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Meta-Analysis
. 2020 Feb 7;2(2):CD006080.
doi: 10.1002/14651858.CD006080.pub3.

Percutaneous pinning for treating distal radial fractures in adults

Alexia Karantana  1 , Helen Hg Handoll  2 , Ammar Sabouni  3
Affiliations
Meta-Analysis

Percutaneous pinning for treating distal radial fractures in adults

Alexia Karantana et al. Cochrane Database Syst Rev. .

Abstract

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. This is an update of a Cochrane Review published in 2007.

Objectives: To assess the effects (benefits and harms) of percutaneous pinning versus cast immobilisation alone and of different methods and techniques of percutaneous pinning, modalities or duration of immobilisation after pinning, and methods or timing of pin or wire removal for treating fractures of the distal radius in adults. Our primary focus was on dorsally displaced fractures.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registers, conference proceedings and reference lists of articles up to June 2019.

Selection criteria: Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with non-surgical treatment or different aspects of percutaneous pinning. Our main outcomes were patient-reported function at the short term (up to three months), medium term (three up to 12 months) and long term (greater than 12 months); overall numbers of participants with complications requiring secondary treatment and any complication; grip strength and health-related quality of life at 12 months.

Data collection and analysis: At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome.

Main results: We included 21 randomised controlled trials (RCTs) and five quasi-RCTs, involving 1946 generally older and female adults with dorsally displaced and potentially or evidently unstable distal radial fractures. Trial populations varied but the majority of studies reported mean ages in the sixth decade or older. All trials were at high risk of bias, invariably performance bias - which for most trials reflected the impracticality of blinding care providers or participants to treatment allocation - and often detection bias and selective reporting bias. Allocation concealment was secure in one trial only. All trials reported outcomes incompletely. The studies tested one of 10 comparisons. In the following, we report on those of the main outcomes for which evidence was available. No subgroup analysis, such as by pinning methods, was viable. Eleven heterogeneous trials involving 917 participants compared percutaneous pinning with plaster cast immobilisation after closed reduction of the fracture. The quality of the evidence was very low for all reported outcomes. Thus, we are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported function, measured using the DASH questionnaire, at six weeks or six months (incomplete data from one trial). Overall numbers of participants with complications were not reported. Redisplacement resulting in secondary treatment occurred on average in 12% (range 3.3% to 75%) of participants treated by cast alone (six trials) whereas pin tract infection requiring antibiotics and, often, early wire removal, occurred on average in 7.7% (range 0% to 15%) of pinning group participants (seven trials). We are uncertain whether pinning makes a difference to the incidence of complex regional pain syndrome, reported in four studies. Although two studies found finger stiffness after cast removal was less common after pinning (20% versus 36%), the treatment implications were not reported. Other reported complications were mainly surgery-related. Based on incomplete data or qualitative statements from only four studies, we are uncertain of the effects of pinning on grip strength at 12 months. We are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported quality of life at four months (one study). Five comparisons of different pinning methods were made by six trials in all. One of these trials, which reported results for 96 participants, compared Kapandji intrafocal pinning (2 or 3 wires) with early mobilisation versus trans-styloid fixation (2 wires) with six weeks cast immobilisation. We are uncertain whether Kapandji pinning slightly increases the risk of superficial radial nerve symptoms or complex regional pain syndrome, or whether it makes a difference in grip strength at 12 months (very low-quality evidence). Two small trials using two distinct pinning techniques compared biodegradable pins versus metal pins in 70 participants. Although very low-quality evidence, the extra demands at surgery of insertion of biodegradable pins and excess of serious complications (e.g. severe osteolytic reactions) associated with biodegradable material are important findings. Three poorly-reported trials involving 168 participants compared burying of wire ends versus leaving them exposed. We are uncertain whether burying of wires reduces the incidence of superficial infection (very low-quality evidence). There is low-quality evidence that burying of wires may be associated with a higher risk of requiring more invasive treatment for wire removal. Four small trials compared different types or duration of postoperative immobilisation. Very low-quality evidence of small between-group differences in individual complications and grip strength at 17 weeks, means we are uncertain of the effects of positioning the wrist in dorsiflexion versus palmar flexion during cast immobilisation following pinning of redisplaced fractures (one trial; 60 participants). Three small heterogeneous trials compared cast immobilisation for one week (early mobilisation) versus four or six weeks after percutaneous pinning in 170 people. Although we note one trial using Kapandji pinning reported more complications in the early group, the very low-quality evidence means there is uncertainty of the effects of early mobilisation on overall and individual complications, or grip strength at 12 months. No trials tested different methods for, or timing of, pin/wire removal.

Authors' conclusions: Overall, there is insufficient RCT evidence to inform on the role of percutaneous pinning versus cast immobilisation alone or associated treatment decisions such as method of pinning, burying or not of wire ends, wrist position and duration of immobilisation after pinning. Although very low-quality evidence, the serious complications associated with biodegradable materials is noteworthy. We advise waiting on the results of a large ongoing study comparing pinning with plaster cast treatment as these could help inform future research.

PubMed Disclaimer

Conflict of interest statement

AK: None known. HH: None known. AS:None known.

Figures

1
1
Example of a dorsally displaced "Colles'" distal radius fracture
2
2
Study flow diagram for updated review
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.2
1.2. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 2 DASH (30 to 150; worst outcome) at 6 months: reduced function indicated by > 60 score.
1.3
1.3. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 3 Complications.
1.4
1.4. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 4 Non return to work (labourers).
1.7
1.7. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 7 Under half grip strength at 6 months.
1.8
1.8. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 8 Grip strength at 13 to 24 months (kg).
1.9
1.9. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 9 Range of movement at 6 months.
1.11
1.11. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 11 Range of movement at 13 to 24 months.
1.12
1.12. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 12 Short Form‐36.
1.13
1.13. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 13 Overall quality of life (1 very poor to 5 very good) at 13 to 24 months.
1.14
1.14. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 14 Pain (occasional).
1.15
1.15. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 15 Patient satisfaction at 12 wks: excellent result (no pain, disability or motion limitation).
1.16
1.16. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 16 Patient satisfaction at 13 to 24 months (1 to 4, lower score equals higher satisfaction).
1.17
1.17. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 17 Deformity (clinical and radiological).
1.18
1.18. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 18 Composite score functional grading: fair or poor.
1.19
1.19. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 19 Mayo wrist score at 13 to 24 months (0 to 100; worst outcome).
1.20
1.20. Analysis
Comparison 1 Percutaneous pinning versus plaster cast, Outcome 20 Anatomical measurements.
2.1
2.1. Analysis
Comparison 2 Kapandji intrafocal pinning (2 or 3 wires) versus trans‐styloid fixation (2 wires), Outcome 1 Complications.
3.1
3.1. Analysis
Comparison 3 Modified Kapandji (dorsal Kapandji wires and trans‐styloid fixation) versus Kapandji intrafocal pinning, Outcome 1 Anatomical measurements (at 45 days).
4.1
4.1. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 1 DASH score at one year (0: worst disability to 100: no disability).
4.2
4.2. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 2 Subjective results: pain and function (normal = 30 points); from Jakim score.
4.3
4.3. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 3 Complications.
4.4
4.4. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 4 Objective results: mobility, grip strength, deformity (normal = 30 points); from Jakim score.
4.5
4.5. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 5 Overall results: radiological, subjective and objective (normal = 100 points); from Jakim score.
4.6
4.6. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 6 Overall outcome grades.
4.7
4.7. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 7 Radiological results (normal = 40 points); from Jakim score.
4.8
4.8. Analysis
Comparison 4 Kapandji intrafocal pinning (3 wires) versus Py isoelastic pinning (2 wires), Outcome 8 Anatomical measurements at one year.
5.1
5.1. Analysis
Comparison 5 Modified Kapandji pinning (3 wires) versus Willenegger pinning (2 wires), Outcome 1 Complications.
6.1
6.1. Analysis
Comparison 6 “Spring‐loaded intramedullary" pinning (not Py) versus transcortical pinning, Outcome 1 Complications.
7.1
7.1. Analysis
Comparison 7 Biodegradeable pins versus Kirschner wires, Outcome 1 Complications.
7.2
7.2. Analysis
Comparison 7 Biodegradeable pins versus Kirschner wires, Outcome 2 Range of movement.
7.3
7.3. Analysis
Comparison 7 Biodegradeable pins versus Kirschner wires, Outcome 3 Anatomical measurements.
8.1
8.1. Analysis
Comparison 8 Buried wires versus exposed percutaneous wires, Outcome 1 Complications.
8.2
8.2. Analysis
Comparison 8 Buried wires versus exposed percutaneous wires, Outcome 2 More invasive treatment for wire removal.
9.1
9.1. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 1 Complications.
9.2
9.2. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 2 Grip strength (as percentage of other side minus 30% for nondominant side).
9.3
9.3. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 3 Pinch strength (as percentage of contralateral minus 30% for nondominant side)(.
9.4
9.4. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 4 Range of motion (as percentage of contralateral normal side).
9.5
9.5. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 5 Rolyan nine hole peg test of dexterity (seconds).
9.6
9.6. Analysis
Comparison 9 Immobilisation of wrist in dorsiflexion versus palmar flexion (intrafocal pinning), Outcome 6 Anatomical measurements at week 17.
10.1
10.1. Analysis
Comparison 10 Early (after 1 week cast immobilisation) versus later (after 4 to 6 weeks) mobilisation post surgery, Outcome 1 Complications.
10.2
10.2. Analysis
Comparison 10 Early (after 1 week cast immobilisation) versus later (after 4 to 6 weeks) mobilisation post surgery, Outcome 2 Range of movement (at 1.5 months; interim results).
10.3
10.3. Analysis
Comparison 10 Early (after 1 week cast immobilisation) versus later (after 4 to 6 weeks) mobilisation post surgery, Outcome 3 Pain at 3 months: usually or during effort.
10.4
10.4. Analysis
Comparison 10 Early (after 1 week cast immobilisation) versus later (after 4 to 6 weeks) mobilisation post surgery, Outcome 4 Patient dissatisfaction with outcome.
10.5
10.5. Analysis
Comparison 10 Early (after 1 week cast immobilisation) versus later (after 4 to 6 weeks) mobilisation post surgery, Outcome 5 Anatomical measurements (at 1 year): standard errors conversion.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Mardani 2011 {published data only}
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Milliez 1992 {published data only}
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Murphy 2008 {published data only}
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Rodriguez‐Merchan 1997 {published data only}
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Saddiki 2012 {published data only}
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Shannon 2003 {published data only}
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Snow 2007 {unpublished data only}
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Stoffelen 1998 {published data only}
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Verhulst 1990 {published data only}
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Wong 2010 {published data only}
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References to studies excluded from this review

Biedermann 2001 {published and unpublished data}
    1. Biedermann M. Confirmed it was not an RCT [personal communication]. Email to: H Handoll 25 July 2002.
    1. Biedermann M, Gerber BE. Minimal invasive stabilisation of distal radius fractures with an 1 K‐wire technique [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 2001;83 Suppl 2:258.
Chung 2019 {published and unpublished data}
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Delattre 1994 {published data only}
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Galli 2002 {published data only}
    1. Galli S, Filippo G, Bonaspetti G, Zarattini G, Pazzaglia UE. Long arm cast versus percutaneous pinning in the treatment of distal radial fractures [abstract]. Journal of Hand Surgery ‐ British Volume 2002;27 Suppl 1:6‐7.
Gunay 2015 {published data only}
    1. Gunay C, Oken OF, Yavuz OY, Gunay SH, Atalar H. Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques?. Ulusal Travma ve Acil Cerrahi Dergisi [Turkish Journal of Trauma & Emergency Surgery] 2015;21(2):119‐26. - PubMed
Harper 2000 {published and unpublished data}
    1. Harper WM. A randomised prospective trial comparing MUA and POP with K wire fixation in Colles fractures. nihr.ac.uk/404/ (accessed prior to 2 February 2020).
    1. Harper WM. Trial was abandoned [personal communication]. Email to: H Handoll October 2001.
IRCT2013120814271N2 {published data only}
    1. IRCT2013120814271N2. Comparison of treatment outcome of distal extra‐articular radius fracture treatment with percutaneous pinning and pin‐in plaster in patients older than 60 years old. apps.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2013120814271N2 (first received 07 January 2007).
IRCT2016061828510N1 {published data only}
    1. IRCT2016061828510N1. The effect of ulnar styloid fracture fixation in treatment of radius fracture. en.irct.ir/trial/23119 (first received 13 July 2016).
ISRCTN37842313 {published data only}
    1. ISRCTN37842313. A randomised controlled trial comparing Kirschner wire stabilisation versus manipulation under anaesthesia (MUA) plaster treatment for displaced radial fractures. who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN37842313 (first received 29 September 2006).
NCT02353338 {unpublished data only}
    1. NCT02353338. Distal radial fractures in the late middle aged (RIST) (version 6). clinicaltrials.gov/ct2/show/study/NCT02353338 (first received 2 February 2015).
Seifert 1998 {published data only}
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References to studies awaiting assessment

Kanakeshwar 2017 {published data only}
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Mirhamidi 2013 {published data only}
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Russe 2000 {published and unpublished data}
    1. David A. Confirmed that it was a multicentre trial [personal communication]. Email to: H Handoll 16 August 2006.
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References to ongoing studies

DRAFFT 2 {unpublished data only}
    1. Achten J, Sones W, Dias J, Hedley H, Cook JA, Dritsaki M, et al. Surgical fixation with K‐wires versus plaster casting in the treatment of dorsally displaced distal radius fractures: protocol for Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT 2). BMJ Open 2019;9(3):e028474. - PMC - PubMed
    1. Anonymous. DRAFFT 2: Distal Radius Acute Fracture Fixation Trial 2. www.nets.nihr.ac.uk/projects/hta/152701 (accessed 28 August 2016).
    1. Anonymous. DRAFFT2: Distal Radius Acute Fracture Fixation Trial 2. drafft2.octru.ox.ac.uk/ (accessed 30 September 2019).
    1. ISRCTN11980540. Comparison of surgical procedures for patients with a fracture of the wrist. isrctn.com/ISRCTN11980540 (first received 02 August 2016).
IRCT20160508027797N4 {published data only}
    1. IRCT20160508027797N4. Comparison outcome of unstable fractures of the distal radius bone between the two surgical methods. apps.who.int/trialsearch/Trial2.aspx?TrialID=IRCT20160508027797N4 (first received 11 March 2019).
IRCT2016112727797N1 {unpublished data only}
    1. Hosseinzadeh D, Janmohammadi N, Ganji SME, Frydoni MB. Comparison of radiographic results between three crossed pinning and four‐pin radioulnar transfixation methods in the treatment of unstable distal radius fracture. Journal of Evolution of Medical and Dental Sciences 2019;8(33):2587‐91. [DOI: 10.14260/jemds/2019/566] - DOI
    1. IRCT2016112727797N1. Comparison of radiologic changes of unstable fractures of the distal radius bone using of three cross pin with 4 pin trans‐radioulnar. en.irct.ir/trial/22701 (accessed 26 April 2018).
NCT03311633 {unpublished data only}
    1. NCT03311633. Complications in distal radius fracture (version 2). clinicaltrials.gov/ct2/show/NCT03311633 (first received 17 October 2017).
RBR‐8mq8bs {published data only}
    1. Maradei‐Pereira JAR. Information on the trial status [personal communication]. Email to: H Handoll 30 August 2019.
    1. Pereira JARM. Buried or exposed pins in wrist fractures ‐ what causes more infection? A randomized clinical trial. ensaiosclinicos.gov.br/rg/RBR‐8mq8bs/ (first received 15 August 2017).

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References to other published versions of this review

Handoll 2007
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Publication types