. To optimize the effectiveness of casting, the brachioradialis
was identified as a major deforming force, necessitating the use of a long-arm
brace in supination to neutralize its action [15]. However, based on three RCTs analyzed in this systematic
review, there is no significant difference in DASH scores between long-arm and
short-arm casts. We also discuss the results of studies on various periods of
immobilization.
Patient-reported outcome measures for the upper extremity
Patient-reported outcome measures are crucial in short-term follow-up because
recent evidence suggests they do not correlate with radiological measures
[3,16,17]. However, it is
important to use a consistently reliable measurement tool to ensure valid
comparisons between different treatments. Previous studies have shown that
the DASH and PRWE scales are reliable, valid, and responsive tools for
assessing upper limb injuries, making them superior to other outcome
measures [18,19].
When to place a long arm cast and how long to immobilize the patient in a
plaster cast?
The main disadvantage of a long arm cast is that it restricts forearm
rotation and elbow flexion-extension. It is also heavy and cumbersome, which
can increase the incidence of shoulder pain [6] and limit daily activities [20]. Conversely, a short arm cast may offer the advantage of
causing less temporary disability and inconvenience, as it allows for elbow
motion. However, a long arm cast is known to better maintain reduction
because it prevents the long wrist flexors and extensors from deforming the
fracture [20]. Some surgeons
recommend using a long arm cast for unstable fractures, generally defined by
the Lafontaine criteria, which include at least three of the following:
dorsal angulation of more than 20 degrees, dorsal comminution,
intra-articular radiocarpal fracture, associated ulnar fracture, and age
over 60 years [21]. In these cases,
it is believed that the long arm cast prevents elbow motion and forearm
rotation, minimizing the risk of fracture displacement. However, this
approach remains a matter of debate, as some surgeons still prefer short arm
casts regardless of fracture stability [6].
The current systematic review revealed no significant differences in
functional scores between short arm casts and long arm casts for stable or
extra-articular distal radius fractures. Tolerance for functional loss
appears to be influenced by age and activity level, with younger individuals
demonstrating better DASH scores after short-term follow-up. Additionally,
many authors have noted that older populations are more accepting of
functional deficits or imperfect outcomes due to their lower functional
demands [22].
The immobilization period is a significant factor in the non-operative
treatment of distal radius fractures. Removing the plaster cast early is
aimed at facilitating quicker functional recovery and enhancing clinical
outcomes. However, our literature review indicates that removing the plaster
cast before 1 month leads to poorer functional [9] and radiological outcomes [23]. It was also recommended to immobilize the arm in a
functional position [23].
Strengths and limitations of the study
In previous systematic reviews, van Delft et al. [24] and de Bruijn et al. [25]
explored the duration of cast immobilization for distal radius fractures.
However, these reviews did not set a time restriction for the inclusion of
studies, which could introduce bias. Additionally, their focus was limited to
the duration of casting, without considering other relevant parameters. Saka et
al. [26] compared the effectiveness of
below-elbow and above-elbow casts for treating this condition, yet the evidence
provided was of low certainty. Similarly, Raj et al. [27] investigated various immobilization techniques, but the
significant variation in mean follow-up periods raised concerns about potential
bias in their findings.
This study aims to objectively compare clinical and radiological parameters
concerning conservative treatment methods for distal radius fractures, focusing
on the technique of application and the duration of immobilization. All included
studies are recently published RCTs with a minimum follow-up period of three
months, which should provide a high-quality overall analysis. However, our study
has several limitations. The number of RCTs investigating non-operative
treatment methods for distal radius fractures remains limited. Among the
available studies, the strength of evidence is insufficient, with notable
heterogeneity, particularly in terms of fracture types. Future studies should
consider pooling outcomes from RCTs that involve similar fracture types. Despite
these limitations, this study provides evidence supporting conservative
treatment for distal radius fractures.
Conclusion
In patients with distal radius fractures, both short arm casts and long arm casts
provide similar functional and radiological outcomes. To prevent
re-displacement, an immobilization period of at least 3 weeks should be
considered.
2. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating
unstable distal radius fractures in the elderly. J Hand Surg 2011;36(5):824-835.
3. Gutiérrez-Monclus R, Gutiérrez-Espinoza H, Zavala-González J, Olguín-Huerta C, Rubio-Oyarzún D, Araya-Quintanilla F. Correlation between radiological parameters and functional
outcomes in patients older than 60 years of age with distal radius
fracture. Hand 2019;14(6):770-775.
4. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. Annu Intern Med 2009;151(4):264-269.
5. Furlan AD, Malmivaara A, Chou R, Maher C, Deyo RA, Schoene M, et al. Updated method guideline for systematic reviews in the cochrane
back and neck group. Spine 2015;40(21):1660-1673.
6. Park MJ, Kim JP, Lee HI, Lim TK, Jung HS, Lee JS. Is a short arm cast appropriate for stable distal radius
fractures in patients older than 55 years? A randomized prospective
multicentre study. J Hand Surg Eur Vol 2017;42(5):487-492.
7. Caruso G, Tonon F, Gildone A, Andreotti M, Altavilla R, Valentini A, et al. Below-elbow or above-elbow cast for conservative treatment of
extra-articular distal radius fractures with dorsal displacement: a
prospective randomized trial. J Orthop Surg Res 2019;14:477
8. Okamura A, de Moraes VY, Neto JR, et al. No benefit for elbow blocking on conservative treatment of distal
radius fractures: A 6-month randomized controlled trial. PLoS One 2021;16(6):0252667.
9. Christersson A, Larsson S, Sandén B. Clinical outcome after plaster cast fixation for 10 days versus 1
month in reduced distal radius fractures: a prospective randomized
study. Scand J Surg 2018;107(1):82-90.
10. Bentohami A, van Delft EAK, Vermeulen J, Sosef NL, de Korte N, Bijlsma TS, et al. Non- or minimally displaced distal radial fractures in adult
patients: three weeks versus five weeks of cast immobilization: a randomized
controlled trial. J Wrist Surg 2019;8(01):043-048.
11. Boersma EZ, Hekma EJ, Kraaijvanger N, Mollen RMHG, Nijhuis-van der Sanden MWG, Edwards MJR. Cast-OFF Trial: one versus 4 to 5 weeks of plaster cast
immobilization for nonreduced distal radius fractures: a randomized clinical
feasibility trial. Hand 2022;17:1_suppl. 60S-69S.
12. Olech J, Kopczyński B, Tomczyk , Konieczny G, Kazubski K, Morasiewicz P. The functional and radiographic outcomes following distal radius
fracture treatment in a cast for 4 and 6 weeks in the elderly: a randomized
trial. Adv Clin Exp Med 2022;31(6):701-706.
14. Saving J, Severin Wahlgren S, Olsson K, Enocson A, Ponzer S, Sköldenberg O, et al. Nonoperative treatment compared with volar locking plate fixation
for dorsally displaced distal radial fractures in the elderly: a randomized
controlled trial. J Bone Joint Surg 2019;101(11):961-969.
15. Bong MR, Egol KA, Leibman M, Koval KJ. A comparison of immediate postreduction splinting constructs for
controlling initial displacement of fractures of the distal radius: a
prospective randomized study of long-arm versus short-arm
splinting. J Hand Surg 2006;31(5):766-770.
16. Hohmann E, Meta M, Navalgund V, Tetsworth K. The relationship between radiological alignment of united distal
radius fractures and functional and patient-perceived outcomes in elderly
patients. J Orthop Surg 2017;25(1):2309499016684976
18. Dacombe PJ, Amirfeyz R, Davis T. Patient-reported outcome measures for hand and wrist trauma: is
there sufficient evidence of reliability, validity, and
responsiveness? Hand 2016;11(1):11-21.
19. Kleinlugtenbelt YV, Nienhuis RW, Bhandari M, Goslings JC, Poolman RW, Scholtes VAB. Are validated outcome measures used in distal radial fractures
truly valid? Bone Joint Res 2016;5(4):153-161.
20. Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced
fractures in the distal third of the forearm in children. J Bone Joint Surg 2006;88(1):9-17.
23. Raittio L, Launonen AP, Hevonkorpi T, Luokkala T, Kukkonen J, Reito A, et al. Two casting methods compared in patients with Colles’
fracture: a pragmatic, randomized controlled trial. PLoS One 2020;15(5):0232153.
24. van Delft EAK, van Gelder TG, de Vries R, Vermeulen J, Bloemers FW. Duration of cast immobilization in distal radial fractures: a
systematic review. J Wrist Surg 2019;08(05):430-438.
25. de Bruijn MAN, van Ginkel LA, Boersma EZ, van Silfhout L, Tromp TN, van de Krol E, et al. Cast immobilization duration for distal radius fractures, a
systematic review. Eur J Trauma Emerg Surg 2024;Mar 20 [Epub].
26. Saka N, Hoshika S, Inoue M, Watanabe J, Banno M. Below- or above-elbow immobilization in conservative treatment of
distal radius fractures: a systematic review and
meta-analysis. Injury 2022;53(2):250-258.
27. Raj V, Barik S, Richa . Comparison of above elbow and below elbow immobilisation for
conservative treatment of distal end radius fracture in adults: a systematic
review and meta-analysis of randomized clinical trials. Chin J Traumatol 2023;26(4):204-210.
SACs were as effective as LACs for
stable distal radius fractures in older patients.
Furthermore, they were more comfortable and introduced fewer
restrictions on daily activities.
Patients treated with SACs had
comparable radiological and functional scores to those
treated with LACs, with fewer complications secondary to
immobilization of the elbow joint.
Similar VAS and Mayo Wrist Scores
between the two groups. The greatest volar tilt angle
occurred after 6 wk of PC. No significant differences in
other radiological parameters between the two groups.
NA
NA
I: 58.46 ±21.24 C:
61.87 ±22.97
VAS pain: I:
2.53±3.06 C: 3.58±2.56 VAS
activity: I: 7.61 ±1.83 C: 7.58
±2.3
NA
DASH, Disabilities of the Arm, Shoulder, and Hand; PRWE,
Patient-Rated Wrist Evaluation; VAS, visual analog scale; SAC,
short arm cast; LAC, long arm cast; NA, not available; PC,
plaster cast; I, intervention; C, control; DRF, distal radius
fracture; DRUJ, distal radioulnar joint; CRPS, complex regional
pain syndrome.
DASH, Disabilities of the Arm, Shoulder, and Hand; PRWE,
Patient-Rated Wrist Evaluation; VAS, visual analog scale; SAC,
short arm cast; LAC, long arm cast; NA, not available; PC,
plaster cast; I, intervention; C, control; DRF, distal radius
fracture; DRUJ, distal radioulnar joint; CRPS, complex regional
pain syndrome.
Table 3.
Comparison of radiological outcomes
SAC, short arm cast; LAC, long arm cast; NA, not available.
, Claudia Santosa1,2
