Anaesthesia For Treating Distal Radial Fracture in Adults

Anaesthesia for treating distal radial fracture in adults
(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)
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)
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)
[Intervention Review]
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.
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)
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
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
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
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
(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.
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.
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.
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)
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
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).
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
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
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-
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
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
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
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.
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).
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
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
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
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.
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.
Nerve
block (el-
bow)
Haematoma
block (1b.)
Manipula-
tion
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
dosage of
di-
azepam for
elderly pa-
tients.
Haematoma
block with
sedation
(midazo-
lam)
General
(IV) anaes-
thesia (1f.)
Manipula-
tion
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
cient evi-
dence
available
and lack of
details on
method of
gen-
eral anaes-
thesia.
Some evi-
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
cient
evidence
available
and lack
of details
on method
of general
anaes-
thesia.
Some evi-
dence that
general
anaesthesia
was only
marginally
better at
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
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-
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
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-
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
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
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
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.
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
tested by other anaesthetists.
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.
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.
Cobb AG, Houghton GR. Local anaesthetic inltration versus

Biers block for Colles fractures. BMJ 1985;291:16834.
Eastwood 1986 {published and unpublished data}
Eastwood D, Grifths S, Jack J, Porter K, Watt J. Biers block--an
improved technique. Injury 1986;17(3):1878.
Erlacher 2001 {published and unpublished data}
Erlacher W, Schuschnig C, Koinig H, Marhofer P, Melischek M,
Mayer N, et al.Clonidine as adjuvant for mepivacaine, ropivacaine
and bupivacaine in axillary, perivascular brachial plexus block.
Canadian Journal of Anaesthesia 2001;48(6):5225.
Esmaoglu 1995 {published data only}
Esmaoglu A, Tercan E, Arikan N, Bilen A, Ersoy O, Boyaci A.
Addition of vecuronium to local anaesthetic solution in regional
intravenous anaesthesia [Rejiyonal intravenoz anestezide lokal
anestezik solusyona vekuronyum eklenmesi]. Turk Anesteziyoloji Ve
Reanimasyon 1995;23(9):44851.
Funk 1997 {published and unpublished data}
Funk L. A prospective trial to compare three anaesthetic techniques
used for the reduction of fractures of the distal radius. Injury 1997;
28(3):20912.
Haasio 1990 {published data only}
Haasio J. Cubital nerve block vs haematoma block for the
manipulation of Colles fracture. Annales Chirurgiae et
Gynaecologiae 1990;79:16871.
Hollingworth 1982 {published data only}
Hollingworth A, Wallace WA, Dabir R, Ellis SJ, Smith AF.
Comparison of bupivacaine and prilocaine used in Bier block--a
double blind trial. Injury 1982;13(4):3316.
Jones 1996 {published data only}
Jones NC, Pugh SC. The addition of tenoxicam to prilocaine for
intravenous regional anaesthesia. Anaesthesia 1996;51(5):4468.
Kendall 1997 {published and unpublished data}
Kendall JM, Allen P, Younge P, Meek SM, McCabe SE.

Haematoma block or Biers block for Colles fracture reduction in
the accident and emergency department--which is best?. Journal of
Accident and Emergency Medicine 1997;14(6):3526.
Lockey A. Anaesthetic for Colles fracture [letter; comment].
Journal of Accident & Emergency Medicine 1998;15(3):207.
London 1996 {published data only}
London NJ, Osman FA, Ramagopal K, Journeaux SF.
Hyaluronidase (Hyalase): a useful addition in haematoma block?.
Journal of Accident and Emergency Medicine 1996;13(5):3378.
McGlone 1988 {published and unpublished data}
McGlone R. Muscle relaxants and Biers block [Letter]. Archives of
Emergency Medicine 1989;6(3):232.
McGlone R, Heyes F, Harris P. The use of muscle relaxant to

supplement local anaesthetics for Biers blocks. Archives of
Emergency Medicine 1988;5(2):7985.
Pippa 2000 {published and unpublished data}
Pippa P. Brachial plexus block using a new subclavian perivascular
technique: the proximal cranial needle approach. European Journal
of Anaesthesiology 2000;17(2):1205.
Singh 1992 {published data only}
Singh GK, Manglik RK, Lakhtakia PK, Singh A. Analgesia for the
reduction of Colles fracture. A comparison of hematoma block and
intravenous sedation. Online Journal of Current Clinical Trials
1992 (Oct 1); Vol. Doc No 23.
Walther-Larsen 1988 {published data only}
Walther-Larsen S, Christophersen D, Fauner M, Varmarken JE.
Intravenous regional analgesia compared to inltration analgesia in
the reduction of distal forearm fractures [Intravenos regional kontra
inltrationsanalgesi ved reposition af distale
antebrachiumfrakturer]. Ugeskrift for Laeger 1988;150(32):19302.
Wardrope 1985 {published data only}
Wardrope J, Flowers M, Wilson DH. Comparison of local
anaesthetic techniques in the reduction of Colles fracture. Archives
of Emergency Medicine 1985;2(2):6772.
References to studies excluded from this review
Atanassoff 2001 {published data only}
Atanassoff PG, Ocampo CA, Bande MC, Hartmannsgruber MW,
Halaszynski TM. Ropivacaine 0.2% and lidocaine 0.5% for
intravenous regional anesthesia in outpatient surgery. Anesthesiology
2001;95(3):62731.
Bhattacharjee 2000 {unpublished data only}
Bhattacharjee C. Analgesia for the reduction of Colles fracture - a
comparison between use of lignocaine alone and the combination of
lignocaine and bupivacaine in haematoma block. In: The National
Research Register, Issue 4, 2001. Oxford: Update Software.
Brady 1998 {published and unpublished data}
Brady OH, Mullan GB, Cashman WFC, Curtin JC, McGuiness A,
Barry K, et al.Manipulation of wrist fractures under haematoma
block M.U.L.A. v.M.U.G.A. [Abstract]. Journal of Bone and Joint
Surgery. British Volume 1998;80 Suppl 1:63.
Chan 2001 {published data only}
Chan VWS, Peng PWH, Kaszas Z, Middleton WJ, Muni R,
Anastakis DG, et al.A comparative study of general anesthesia,
intravenous regional anesthesia, and axillary block for outpatient
hand surgery: Clinical outcome and cost analysis. Anesthesia &
Analgesia 2001;93(5):11814.
Cope 2001 {unpublished data only}
Cope M. A randomised trial into two techniques of haematoma
block. In: The National Research Register, Issue 1, 2001. Oxford:
Update Software.
Cornish 2001 {published and unpublished data}
Cornish PB, Nowitz M. A comparison of bent vs straight needles
for achieving brachial plexus anaesthesia [Abstract]. Anaesthesia and
Intensive Care 2001;29(6):647.
Eerola 1974 {published data only}
Eerola R. A comparative study of carticaine and prilocaine in
regional intravenous analgesia. Praktische Anaesthesie,
Wiederbelebung und Intensivtherapie 1974;9(3):1715.
James 1994 {published and unpublished data}
James NK, Khoo CTK, Fell RH. The mini-Biers block: A new
technique for prevention of tourniquet pain during axillary brachial
plexus anaesthesia. Journal of Hand Surgery. British Volume 1994;19
(3):3479.
Johansson 1992 {published data only}
Johansson C, Engstrom B, Tornkvist H, Hedlund R. Reposition of
Colles fracture--a new, more rapid, simpler and cheaper method
[Reposition av Colles fractur-ny metod snabbare, enklare,
billigare]. Lakartidningen 1992;89(19):16625.
Kongsholm 1981 {published data only}
Kongsholm J, Buring K, Lindh C, Duarte-Martins H. A
prospective study on the treatment of Colles fracture [Abstract].
Acta Orthopaedica Scandinavica 1981;52:693.
Kongsholm 1987 {published data only}
Kongsholm J, Olerud C. Neurological complications of dynamic
reduction of Colles fractures without anesthesia compared with
traditional manipulation after local inltration anesthesia. Journal
of Orthopaedic Trauma 1987;1(1):437.
Kongsholm J, Olerud C. Reduction of Colles fractures without

anaesthesia using a new dynamic bone alignment system. Injury
1987;18(2):1336.
Loryman 2003 {unpublished data only}
Kelly C. personal communication June 26 2003.
Loryman B. Randomised controlled trial of interosseous blocks in
the management of patients with Colles fractures in the Accident
and Emergency Department. In: The National Research Register,
Issue 2, 2003. Oxford: Update Software.
Mouzas 1973 {published and unpublished data}
Mouzas GL. Diazepam used intravenously during reduction of
fractures and dislocations. Practitioner 1973;211:8058.
Omeroglu 1998 {published data only}
Omeroglu H, Ucaner A, Tabak AY, Guney O, Bicimoglu A, Gunel
U. The effect of using a tourniquet on the intensity of postoperative
pain in forearm fractures. A randomized study in 32 surgically
treated patients. International Orthopaedics 1998;22(6):36973.
Porter 1998 {unpublished data only}
Porter JE. Comparison of haematoma block versus Biers block in
the management of Colles fractures. In: The National Research
Register, Issue 4, 2001. Oxford: Update Software.
Quinton 1988 {published data only}
Quinton DN. Local anaesthetic toxicity of haematoma blocks in
manipulation of Colles fractures. Injury 1988;19(3):23940.
Sherry 1989 {published data only}
Sherry E, Henderson A, Cotton J. Comparison of midazolam and
diazepam for the reduction of shoulder dislocations and Colles
fractures in skiers on an outpatient basis. Australian Journal of
Science and Medicine in Sport 1989;21(1):237.
Tan 2001 {published data only}
Tan SM, Pay LL, Chan ST. Intravenous regional anaesthesia using
lignocaine and tramadol. Annals of the Academy of Medicine,
Singapore 2001;30(5):5169.
Additional references
Altman 2001
Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elborne
D, et al.The revised CONSORT statement for reporting
randomized trials: explanation and elaboration. Annals of Internal
Medicine 2001;134(8):66394.
BNF 2000
British Medical Association, Joint Formulary Committee, Royal
Pharmaceutical Society of Great Britain. British National
Formulary. Vol. 39, London: British Medical Association and
Royal Pharmaceutical Society of Great Britain, March 2000.
Burke 1988
Burke FD. Colless fractures: conservative treatment. In: Barton N
editor(s). Fractures of the hand and wrist. Edinburgh: Churchill
Livingstone, 1988:26775.
Burke 2002
Burke D, Henderson DJ. Chirality: a blueprint for the future.
British Journal of Anaesthesia 2002;88(4):56376.
Chitnavis 1999
Chitnavis J. The wrist. In: Pynsent PB, Fairbank JCT, Carr AJ
editor(s). Classication of musculoskeletal trauma. Oxford:
Butterworth Heinemann, 1999:14670.
Clarke 2003
Clarke M, Oxman AD, editors. MEDLINE highly sensitive search
strategy for b.1) SilverPlatter-MEDLINE, b.2) OVIDMEDLINE,
and b.3) PubMed. Cochrane Reviewers Handbook 4.2.0 [updated
March 2003]; Appendix 5b. In: The Cochrane Library [database
on disk and CDROM]. The Cochrane Collaboration. Oxford:
Update Software; 2003, issue 2. Oxford.
Cummings 1985
Cummings SR, Kelsey JL, Nevitt MC, ODowd KJ. Epidemiology
of osteoporosis and osteoporotic fractures. Epidemiologic Reviews
1985;7:178208.
Green 2002
Green SM, Krauss B. Procedural sedation terminology: Moving
beyond conscious sedation. Annals of Emergency Medicine 2002;
39(2):4335.
Handoll 2003a
Handoll HHG, Madhok R. Conservative interventions for treating
distal radial fractures in adults (Cochrane Review). Cochrane
Database of Systematic Reviews 2003, Issue 2.[Art. No.: CD000314.
DOI: 10.1002/14651858.CD000314]
Handoll 2003b
Handoll HHG, Madhok R. Surgical interventions for treating
distal radial fractures in adults (Cochrane Review). Cochrane
Database of Systematic Reviews 2003, Issue 3.[Art. No.: CD003209.
DOI: 10.1002/14651858.CD003209.pub2]
Handoll 2003c
Handoll HHG, Madhok R. Closed reduction methods for treating
distal radial fractures in adults (Cochrane review). Cochrane
Database of Systematic Reviews 2003, Issue 1.
Heath 1982
Heath 1982. Deaths after intraveneous regional anaesthesia. BMJ
1982;285:9134.
Hunter 1989
Hunter JB, Scott MJL, Harries SA. Methods of anaesthesia used for
reduction of Colles fractures. BMJ 1989;299:13167.
JCAHO 2001
Joint Commission on Accreditation of Healthcare. Standards and
Intents for Sedation and Anesthesia. In: Care Revisions to
Anesthesia Care Standards. Comprehensive Accredation Manual
for Ambulatory Care. Effective January 1, 2001. http://
www.jcaho.org/standardsfrm.html (Accessed 21/05/02).
Kendall 1995
Kendall JM, Allen PE, McCabe SE. A tide of change in the
management of an old fracture?. Journal of Accident & Emergency
Medicine 1995;12(3):1878.
MacDermid 2000
MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH.
Responsiveness of the short form-36, disability of the arm,
shoulder, and hand questionnaire, patient-rated wrist evaluation,
and physical impairment measurements in evaluating recovery after
a distal radius fracture. Journal of Hand Surgery. American Volume
2000;25(2):33040.
Mollmann 2000
Mollmann M, Auf der Landwehr U. Treatment of pain in trauma
patients with injuries of the upper limb. Injury 2000;31 Suppl 1:
S3S10.
Nguyen 2001
Nguyen TV, Center JR, Sambrook PN, Eisman JA. Risk factors for
proximal humerus, forearm, and wrist fractures in elderly men and
women. The Dubbo Osteoporosis Epidemiology Study. American
Journal of Epidemiology 2001;153(6):58795.
NHS EED 2003
NHS Centre for Reviews and Dissemination. A prospective trial to
compare three anaesthetic techniques used for the reduction of
fractures of the distal radius (NHS EED abstract 970993). In: The
NHS Economic Evaluation Database. In: The Cochrane Library,
Issue 2, 2003. Oxford: Update Software. Updated quarterly or at
http://nhscrd.york.ac.uk/online/nhseed/970993.htm.
ONeill 2001
ONeill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et
al.Incidence of distal forearm fracture in British men and women.
Osteoporosis International 2001;12(7):5558.
Older 1965
Older TM, Stabler EV, Cassebaum WH. Colles fracture: Evaluation
and selection of injury. Journal of Trauma 1965;5(4):46974.
Quinton 1988a
Quinton DN. Local anaesthetic toxicity of haematoma blocks in
manipulation of Colles fractures. Injury 1988;19(3):23940.
Sahlin 1990
Sahlin Y. Occurrence of fractures in a dened population: a 1-year
study. Injury 1990;21(3):158.
Shipton 2002
Shipton EA. Comments at editorial review May 2002.
Singer 1998
Singer BR, McLauchlan GJ, Robinson CM, Christie J.
Epidemiology of fractures in 15,000 adults: the inuence of age
and gender. Journal of Bone & Joint Surgery. British Volume 1998;80
(2):243.
Wakai 2001
Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic
tourniquets in extremity surgery. Journal of the American Academy of
Orthopaedic Surgeons 2001;9(5):34551.
Whiteside 2001
Whiteside JB, Wildsmith JAW. Developments in local anaesthetic
drugs. British Journal of Anaesthesia 2001;87(1):2735.
Indicates the major publication for the study

C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Abbaszadegan 1990
Methods Method of randomisation: not stated
Assessor blinding: no mention
Intention-to-treat: no information
Loss to follow-up: no data
Participants Danderyd Hospital, Danderyd, Sweden
99 patients participated
Inclusion criteria: displaced Colles fracture.
Exclusion criteria: shortening 5+mm, hypertension.
Classication: Older, Frykman
sex: 88 female (89%)
age: mean 64 years; range 21-86 years
Assigned: 50/49 [Regional IV/local]
Assessed: ?/? (24 weeks)
Interventions Timing of intervention: After initial X-ray and before reduction.
a. Regional intravenous block: 3mg prilocaine/kg.
b. Local anaesthesia into fracture haematoma: 15-20ml prilocaine.
All patients treated in a below-the-elbow cast for 4 weeks.
Outcomes Length of follow-up: 24 weeks (6 months); also post reduction, 10-12 days, 1, 2 and 3 months.
a. Efcacy of anaesthesia: pain (VAS)
b. Anatomical: radial shortening, dorsal angulation, redislocation
c. Adverse effects: no mention
d. Clinical: complications: median nerve compression (operation), tendon rupture (patient had rheuma-
toid arthritis)
e. Functional: grip strength, range of motion, pain
f. Resource: no mention
Notes Anaesthesia given by: no information, probably orthopaedic surgeons.
Request for further details of the trial sent 01/10/01.
Risk of bias
Item Authors judgement Description
Allocation concealment? Unclear B - Unclear
Blyth 1995
Assessor blinding: no
Intention-to-treat: likely
Loss to follow-up: none
Participants Glasgow Royal Inrmary, Glasgow, UK
Inclusion criteria: distal radial metaphyseal fracture requiring manipulation under Biers block.
Exclusion criteria: none provided.
Classication: none
sex: 80% female
age: mean 56 years, range 20-93 years
Assigned: 50/50 [elbow/hand]
Assessed: 50/50 (on completion of procedure)
Interventions Timing of intervention: Before reduction.
All had Biers block using a pneumatic double cuff: 40ml prilocaine injected over 90 seconds into:
a. Antecubital fossa (elbow).
b. Dorsum (back) of the hand.
Outcomes Length of follow-up: until completion of procedure.
a. Efcacy of anaesthesia: pain (VAS), time to anaesthesia, failed cannulation, number of manipulations
b. Anatomical: no mention
c. Adverse effects: injection site bleeding/haematoma causing problems in application of plaster, none
systemic
d. Clinical: complications: no record
e. Functional: no mention
Notes Anaesthesia given in an operating room complete with a trained staff and resuscitation equipment. Two
medical staff always present, procedure probably by surgeons (A&E).
Risk of bias
Bultitude 1972
Methods Quasi-randomised: by alternation after pilot study of 10 patients given diazepam
Assessor blinding: yes for orthopaedic surgeons assessing quality of reduction
Intention-to-treat: no, 10 in pilot study included in analysis
Participants The Royal Hospital, Wolverhampton, UK
71 patients participated (10 in non-randomised pilot study and 1 fracture remanipulated and included
in both groups)
Bultitude 1972 (Continued)
Inclusion criteria: distal radial fracture requiring manipulation.
Classication: Colles (63), Smiths (4), separation of epiphysis (4)
sex: 77% female
age: 9+ years; 7 < 20 years, most >40 years.
Assigned: 40/32 [Diazepam/general]
Assessed: 40/32 (at 6 weeks)
a. Single IV dose of Diazepam administered over a period of seconds according to dosage: 20mg (34
patients); 30mg (4 heavy patients); 10mg (9 year old). Treated irrespective of when patient had last eaten.
Reduction after 60-90 seconds.
b. General anaesthesia: IV barbiturate then inhalation agents. Delay until 4 hours since last meal.
Fracture reduced and immobilised in a complete below-elbow plaster for 5-6 weeks.
Outcomes Length of follow-up: 5-6 weeks; also during reduction, at discharge and rst fracture clinic.
a. Efcacy of anaesthesia: reactions during reduction, delayed reduction, apprehensive of anaesthesia
method in future
b. Anatomical: quality of reduction, slipped at 6 weeks
c. Adverse effects: rash, injection site pain, vomit, headache, drowsiness or giddy post discharge, other
d. Clinical: complications: blood pressure, pulse, respiratory rate up to 1 hour.
Notes Anaesthesia given by: not clear, sedative probably given by surgeon in A&E; general anaesthesia: unknown.
Nurse assisted surgeon by observing patients airway and respiration. Fully equipped anaesthetic trolley to
hand.
Risk of bias
Allocation concealment? No C - Inadequate
Cobb 1985
Intention-to-treat: no, 17 excluded due to missing data
Loss to follow-up: none but 17 excluded
Participants John Radcliffe Hospital, Oxford, UK
Inclusion criteria: closed Colles fracture requiring manipulation, age 15+ years, normal sensation and
circulation of limb.
Exclusion criteria: diabetes, epilepsy, sickle-cell disease, relevant allergy.
Classication: none
Cobb 1985 (Continued)
sex: no details
age: no details
Assigned: ?/? [Biers block/local]
Assessed: 44/39 (on completion of plaster)
a. Biers block: 30-40ml 0.5% prilocaine injected in vein on back of the hand. Use of a double cuff, upper
cuff deated after 20 minutes.
b. Local anaesthesia into fracture cavity and adjacent perioteum, including ulnar styloid: 10ml of 2%
lignocaine. Forearm cleansed and sterile gloves used.
Fracture manipulated after 10 minutes in both groups. All patients treated with plaster cast.
Outcomes Length of follow-up: until plaster cast completion.
a. Efcacy of anaesthesia: pain (LAS, duration), effectiveness rated by operator (LAS), duration of proce-
dure, patient wait
b. Anatomical: inadequacy of reduction
c. Adverse effects: none signicant
d. Clinical: complications: none signicant
f. Resource: duration of procedure, staff time
Notes Anaesthesia given by: no information, probably orthopaedic surgeons.
Risk of bias
Eastwood 1986
Methods Method of randomisation: use of envelopes
Loss to follow-up: probably none
Participants General Hospital, Birmingham, UK
Inclusion criteria: closed displaced Colles fracture.
Classication: none
sex: 76% female
age: mean 70.5 years
Assigned: 25/25 [modied/standard]
Assessed: 25/25 (before manipulation)
Eastwood 1986 (Continued)
All had Biers block using 0.6ml/Kg body weight of 0.5% prilocaine injected through cannula in dorsum
of hand. Two orthopaedic tourniquets applied to upper arm, armelevated for 3+ minutes before proximal
cuff inated.
a. A rubber venepuncture tourniquet was applied rmly round the arm immediately proximal to fracture
site before prilocaine injection. The venepuncture tourniquet was removed before the plaster back slab
was applied. The more distal of the two upper arm tourniquets was inated and then upper cuff deated.
b. Prilocaine injection alone. Standard Bier procedure.
Fractures were then manipulated (manual manipulation, distraction by 2 people) and a plaster back slab
applied. At 5-10 days, a below-elbow plaster cast for 5 weeks.
Outcomes Length of follow-up: until manipulation.
a. Efcacy of anaesthesia: time to reach anaesthesia (loss of perception of pin prick at the fracture site).
c. Adverse effects: none recorded
Notes Anaesthesia given by: anaesthetist senior registrars (2 involved). Orthopaedic senior registrars and consul-
tant also involved.
Standard deviations calculated from frequency diagrams presented in the trial report.
Further details (method of randomisation, no adverse outcomes, details of who provided the care) received
via Mr Porter on 04/02/02.
Risk of bias
Erlacher 2001
Methods Method of randomisation: computer-generated randomisation list (placebo controlled, double-blinded)
Assessor blinding: not stated, but blinding likely
Loss to follow-up: none probably
Participants Hospital Lainz, Vienna, Austria
57 of the 120 participants had distal radial fractures
Inclusion criteria: Undergoing surgery of forearm or hand after trauma, ASA score 1, 2 or 3, written
informed consent.
Exclusion criteria: See above.
Classication: none
sex: (of 57) 39 female (65%)
age: (of 57) mean 52.5 years
Assigned: 9/11/8/7/10/12 (distal radial fractures); 20/20/20/20/20/20 (overall) [Mc/Mo/Rc/Ro/Bc/Bo -
see Interventions]
Erlacher 2001 (Continued)
Assessed: same as assigned (recovery from anaesthesia)
Interventions Timing of intervention: Before surgery.
All had axillary perivascular brachial plexus block according to Winnie; use of nerve stimulator.
a. Clonidine (0.15mg in 1ml) + 40ml mepivacaine (1%) [Mc]
b. 40ml mepivacaine (1%) + 1ml NaCl (0.9%) [Mo]
c. Clonidine (0.15mg in 1ml) + 40ml ropivacaine (0.75%) [Rc]
d. 40ml ropivacaine (0.75%) + 1ml NaCl (0.9%) [Ro]
e. Clonidine (0.15mg in 1ml) + 40ml bupivacaine (0.5%) [Bc]
f. 40ml bupivacaine (0.5%) + 1ml NaCl (0.9%) [Bo]
Distal radial fracture patients had open reduction and internal xation.
Outcomes Length of follow-up: to recovery from anaesthesia.
a. Efcacy of anaesthesia: Extent and onset of sensory block (VAS), duration of motor blockade
c. Adverse effects: none (hypotension, nausea, vomiting)
d. Clinical: no mention
Notes Anaesthesia given by: not stated; named trialists were based in anaesthetics department.
Separate results data for distal radial fracture patients received from Dr Erlacher on 18/11/01.
Risk of bias
Esmaoglu 1995
Methods Method of randomisation: not clear. Trials stated that patients were randomly assigned according to
operation type
Assessor blinding: not stated
Loss to follow-up: none probably
Participants Hospital in Turkey
17 out of 40 patients had distal radial fracture
Inclusion criteria: Forearm/wrist fracture requiring reduction. ASA score 1 or 2.
Exclusioncriteria: Raynauds disease, sclerosis, sickle cell anaemia, large lacerationandinfectionof operated
area, myasthenia gravis, degenerative heart disease, liver dysfunction.
Classication: none
sex: not given
age: (of 40) mean 31.5 years, range 18-50 years
Assigned: 9/8 (distal radial fracture); 20/20 (overall) [vecuronium/control]
Assessed: 9/8 (distal radial fracture) 20/20 (overall); (recovery from anaesthesia)
Esmaoglu 1995 (Continued)
All had IVregional anaesthesia with 3mg/kg of lidocaine made up with saline to 40ml and applied over 90
seconds; affected limb drained by elevation and pressure on brachial artery for 2 minutes prior to double
tourniquet ination.
a. 0.5mg vecuronium (muscle relaxant) included in 40ml.
b. Control: lidocaine only.
IV fentanyl applied to patients requiring additional analgesic.
Outcomes Length of follow-up: to recovery from anaesthesia.
a. Efcacy of anaesthesia: 4 point scale including requirement for general anaesthesia. Onset of sensorial
& motor block, recovery of sensorial and motor function. Requiring additional analgesic.
b. Anatomical: remanipulation (none)
c. Adverse effects: dizziness, nausea, no others
Notes Anaesthesia given by: the two named trialists who were based in anaesthetics department.
Translation from Turkish by Dr Murat Genc.
Further details, including some separate data for distal radial fracture patients, of the trial received from
Aliye Esmaoglu on 11/12/01. Request for clarication of randomisation method sent 11/12/01.
Risk of bias
Funk 1997
Methods Method of randomisation: computer generated, number allocated to patient on arrival to A&E
Assessor blinding: yes for X-rays
Intention-to-treat: no information, questions over numbers randomised/analysed
Participants Bolton Royal Inrmary, Bolton, UK
58 (or 59) patients participated
Inclusion criteria: distal radial fracture requiring manipulation, age 16+ years.
Exclusion criteria: analgesia given within 4 hours before manipulation.
Classication: Colles, Smith, other
age: mean 63 years; range 16-91 years
Assigned: 21/19/19 [General/Haematoma block + IV sedation/Haematoma block]
Assessed: ?/?/? (at recovery from anaesthesia)
Interventions Timing of intervention: At casualty, after initial X-ray and before reduction.
a. General anaesthetic with propofol.
b. Local anaesthetic into fracture haematoma: no more than 2mg/kg of 1% lignocaine injected into site
Funk 1997 (Continued)
until tight. IV sedation with 1-10mg midazolam - slowly injected until patient was sedated. 5 minutes
wait before manipulation.
c. Local anaesthesia into fracture haematoma: as above, no sedation. 5 minutes wait before manipulation.
Intravenous access essential for both groups b & c.
Airway patency, respiration and pulse rates closely monitored. Pulse oximetry, masked oxygen provided.
Flumazenil and resuscitation equipment always at hand.
Outcomes Length of follow-up: up to recovery from anaesthesia.
a. Efcacy of anaesthesia: pain (VAS), time for manipulation
b. Anatomical: radial shortening (best guess results), dorsal angulation
c. Adverse effects: none (infection/respiratory depression)
f. Resource: costs (drugs, consumables, staff salaries), wait for staff, total wait for procedure.
Notes Anaesthesia given by: anaesthetist for general anaesthesia, and orthopaedic surgeon for haematoma blocks.
Conrmation from Lennard Funk that this was a randomised trial received 21 August 2001.
Request for further details of the trial sent 18/10/01 & 12/11/01.
Request sent again: 23/06/03
Risk of bias
Haasio 1990
Participants Surgical Hospital, University Central Hospital, Helsinki, Finland
Inclusion criteria: Colles fracture up to 6 hours old scheduled for manipulation and reposition. Informed
consent.
Exclusion criteria: see above.
Classication: none
age: mean 62 years
Assigned: 16/19 [nerve block/local]
Assessed: 16/19 (during procedure)
15ml of 10mg/ml prilocaine used in both groups
a. Conduction block: 5ml doses injected into areas innervated by the radial, median and ulnar nerves in
the elbow region. Nerve identied using nerve stimulator and a stimulation-injection needle.
Haasio 1990 (Continued)
b. Local anaesthesia: injection into fracture haematoma from the dorsum of the wrist.
Outcomes Length of follow-up: until end of procedure
a. Efcacy of anaesthesia: pain (no, moderate, severe), patient satisfaction, relaxation of wrist (enabling
reduction), time to start manipulation, pin prick analgesia
c. Adverse effects: none (systemic anaesthetic toxicity)
d. Clinical: complications: no mention
Notes Anaesthesia given by anaesthetist.
Risk of bias
Hollingworth 1982
Methods Method of randomisation: use of random numbers, double-blind, identical drug preparations produced
externally, involvement of statistician
Assessor blinding: yes, patient/provider/assessor blinding
Intention-to-treat: no, missing information
Loss to follow-up: 25
Participants Queens Medical Centre, Nottingham, UK
200 patients participated (142/175 had Colles or Smiths fractures)
Inclusion criteria: upper limb injury requiring reduction/minor operation, suitable for a Biers block.
Attending A&E.
Exclusion criteria: age <16 years, history of adverse reaction to local anaesthetic agents, history of epilepsy,
contraindicated to Biers block, systolic blood pressure >200mmHg.
Classication: Colles, Smiths, other distal forearm fractures
sex: (of 175) 70% female
age: 16 to 80+ years
Assigned: ?/? [bupivacaine/prilocaine]
Assessed: 85/90 (after end of procedure)
Interventions Timing of intervention: Before manipulation/operation.
All had Biers block with a single cuff. Identical injection into dorsum of hand.
a. 40ml of 0.25% bupivacaine (100mg).
b. 40ml of 0.5% prilocaine (200mg).
Outcomes Length of follow-up: after procedure.
a. Efcacy of anaesthesia: quality of reduction/procedure including remanipulation/abandoned procedure
(categorical scale: good, acceptable, poor); time to analgesia; pain (doctor, patient, site: injury/cuff );
Hollingworth 1982 (Continued)
(patient acceptability of Biers block)
b. Anatomical: quality of reduction (see a)
c. Adverse effects: (all minor), tingling/pain in ngers; metal taste in mouth, tinnitus, feeling nauseous,
odd, sweaty
Notes Anaesthesia given by A&E doctors (20 involved).
Of 175 patients:
137 (78%) had Colles fractures
5 (3%) had Smiths fractures
20 (11%) had hand injuries (fractures/lacerations)
2 (1%) had elbow dislocations
11 (6%) had other distal forearm fractures.
Risk of bias
Allocation concealment? Yes A - Adequate
Jones 1996
Methods Method of randomisation: not stated but double-blind
Assessor blinding: likely, patient/provider/assessor blinding
Participants Brook General Hospital or Guys Hospital, London, UK
Inclusion criteria: Uncomplicated Colles fracture for manipulation under a Biers block, age > 12 years,
in good health, ASA score 1 or 2.
Exclusion criteria: history of gastrointestinal bleeds, asthma, renal impairment, allergy to aspirin or other
NSAIDS; currently taking anticoagulants or possibly/actually pregnant.
Classication: none, Colles
sex: 80% female
age: mean 62 years, range 13-88 years
Assigned: 15/15/15 [tenoxicam in block/tenoxicam opposite arm/control]
Assessed: 15/15/15 (24 hours)
Interventions Timing of intervention: Before manipulation.
All had Biers block with 0.5ml/kg of 0.5% prilocaine; affected limb elevated for 2 minutes prior to single
cuff ination. Cannula inserted intravenously into each hand.
a. 2mg tenoxicam (2ml) IV into block and 2ml saline IV into opposite arm.
b. 2mg tenoxicam (2ml) IV into opposite arm and 2ml saline IV into block.
c. Control, prilocaine only (2ml saline IV into affected arm + 2ml saline IV into opposite arm).
Jones 1996 (Continued)
Tourniquet release minimum 20 minutes (20-60 minutes).
Outcomes Length of follow-up: 24 hours at fracture clinic.
a. Efcacy of anaesthesia: no mention
c. Adverse effects: none
d. Clinical: pain (time to rst analgesic, number of co-dydramol, numeric rating scale, verbal rating
category); complications: no mention
Notes Anaesthesia givenby: not stated; but bothnamedtrialists were specialising inanaesthesia (fromDepartment
of Anaesthesia).
Risk of bias
Kendall 1997
Methods Method of randomisation: consecutive computer generated random numbers (randomisation table was
not concealed)
Assessor blinding: no for main comparison
Intention-to-treat: no, 8 excluded due to missing data
Loss to follow-up: none but 8 excluded
Participants Gloucester Royal Hospital, Gloucester and Bristol Frenchay Hospital, Bristol, UK
Inclusion criteria: Colles fracture requiring manipulation, >15 degrees dorsal angulation, >2mm radial
shortening, age 16+years.
Classication: Frykman
sex: (of 142) 125 female (88%)
age: (for 142) mean 63 years
Assigned: ?/? [Biers/local]
Assessed: 72/70 (at fracture clinic next day)
Interventions Timing of intervention: After initial X-ray and before reduction.
a. Biers block: 0.5% prilocaine, volume according to patients weight.
b. Local anaesthesia into fracture haematoma: 10ml of 1% lignocaine (diluent either sodium bicarbonate
(alkalinised) or sodium chloride (not alkalinised)).
All patients had manipulation by distraction of fracture, then palmar exion and ulnar deviation and
forearm placed in incomplete plaster backslab. Fracture clinic next day.
Kendall 1997 (Continued)
Outcomes Length of follow-up: 3 months (data unavailable); also next day fracture clinic and during procedure.
a. Efcacy of anaesthesia: pain (VAS), timing of various procedural phases
b. Anatomical: radial shortening, dorsal angulation, radial angulation, remanipulation
c. Adverse effects: none (infection, systemic anaesthetic toxicity)
e. Functional: no mention (assessed at 3 months - see notes)
f. Resource: no mention, except standard practice: two doctors for Biers and one for local.
Notes Anaesthesia given by A&E SHOs and registrars from2 emergency departments (approx. 15 to 20 doctors)
.
The randomised and blinded comparison of alkalinised versus non-alkalinised lignocaine for haematoma
block group is not included in this review.
Report indicated that data collection was ongoing with patients being followed up in the medium term.
Response from Jason Kendall received 18/10/01. Response from Patricia Allen received 11/12/01 on
follow-up study indicated that the numbers available at 3 months meant that its almost impossible to
draw particularly meaningful conclusions on the nal position + function at 3 months.
Risk of bias
London 1996
Methods Method of randomisation: not stated, double-blind
Assessor blinding: yes, patient/provider blinding
Intention-to-treat: problems, 2 excluded
Loss to follow-up: probably none
Participants District Hospital, Harrogate, UK
Inclusion criteria: distal radial fracture for manipulation under a haematoma block, informed consent.
Classication: none, all Colles
sex: (of 31) 97% female
age: (of 31) mean 68 years
Assigned: 16/17 [hyaluronidase/control]
Assessed: 14/17 (after manipulation)
All had haematoma block 10ml 1% lignocaine; 8ml injected into haematoma, 2ml around ulnar styloid.
a. 1500IU Hyaluranidase (Hyalase).
b. Control, lignocaine only.
Fractures were manipulated after 10 minutes by one of 2 experienced clinicians.
London 1996 (Continued)
Outcomes Length of follow-up: after manipulation.
a. Efcacy of anaesthesia: subjective VAS, severity of pain, satisfaction with pain control
b. Anatomical: remanipulation
c. Adverse effects: none
Notes Anaesthesia given by: blinded anaesthetist mentioned.
Risk of bias
McGlone 1988
Methods Method of randomisation: use of sealed envelopes; trialist stated that allocation was concealed
Assessor blinding: yes, patient/provider/assessor blinding
Participants Hull Royal Inrmary, UK
Inclusion criteria: wrist fracture for manipulation under a Biers block, age < 55 years, informed consent.
Classication: none
sex: 69% female
age: not given
Assigned: 18/18 [atracurium/control]
Assessed: 18/18 (after cuff release)
All had Biers block with 40ml 0.5%prilocaine; affected limb elevated for 3 minutes prior to cuff ination.
a. 2mg atracurium (muscle relaxant).
b. Control, prilocaine only.
Fractures were manipulated, using simple manual reduction, after 10 minutes by one of 2 experienced
clinicians. Followed by short-arm plaster cast.
Outcomes Length of follow-up: after manipulation.
a. Efcacy of anaesthesia: pain (VAS), ease of reduction, failed reduction
b. Anatomical: remanipulation, reduced position
c. Adverse effects: dysaesthesia (sensorial impairment), diplopia (double vision), time to return of ne
movement
McGlone 1988 (Continued)
Notes Anaesthesia given by: 2 A&E doctors
Further details of the trial received from Raymond McGlone 17/10/01.
Risk of bias
Pippa 2000
Methods Quasi-randomised: by date of birth
Assessor blinding: stated to be so for anaesthesia, no indication of measures taken
Participants Centro Traumatologico, Careggi, Florence, Italy
7 patients of 60 participants had distal radial fracture
Inclusion criteria: undergoing upper limb orthopaedic surgery, ASA class I or II, written consent.
Classication: none
sex: (of 60) 26 female (43%)
age: (of 60) median 36 years, range 20-65 years
Assigned: 4/3 (distal radial fracture); 30/30 (overall) [proximal cranial needle approach/supraclavicular
approach: see interventions]
Assessed: 4/3; 30/30 (after 20 minutes)
Interventions Timing of intervention: Surgery 2-3 days post fracture. Brachial plexus block at least 30 minutes before
surgery.
All patients given diazapam 10mg orally and atropine 0.5mg intramuscularly 20 minutes before starting
the brachial plexus block. Anaesthetic was 30ml in equal parts of bupivacaine 0.5% with epinephrine 1:
200,000 and lignocaine 2%. Nerve stimulators used in both techniques.
a. Proximal cranial needle approach. Needle inserted via sternocleimastoid muscle at clavicular bone.
b. Winnie and Collins technique involving a supraclavicular approach.
Full details, including diagrams, of the two techniques provided in report.
Outcomes Length of follow-up: 20 minutes post block.
a. Efcacy of anaesthesia: pin-prick analgesia, quality of anaesthesia (categorical scale: excellent, good,
insufcient, failure)
c. Adverse effects: pneumothorax, phrenic nerve block with respiratory failure, accidental puncture of
subclavian artery (Horners syndrome was not considered a complication)
Pippa 2000 (Continued)
Notes Anaesthesia given by an anaesthetist (Dr Pippa)
Separate data for the 7 distal radial fracture patients provided by Dr P Pippa on 7 October 2001. Further
details provided by Dr P Pippa 26 November 2001.
Risk of bias
Singh 1992
Methods Method of randomisation: double-blind, computer generated randomisation list, sealed envelopes
Assessor blinding: yes, pain and 8 week assessment
Intention-to-treat: likely; though 1 case excluded due to a failed IV injection at fracture site (inclusion of
data from this case reported as not affecting trial results)
Loss to follow-up: none, but 1 excluded from follow-up
Participants Teaching hospital, Lucknow, India
Inclusion criteria: Colles fracture requiring manipulation, simple transverse radial fracture within 0.25
inches of the distal articulating surface. Injury duration < 96 hours, informed consent.
Exclusion criteria: contraindication to any method of analgesia, analgesic use during past 8 hours, mental,
auditory or visual impairment, associated injury.
Classication: none
sex: (of 66) 20 female (30%)
Assigned: 34/33 [sedation/local]
Assessed: 33/33 (8 weeks)
Interventions Timing of intervention: Before reduction, within 96 hours of injury.
a. Sedation: intravenous injection on dorsum of affected wrist of 30mg pentazocine with 5mg diazepam.
b. Local anaesthesia injected into fracture haematoma: 22cc of 1.5% Xylocaine (anhydrous lignocaine
hydrochloride).
Fracture manipulated after 5 minutes in both groups, followed by plaster. Six weeks immobilisation and
then 2 weeks institutional physiotherapy.
Outcomes Length of follow-up: 8 weeks; also 13-15 hours post reduction.
a. Efcacy of anaesthesia: pain (VAS), time for reduction
b. Anatomical: reduction failure, non-union, substantial deformity
c. Adverse effects: local sensitivity, signicant drug toxicity, infection (none)
e. Functional: rest pain, stiffness (substantial = bothering the patient)
Notes Anaesthesia given by one of two orthopaedic surgeons. Report notes that anaesthesia facilities would not
be available for these patients in developing countries.
All patients tested for Xylocaine sensitivity beforehand.
Singh 1992 (Continued)
Risk of bias
Allocation concealment? Yes A - Adequate
Walther-Larsen 1988
Assessor blinding: yes, radiological and clinical outcome assessment
Loss to follow-up: 6 (4 lost to follow-up and 2 dead)
Participants Gentofte Hospital, Copenhagen, Denmark
Inclusion criteria: closed displaced distal radial fractures, age 14+ years, patient consent.
Exclusion criteria: skin, vessel, tendon lesions, other fracture treated during admission. Other competing
(as translated) diseases.
Classication: Older
sex: 96% female
Assigned: 23/25 [IV regional anaesthesia/local]
Assessed: 21/21 (6 months)
a. Intravenous regional anaesthesia: mepivacaine 0.5%, without adrenaline, 40 ml (200mg). Elevation of
limb for 5 minutes before cuff inated and injection.
b. Local anaesthesia into fracture haematoma and at ulnar styloid process: 10ml 2% lignocaine. Disinfec-
tion beforehand.
Reduction and immobilisation in low dorsal radial plaster cast.
Outcomes Length of follow-up: 6 months; also 1, 2 and 5 weeks.
a. Efcacy of anaesthesia: pain (VAS)
b. Anatomical: repositioning during anaesthesia, later remanipulation, grade (excellent, good, poor) of
reduction/anatomical result (Older 1965)
c. Adverse effects: no systemic or infection
d. Clinical: complications: RSD, nerve complication (median nerve compression, paresthesia, hyposensi-
bility)
e. Functional: grade (excellent, good, poor) including strength, pain, limitation in wrist ROM (Older
1965)
f. Resource: mentioned that IV regional anaesthesia was more time consuming - no indication if recorded
Notes Anaesthesia given by: no information.
Translation from Danish by Dr Steen Barnung
Request for further details of the trial sent 09/10/01. Envelope returned - address unknown in November
2001.
Walther-Larsen 1988 (Continued)
Risk of bias
Wardrope 1985
Methods Quasi-randomised: treatments used on alternative days
Intention-to-treat: no, discrepancies
Participants Leeds General inrmary, Leeds, UK
81 (or more) patients participated
Inclusion criteria: Colles fracture requiring manipulation, age 45+ years.
Exclusion criteria: previous wrist fracture on injured side, contraindications to Biers block/local anaes-
thesia.
Classication: none
sex: no details
age: mean 65 years
Assigned: ?/? [Biers/local]
Assessed: 45/36 (at fracture clinic discharge); or 42/37 (patient questionnaires)
a. Biers block: 0.5% prilocaine, 0.6ml/kg. Cuff inated and injection given over 1 minute.
b. Local anaesthesia into fracture haematoma and near ulnar styloid: 1% lignocaine, 0.2ml/kg. Skin
cleansed beforehand.
Fracture manipulated after 5 minutes in both groups, followed by padded plaster of Paris backslab. If
reduction inadequate, further attempt made during same anaesthetic.
Outcomes Length of follow-up: until discharge from fracture clinic; also after reduction.
a. Efcacy of anaesthesia: pain (VAS and categories), remanipulation during anaesthesia
b. Anatomical: radial shortening, dorsal angulation, ulnar angulation, re-reduction
c. Adverse effects: infection (none)
d. Clinical: complications: swelling, neurological
f. Resource: time to discharge from fracture clinic
Notes Anaesthesia given by junior staff (A&E department).
Discrepancies in numbers followed up.
Risk of bias
Wardrope 1985 (Continued)
ASA = American Society of Anaesthetists
A&E = Accident and Emergency
cc = cubic centimetres
IV = intravenous
LAS = linear analogue scale
NSAIDs = Non-steroidal anti-inammatory drugs
RSD = reex sympathetic dystrophy
SHO = senior house ofcer
VAS = visual analogue scale
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Atanassoff 2001 Comparison of ropivacaine with lidocaine for IVRA. No patients with fractures of the distal radius.
Bhattacharjee 2000 Complex comparison of drugs (bupivacaine (Marcain 0.5% in 10ml) + lignocaine (1% in 10ml) versus ligno-
caine (1% in 20ml)) in same class. Used for haematoma block in 40+ patients with Colles fracture.
Brady 1998 Indicated as a prospective study in a conference abstract. Contact with lead trialist conrmed that this was not
a randomised trial: the rst 20 patients had general anaesthetic and the next 20 patients had local anaesthetic.
Chan 2001 Indicated as a comparative study of general anaesthesia, IVRA and axillary block. Not a randomised trial -
treatment primarily determined by the patient. Also may not include patients with fracture of the distal radius.
Cope 2001 Study discontinued after 6 patients. No plans to write up.
Cornish 2001 Trialist conrmed that none of the patients had distal radial fractures.
Eerola 1974 Comparison of carticaine (Articaine: British National Formulary) with prilocaine for IVRA during upper and
lower limb operations. Unknown number of patients with fractures of the distal radius. Incomplete study,
which may not have been randomised though double blind. Comparison of drugs in the same class.
James 1994 Trialists conrmed that none of the patients had distal radial fractures.
Johansson 1992 Study of reduction technique rather than method of anaesthesia.
Kongsholm 1981 Study of reduction technique rather than method of anaesthesia.
Kongsholm 1987 Study of reduction technique rather than method of anaesthesia.
(Continued)
Loryman 2003 Study had received ethical permission but may not have started recruiting before the lead trialist left. It has
now been abandoned.
Mouzas 1973 Not randomised. Trialist conrmed that anaesthetic method was selected according to patient characteristics;
generally general anaesthesia was given to children and when the fracture was badly displaced/impacted,
especially in young adults.
Omeroglu 1998 Quasi-randomised study of tourniquet use for operative xation of forearm fractures (closed fractures of the
radial and ulna shafts). Inhalation anaesthesia used. No fractures of the distal radius.
Porter 1998 Trial not started. The named contact was not sure how the trial, intended to compare haematoma with IVRA,
reached the National Research Register as it was being presented to the local ethics committee when she retired.
Quinton 1988 Drug (lignocaine) toxicity study only.
Sherry 1989 Comparison of drugs (midazolam versus diazepam) in same class. Mixed population including 15 Colles
fractures.
Tan 2001 Randomised trial evaluating addition of tramadol to IVRA for upper limb surgery. There were no patients with
fractures of the distal radius.
IVRA = intravenous regional anaesthesia
D A T A A N D A N A L Y S E S
Comparison 1. Intravenous regional anaesthesia (IVRA) versus haematoma block
Outcome or subgroup title
No. of
studies
No. of
participants
Statistical method Effect size
1 Pain 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 During manipulation
(VAS: 0 (no pain) to 10 (severe
pain))
1 83 Mean Difference (IV, Fixed, 95% CI) -2.89 [-4.35, -1.43]
1.2 Duration of post-op
painlessness (hours)
1 83 Mean Difference (IV, Fixed, 95% CI) -0.30 [-1.59, 0.99]
2 Pain and preferences 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 Number of patients
indicating that procedure was
painful
1 79 Risk Ratio (M-H, Fixed, 95% CI) 0.61 [0.32, 1.13]
2.2 Numbers with VAS pain
rating > 2cm (0 = no pain)
2.3 Numbers expressing
preference for a general
anaesthesia
3 Re-manipulation 3 271 Risk Ratio (M-H, Fixed, 95% CI) 0.30 [0.16, 0.57]
4 Post reduction anatomical
measurements
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
4.1 Volar angulation (stated
normal 10-15 degrees)
1 81 Mean Difference (IV, Fixed, 95% CI) 1.9 [-1.77, 5.57]
4.2 Ulnar angulation (degrees) 1 81 Mean Difference (IV, Fixed, 95% CI) 4.0 [1.43, 6.57]
4.3 Radial length (stated
normal: 12-16 mm)
1 81 Mean Difference (IV, Fixed, 95% CI) 1.80 [0.56, 3.04]
5 Poor quality of reduction and
anatomical scores
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
5.1 Poor reduction result 1 47 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.33, 1.25]
5.2 Poor anatomical result (5
weeks)
6 Later redislocation/re-reduction
of fracture
6.1 Redislocation of fracture 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.11 [0.01, 1.97]
6.2 Later reduction of
redislocated fracture
7 Operator judgement of
effectiveness of procedure
(linear analogue scale)
8 Timing of procedure 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
8.1 Waiting time for
procedure (minutes)
8.2 Duration of procedure
(minutes)
9 Adverse effects/Complications 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
9.1 Infection 3 271 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
9.2 Systemic complications 2 190 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
9.3 Median nerve compression 2 147 Risk Ratio (M-H, Fixed, 95% CI) 0.72 [0.15, 3.58]
9.4 Other nerve problems:
parathesias / hyposensibility
9.5 RSD 1 48 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.07, 16.39]
9.6 Tendon rupture 1 99 Risk Ratio (M-H, Fixed, 95% CI) 2.94 [0.12, 70.50]
10 Poor functional score 1 42 Risk Ratio (M-H, Fixed, 95% CI) 0.33 [0.08, 1.47]
Comparison 2. Nerve block (at elbow) versus haematoma block
No. of
studies
No. of
participants
1 Pain (moderate or severe) during
procedure
2 Poor wrist relaxation during
procedure
Comparison 3. Intravenous sedation versus haematoma block
No. of
studies
No. of
participants
1 Pain during reduction: visual
analogue scale (0: no pain to
10: excruciating pain)
2 Pain during reduction: VAS
score > 3 for procedure (0: no
pain; 10: excruciating pain)
3 Time for fracture reduction 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Time: 1 minute or over 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.28 [1.05, 1.57]
3.2 Time: 5 minutes or over 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.38 [0.90, 2.11]
4 Radiological result at 8 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Reduction failure 1 66 Risk Ratio (M-H, Fixed, 95% CI) 2.0 [0.39, 10.18]
4.2 Substantial deformity 1 66 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.29, 1.92]
4.3 Non union 1 66 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5 Adverse effects 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
5.1 Local sensitivity 1 66 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5.2 Signicant drug toxicity 1 66 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5.3 Infection 1 66 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6 Substantial rest pain at 8 weeks 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.67 [0.43, 6.41]
7 Substantial stiffness at 8 weeks 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.75 [0.57, 5.42]
Comparison 4. General intravenous anaesthesia versus haematoma block
No. of
studies
No. of
participants
1 Radial length shortening 1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.63 [0.66, 4.01]
2 Residual dorsal deformity 1 40 Mean Difference (IV, Fixed, 95% CI) -0.60 [-6.12, 4.92]
3.1 Total waiting time
(minutes)
1 40 Mean Difference (IV, Fixed, 95% CI) 300.0 [66.72,
533.28]
3.2 Waiting time for staff
(minutes)
3.3 Time for anaesthesia +
manipulation (minutes)
Comparison 5. General anaesthesia versus sedation (diazepam)
No. of
studies
No. of
participants
1 Reactions during reduction of
fracture
1.1 Recalled reduction 1 72 Risk Ratio (M-H, Fixed, 95% CI) 0.42 [0.05, 3.82]
1.2 Limb movement 1 72 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.03]
1.3 Delayed reduction due to
vigorous reaction
1.4 Groaned, grimaced or
cried out
1.5 Attempt to withdraw arm
during reduction
1 72 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
2 Quality of initial
reduction/redisplaced at 6
weeks
2.1 Bad quality initial
reduction
2.2 Slipped reductions at 6
weeks
3.1 Precipitous fall in blood
pressure and respiratory rate
3.2 Drowsiness after discharge 1 72 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.29, 3.42]
3.3 Giddy after discharge 1 72 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.01, 5.00]
3.4 Headache 1 72 Risk Ratio (M-H, Fixed, 95% CI) 0.41 [0.02, 9.84]
3.5 Vomiting 1 72 Risk Ratio (M-H, Fixed, 95% CI) 6.21 [0.31, 124.97]
3.6 Injection site pain 1 72 Risk Ratio (M-H, Fixed, 95% CI) 0.41 [0.02, 9.84]
3.7 Rash 1 72 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.8 Felt cold 1 72 Risk Ratio (M-H, Fixed, 95% CI) 1.25 [0.08, 19.22]
4 Patient apprehension if given
same method of anaesthesia
again
Comparison 6. General IV anaesthesia versus haematoma block + sedation (midazolam)
No. of
studies
No. of
participants
2 Residual dorsal deformity 1 40 Mean Difference (IV, Fixed, 95% CI) 1.8 [-2.51, 6.11]
(minutes)
1 40 Mean Difference (IV, Fixed, 95% CI) 240.0 [-11.02,
491.02]
(minutes)
Comparison 7. Location of IVRA injection site: antecubital fossa versus hand dorsum
No. of
studies
No. of
participants
1 Procedural problems and adverse
effects
1.1 Patients with failed
cannulations
1.2 Injection site bleeding 1 100 Risk Ratio (M-H, Fixed, 95% CI) 0.09 [0.01, 1.60]
1.3 Injection site haematoma 1 100 Risk Ratio (M-H, Fixed, 95% CI) 0.09 [0.01, 1.60]
1.4 Plaster cast application
problems (from injection site
bleeding or haematoma)
1.5 Systematic toxicity 1 100 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
Comparison 8. Application of an additional tourniquet during IVRA
No. of
studies
No. of
participants
1 Time to clinical anaesthesia
(minutes)
Comparison 9. Brachial plexus block technique: proximal cranial needle (PCN) versus Winnie and Collins (W+C)
No. of
studies
No. of
participants
1 Adverse effects (whole group) 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Pneumothorax 1 60 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
1.2 Phrenic nerve block with
respiratory failure
1.3 Subclavian artery puncture 1 60 Risk Ratio (M-H, Fixed, 95% CI) 0.05 [0.00, 0.87]
Comparison 10. Muscle relaxant supplement to IVRA
No. of
studies
No. of
participants
1Failed reduction/re-manipulation 2 53 Risk Ratio (M-H, Fixed, 95% CI) 0.2 [0.01, 3.89]
2 Additional analgesic required 1 17 Risk Ratio (M-H, Fixed, 95% CI) 0.3 [0.01, 6.47]
3 Unacceptable reduced position
of fracture
4 Duration of tourniquet
application (minutes) - whole
group
5 Timing of sensorial and motor
blockade - whole group
5.1 Time to onset of sensorial
block (seconds)
1 40 Mean Difference (IV, Fixed, 95% CI) -65.5 [-88.61, -
42.39]
5.2 Time to onset of motor
block (seconds)
1 40 Mean Difference (IV, Fixed, 95% CI) -574.5 [-715.23, -
433.77]
5.3 Duration of recovery
period from sensorial block
(seconds)
5.4 Duration of recovery
period from motor block
(minutes)
6 Adverse effects/Complications 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
6.1 Diplopia 2 76 Risk Ratio (M-H, Fixed, 95% CI) 7.0 [0.39, 126.48]
6.2 Dizziness +/- nausea 1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.07, 14.90]
6.3 Dysaethesia 1 36 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
Comparison 11. Analgesic (tenoxicam) supplement to IVRA
No. of
studies
No. of
participants
1 Tourniquet time (minutes) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Tenoxicam into block
versus none
1.2 Tenoxicam into opposite
arm versus none
versus tenoxicam into opposite
arm
2 Time to rst analgesia (minutes) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
versus none
700.97]
arm versus none
400.13]
arm
602.05]
3 Number of painkillers
(co-dydramol) in 24 hours
versus none
arm versus none
arm
4 Pain: numerical rating scale
(0: no pain to 10: worst
imaginable) in 24 hours
versus none
arm versus none
arm
5 Moderate or severe pain in rst
24 hours
versus none
arm versus none
arm
Comparison 12. Sedative (midazolam) supplement to haematoma block
No. of
studies
No. of
participants
2 Residual dorsal deformity 1 38 Mean Difference (IV, Fixed, 95% CI) -2.40 [-6.23, 1.43]
(minutes)
285.91]
(minutes)
Comparison 13. Hyaluronidase (enzyme) supplement to haematoma block
No. of
studies
No. of
participants
1 Unsuccessful manipulation 1 33 Risk Ratio (M-H, Fixed, 95% CI) 3.18 [0.14, 72.75]
Comparison 14. Clonidine supplement to brachial plexus block
No. of
studies
No. of
participants
1 Sensory blockade at 10 minutes
(VAS: 0 (complete) to 100
(none))
1.1 Mepivacaine 1 20 Mean Difference (IV, Fixed, 95% CI) Not estimable
1.2 Ropivacaine 1 15 Mean Difference (IV, Fixed, 95% CI) 3.0 [-17.25, 23.25]
1.3 Bupivacaine 1 22 Mean Difference (IV, Fixed, 95% CI) 19.0 [2.94, 35.06]
2 Sensory blockade at 30 minutes
(VAS: 0 (complete) to 100
(none))
2.1 Mepivacaine 1 20 Mean Difference (IV, Fixed, 95% CI) Not estimable
2.3 Bupivacaine 1 22 Mean Difference (IV, Fixed, 95% CI) 7.0 [1.29, 12.71]
3 Duration of motor blockade
(minutes)
1 57 Mean Difference (IV, Fixed, 95% CI) 198.84 [166.60,
231.08]
3.1 Mepivacaine 1 20 Mean Difference (IV, Fixed, 95% CI) 233.0 [184.58,
281.42]
3.3 Bupivacaine 1 22 Mean Difference (IV, Fixed, 95% CI) 267.0 [212.82,
321.18]
Comparison 15. Bupivacaine versus prilocaine for IVRA
No. of
studies
No. of
participants
1 Pain during procedure 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Great pain according to
doctor
1.2 Great pain at fracture site
according to patient
1.3 Great pain at cuff site
according to patient
2 Unacceptable/poor result 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 Remanipulation /
abandoned procedure
2.2 Not anatomical result
/ incomplete analgesia/
abandoned procedure
3.1 Patients with side effects 1 175 Risk Ratio (M-H, Fixed, 95% CI) 1.76 [0.92, 3.39]
3.2 Tingling / pain in ngers 1 175 Risk Ratio (M-H, Fixed, 95% CI) 1.21 [0.46, 3.19]
3.3 Metal taste in mouth 1 175 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.07, 16.66]
3.4 Tinnitus 1 175 Risk Ratio (M-H, Fixed, 95% CI) 11.64 [0.65, 207.35]
3.5 Feeling funny (nauseous,
sweaty etc)
Analysis 1.1. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome 1
Pain.
Review: Anaesthesia for treating distal radial fracture in adults
Comparison: 1 Intravenous regional anaesthesia (IVRA) versus haematoma block
Outcome: 1 Pain
Study or subgroup IVRA Local Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 During manipulation (VAS: 0 (no pain) to 10 (severe pain))
Cobb 1985 44 2.64 (3.02) 39 5.53 (3.67) 100.0 % -2.89 [ -4.35, -1.43 ]
Subtotal (95% CI) 44 39 100.0 % -2.89 [ -4.35, -1.43 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.89 (P = 0.00010)
2 Duration of post-op painlessness (hours)
Cobb 1985 44 3.7 (3) 39 4 (3) 100.0 % -0.30 [ -1.59, 0.99 ]
Subtotal (95% CI) 44 39 100.0 % -0.30 [ -1.59, 0.99 ]
Test for subgroup differences: Chi
2
= 6.79, df = 1 (P = 0.01), I
2
=85%
-10 -5 0 5 10
Favours IVRA Favours local
Pain and preferences.
Outcome: 2 Pain and preferences
Study or subgroup IVRA Local Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Number of patients indicating that procedure was painful
Wardrope 1985 11/42 16/37 100.0 % 0.61 [ 0.32, 1.13 ]
Subtotal (95% CI) 42 37 100.0 % 0.61 [ 0.32, 1.13 ]
Total events: 11 (IVRA), 16 (Local)
2 Numbers with VAS pain rating > 2cm (0 = no pain)
Wardrope 1985 21/42 29/37 100.0 % 0.64 [ 0.45, 0.90 ]
Subtotal (95% CI) 42 37 100.0 % 0.64 [ 0.45, 0.90 ]
3 Numbers expressing preference for a general anaesthesia
Wardrope 1985 4/42 5/37 100.0 % 0.70 [ 0.20, 2.43 ]
Subtotal (95% CI) 42 37 100.0 % 0.70 [ 0.20, 2.43 ]
0.1 0.2 0.5 1 2 5 10
Re-manipulation.
Outcome: 3 Re-manipulation
Kendall 1997 4/72 17/70 50.1 % 0.23 [ 0.08, 0.65 ]
Walther-Larsen 1988 1/23 4/25 11.1 % 0.27 [ 0.03, 2.26 ]
Wardrope 1985 6/45 12/36 38.8 % 0.40 [ 0.17, 0.96 ]
Total (95% CI) 140 131 100.0 % 0.30 [ 0.16, 0.57 ]
Heterogeneity: Chi
2
= 0.68, df = 2 (P = 0.71); I
2
=0.0%
0.1 0.2 0.5 1 2 5 10
Post reduction anatomical measurements.
Outcome: 4 Post reduction anatomical measurements
1 Volar angulation (stated normal 10-15 degrees)
Wardrope 1985 45 4.5 (8.1) 36 2.6 (8.6) 100.0 % 1.90 [ -1.77, 5.57 ]
Subtotal (95% CI) 45 36 100.0 % 1.90 [ -1.77, 5.57 ]
2 Ulnar angulation (degrees)
Wardrope 1985 45 13.6 (6.6) 36 9.6 (5.2) 100.0 % 4.00 [ 1.43, 6.57 ]
Subtotal (95% CI) 45 36 100.0 % 4.00 [ 1.43, 6.57 ]
3 Radial length (stated normal: 12-16 mm)
Wardrope 1985 45 10.9 (2.3) 36 9.1 (3.2) 100.0 % 1.80 [ 0.56, 3.04 ]
Subtotal (95% CI) 45 36 100.0 % 1.80 [ 0.56, 3.04 ]
2
= 2.31, df = 2 (P = 0.32), I
2
=13%
-10 -5 0 5 10
Not applicable Not applicable
Poor quality of reduction and anatomical scores.
Outcome: 5 Poor quality of reduction and anatomical scores
1 Poor reduction result
Walther-Larsen 1988 8/23 13/24 100.0 % 0.64 [ 0.33, 1.25 ]
Subtotal (95% CI) 23 24 100.0 % 0.64 [ 0.33, 1.25 ]
2 Poor anatomical result (5 weeks)
Walther-Larsen 1988 8/23 12/24 100.0 % 0.70 [ 0.35, 1.38 ]
Subtotal (95% CI) 23 24 100.0 % 0.70 [ 0.35, 1.38 ]
0.1 0.2 0.5 1 2 5 10
Later redislocation/re-reduction of fracture.
Outcome: 6 Later redislocation/re-reduction of fracture
1 Redislocation of fracture
Abbaszadegan 1990 0/50 4/49 48.4 % 0.11 [ 0.01, 1.97 ]
Subtotal (95% CI) 50 49 48.4 % 0.11 [ 0.01, 1.97 ]
2 Later reduction of redislocated fracture
Walther-Larsen 1988 2/23 1/25 10.2 % 2.17 [ 0.21, 22.40 ]
Wardrope 1985 0/45 3/36 41.3 % 0.11 [ 0.01, 2.15 ]
Subtotal (95% CI) 68 61 51.6 % 0.52 [ 0.12, 2.23 ]
Heterogeneity: Chi
2
= 2.46, df = 1 (P = 0.12); I
2
=59%
Total (95% CI) 118 110 100.0 % 0.32 [ 0.09, 1.13 ]
Heterogeneity: Chi
2
= 3.59, df = 2 (P = 0.17); I
2
=44%
0.01 0.1 1 10 100
Operator judgement of effectiveness of procedure (linear analogue scale).
Outcome: 7 Operator judgement of effectiveness of procedure (linear analogue scale)
Cobb 1985 44 7.68 (2.38) 39 6.11 (2.84) 100.0 % 1.57 [ 0.43, 2.71 ]
Total (95% CI) 44 39 100.0 % 1.57 [ 0.43, 2.71 ]
-10 -5 0 5 10
Favours local Favours IVRA
Timing of procedure.
Outcome: 8 Timing of procedure
1 Waiting time for procedure (minutes)
Cobb 1985 44 89 (52) 39 67 (37) 100.0 % 22.00 [ 2.74, 41.26 ]
Subtotal (95% CI) 44 39 100.0 % 22.00 [ 2.74, 41.26 ]
2 Duration of procedure (minutes)
Cobb 1985 44 21.1 (7.9) 39 20.3 (12.5) 100.0 % 0.80 [ -3.76, 5.36 ]
Subtotal (95% CI) 44 39 100.0 % 0.80 [ -3.76, 5.36 ]
2
= 4.41, df = 1 (P = 0.04), I
2
=77%
-100 -50 0 50 100
Adverse effects/Complications.
Outcome: 9 Adverse effects/Complications
Study or subgroup IVRA Local Risk Ratio Risk Ratio
1 Infection
Kendall 1997 0/72 0/70 0.0 [ 0.0, 0.0 ]
Walther-Larsen 1988 0/23 0/25 0.0 [ 0.0, 0.0 ]
Wardrope 1985 0/45 0/36 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 140 131 0.0 [ 0.0, 0.0 ]
Heterogeneity: Chi
2
= 0.0, df = 0 (P<0.00001); I
2
=0.0%
Test for overall effect: Z = 0.0 (P < 0.00001)
2 Systemic complications
Kendall 1997 0/72 0/70 0.0 [ 0.0, 0.0 ]
Walther-Larsen 1988 0/23 0/25 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 95 95 0.0 [ 0.0, 0.0 ]
Heterogeneity: Chi
2
= 0.0, df = 0 (P<0.00001); I
2
=0.0%
3 Median nerve compression
Abbaszadegan 1990 2/50 2/49 0.98 [ 0.14, 6.68 ]
Walther-Larsen 1988 0/23 1/25 0.36 [ 0.02, 8.45 ]
Subtotal (95% CI) 73 74 0.72 [ 0.15, 3.58 ]
Heterogeneity: Chi
2
= 0.28, df = 1 (P = 0.59); I
2
=0.0%
4 Other nerve problems: parathesias / hyposensibility
Walther-Larsen 1988 1/23 1/25 1.09 [ 0.07, 16.39 ]
Subtotal (95% CI) 23 25 1.09 [ 0.07, 16.39 ]
5 RSD
Walther-Larsen 1988 1/23 1/25 1.09 [ 0.07, 16.39 ]
Subtotal (95% CI) 23 25 1.09 [ 0.07, 16.39 ]
0.01 0.1 1 10 100
(Continued . . . )
(. . . Continued)
Study or subgroup IVRA Local Risk Ratio Risk Ratio
6 Tendon rupture
Abbaszadegan 1990 1/50 0/49 2.94 [ 0.12, 70.50 ]
Subtotal (95% CI) 50 49 2.94 [ 0.12, 70.50 ]
0.01 0.1 1 10 100
Analysis 1.10. Comparison 1 Intravenous regional anaesthesia (IVRA) versus haematoma block, Outcome
10 Poor functional score.
Outcome: 10 Poor functional score
Walther-Larsen 1988 2/21 6/21 100.0 % 0.33 [ 0.08, 1.47 ]
Total (95% CI) 21 21 100.0 % 0.33 [ 0.08, 1.47 ]
0.1 0.2 0.5 1 2 5 10
Analysis 2.1. Comparison 2 Nerve block (at elbow) versus haematoma block, Outcome 1 Pain (moderate
or severe) during procedure.
Comparison: 2 Nerve block (at elbow) versus haematoma block
Outcome: 1 Pain (moderate or severe) during procedure
Study or subgroup Nerve block Local Risk Ratio Weight Risk Ratio
Haasio 1990 9/16 6/19 100.0 % 1.78 [ 0.81, 3.93 ]
Total (95% CI) 16 19 100.0 % 1.78 [ 0.81, 3.93 ]
Total events: 9 (Nerve block), 6 (Local)
0.1 0.2 0.5 1 2 5 10
Favours nerve block Favours local
Analysis 2.2. Comparison 2 Nerve block (at elbow) versus haematoma block, Outcome 2 Poor wrist
relaxation during procedure.
Comparison: 2 Nerve block (at elbow) versus haematoma block
Outcome: 2 Poor wrist relaxation during procedure
Study or subgroup Nerve block Local Risk Ratio Weight Risk Ratio
Haasio 1990 0/16 1/19 100.0 % 0.39 [ 0.02, 9.01 ]
Total (95% CI) 16 19 100.0 % 0.39 [ 0.02, 9.01 ]
Total events: 0 (Nerve block), 1 (Local)
0.01 0.1 1 10 100
Favours nerve block Favours local
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).
Comparison: 3 Intravenous sedation versus haematoma block
Outcome: 1 Pain during reduction: visual analogue scale (0: no pain to 10: excruciating pain)
Study or subgroup Sedation Local Mean Difference Weight Mean Difference
Singh 1992 33 8.27 (1.67) 33 2.72 (2.59) 100.0 % 5.55 [ 4.50, 6.60 ]
Total (95% CI) 33 33 100.0 % 5.55 [ 4.50, 6.60 ]
-10 -5 0 5 10
Favours sedation Favours local
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).
Outcome: 2 Pain during reduction: VAS score > 3 for procedure (0: no pain; 10: excruciating pain)
Study or subgroup Sedation Local Risk Ratio Weight Risk Ratio
Singh 1992 32/33 8/33 100.0 % 4.00 [ 2.18, 7.33 ]
Total (95% CI) 33 33 100.0 % 4.00 [ 2.18, 7.33 ]
Total events: 32 (Sedation), 8 (Local)
0.1 0.2 0.5 1 2 5 10
Analysis 3.3. Comparison 3 Intravenous sedation versus haematoma block, Outcome 3 Time for fracture
reduction.
Outcome: 3 Time for fracture reduction
1 Time: 1 minute or over
Singh 1992 32/33 25/33 100.0 % 1.28 [ 1.05, 1.57 ]
Subtotal (95% CI) 33 33 100.0 % 1.28 [ 1.05, 1.57 ]
2 Time: 5 minutes or over
Singh 1992 22/33 16/33 100.0 % 1.38 [ 0.90, 2.11 ]
Subtotal (95% CI) 33 33 100.0 % 1.38 [ 0.90, 2.11 ]
0.01 0.1 1 10 100
Analysis 3.4. Comparison 3 Intravenous sedation versus haematoma block, Outcome 4 Radiological result
at 8 weeks.
Outcome: 4 Radiological result at 8 weeks
Study or subgroup Sedation Local Risk Ratio Risk Ratio
1 Reduction failure
Singh 1992 4/33 2/33 2.00 [ 0.39, 10.18 ]
Subtotal (95% CI) 33 33 2.00 [ 0.39, 10.18 ]
2 Substantial deformity
Singh 1992 6/33 8/33 0.75 [ 0.29, 1.92 ]
Subtotal (95% CI) 33 33 0.75 [ 0.29, 1.92 ]
3 Non union
Singh 1992 0/33 0/33 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 33 33 0.0 [ 0.0, 0.0 ]
0.01 0.1 1 10 100
Analysis 3.5. Comparison 3 Intravenous sedation versus haematoma block, Outcome 5 Adverse effects.
Outcome: 5 Adverse effects
Study or subgroup Sedation Local Risk Ratio Risk Ratio
1 Local sensitivity
Singh 1992 0/33 0/33 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 33 33 0.0 [ 0.0, 0.0 ]
2 Signicant drug toxicity
Singh 1992 0/33 0/33 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 33 33 0.0 [ 0.0, 0.0 ]
3 Infection
Singh 1992 0/33 0/33 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 33 33 0.0 [ 0.0, 0.0 ]
0.1 0.2 0.5 1 2 5 10
Analysis 3.6. Comparison 3 Intravenous sedation versus haematoma block, Outcome 6 Substantial rest
pain at 8 weeks.
Outcome: 6 Substantial rest pain at 8 weeks
Singh 1992 5/33 3/33 100.0 % 1.67 [ 0.43, 6.41 ]
Total (95% CI) 33 33 100.0 % 1.67 [ 0.43, 6.41 ]
0.1 0.2 0.5 1 2 5 10
Analysis 3.7. Comparison 3 Intravenous sedation versus haematoma block, Outcome 7 Substantial stiffness
at 8 weeks.
Outcome: 7 Substantial stiffness at 8 weeks
Singh 1992 7/33 4/33 100.0 % 1.75 [ 0.57, 5.42 ]
Total (95% CI) 33 33 100.0 % 1.75 [ 0.57, 5.42 ]
0.1 0.2 0.5 1 2 5 10
Analysis 4.1. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 1 Radial
length shortening.
Comparison: 4 General intravenous anaesthesia versus haematoma block
Outcome: 1 Radial length shortening
Study or subgroup General Local Risk Ratio Weight Risk Ratio
Funk 1997 9/21 5/19 100.0 % 1.63 [ 0.66, 4.01 ]
Total (95% CI) 21 19 100.0 % 1.63 [ 0.66, 4.01 ]
Total events: 9 (General), 5 (Local)
0.1 0.2 0.5 1 2 5 10
Favours general Favours local
Analysis 4.2. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 2 Residual
dorsal deformity.
Outcome: 2 Residual dorsal deformity
Study or subgroup General Local Mean Difference Weight Mean Difference
Funk 1997 21 3.1 (9.7) 19 3.7 (8.1) 100.0 % -0.60 [ -6.12, 4.92 ]
Total (95% CI) 21 19 100.0 % -0.60 [ -6.12, 4.92 ]
-10 -5 0 5 10
Analysis 4.3. Comparison 4 General intravenous anaesthesia versus haematoma block, Outcome 3 Timing
of procedure.
Study or subgroup General Local Mean Difference Weight Mean Difference
1 Total waiting time (minutes)
Funk 1997 21 558 (426) 19 258 (324) 100.0 % 300.00 [ 66.72, 533.28 ]
Subtotal (95% CI) 21 19 100.0 % 300.00 [ 66.72, 533.28 ]
2 Waiting time for staff (minutes)
Funk 1997 21 127 (53) 19 54 (34) 100.0 % 73.00 [ 45.66, 100.34 ]
Subtotal (95% CI) 21 19 100.0 % 73.00 [ 45.66, 100.34 ]
3 Time for anaesthesia + manipulation (minutes)
Funk 1997 21 20 (13.6) 19 9.8 (3.4) 100.0 % 10.20 [ 4.19, 16.21 ]
Subtotal (95% CI) 21 19 100.0 % 10.20 [ 4.19, 16.21 ]
2
= 25.14, df = 2 (P = 0.00), I
2
=92%
-1000 -500 0 500 1000
Analysis 5.1. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 1 Reactions during
reduction of fracture.
Comparison: 5 General anaesthesia versus sedation (diazepam)
Outcome: 1 Reactions during reduction of fracture
Study or subgroup General Sedative Risk Ratio Risk Ratio
1 Recalled reduction
Bultitude 1972 1/32 3/40 0.42 [ 0.05, 3.82 ]
Subtotal (95% CI) 32 40 0.42 [ 0.05, 3.82 ]
Total events: 1 (General), 3 (Sedative)
2 Limb movement
Bultitude 1972 1/32 5/40 0.25 [ 0.03, 2.03 ]
Subtotal (95% CI) 32 40 0.25 [ 0.03, 2.03 ]
3 Delayed reduction due to vigorous reaction
Bultitude 1972 1/32 0/40 3.73 [ 0.16, 88.53 ]
Subtotal (95% CI) 32 40 3.73 [ 0.16, 88.53 ]
4 Groaned, grimaced or cried out
Bultitude 1972 3/32 33/40 0.11 [ 0.04, 0.34 ]
Subtotal (95% CI) 32 40 0.11 [ 0.04, 0.34 ]
5 Attempt to withdraw arm during reduction
Bultitude 1972 0/32 0/40 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 32 40 0.0 [ 0.0, 0.0 ]
0.01 0.1 1 10 100
Favours general Favours sedative
Analysis 5.2. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 2 Quality of initial
reduction/redisplaced at 6 weeks.
Outcome: 2 Quality of initial reduction/redisplaced at 6 weeks
Study or subgroup General Sedative Risk Ratio Weight Risk Ratio
1 Bad quality initial reduction
Bultitude 1972 1/30 0/38 100.0 % 3.77 [ 0.16, 89.47 ]
Subtotal (95% CI) 30 38 100.0 % 3.77 [ 0.16, 89.47 ]
2 Slipped reductions at 6 weeks
Bultitude 1972 16/30 21/38 100.0 % 0.97 [ 0.62, 1.50 ]
Subtotal (95% CI) 30 38 100.0 % 0.97 [ 0.62, 1.50 ]
0.01 0.1 1 10 100
Analysis 5.3. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 3 Adverse effects.
1 Precipitous fall in blood pressure and respiratory rate
Bultitude 1972 0/32 1/40 0.41 [ 0.02, 9.84 ]
Subtotal (95% CI) 32 40 0.41 [ 0.02, 9.84 ]
2 Drowsiness after discharge
Bultitude 1972 4/32 5/40 1.00 [ 0.29, 3.42 ]
Subtotal (95% CI) 32 40 1.00 [ 0.29, 3.42 ]
3 Giddy after discharge
Bultitude 1972 0/32 2/40 0.25 [ 0.01, 5.00 ]
Subtotal (95% CI) 32 40 0.25 [ 0.01, 5.00 ]
4 Headache
Bultitude 1972 0/32 1/40 0.41 [ 0.02, 9.84 ]
Subtotal (95% CI) 32 40 0.41 [ 0.02, 9.84 ]
5 Vomiting
Bultitude 1972 2/32 0/40 6.21 [ 0.31, 124.97 ]
Subtotal (95% CI) 32 40 6.21 [ 0.31, 124.97 ]
6 Injection site pain
Bultitude 1972 0/32 1/40 0.41 [ 0.02, 9.84 ]
Subtotal (95% CI) 32 40 0.41 [ 0.02, 9.84 ]
0.01 0.1 1 10 100
(Continued . . . )
(. . . Continued)
7 Rash
Bultitude 1972 0/32 0/40 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 32 40 0.0 [ 0.0, 0.0 ]
8 Felt cold
Bultitude 1972 1/32 1/40 1.25 [ 0.08, 19.22 ]
Subtotal (95% CI) 32 40 1.25 [ 0.08, 19.22 ]
0.01 0.1 1 10 100
Analysis 5.4. Comparison 5 General anaesthesia versus sedation (diazepam), Outcome 4 Patient
apprehension if given same method of anaesthesia again.
Outcome: 4 Patient apprehension if given same method of anaesthesia again
Bultitude 1972 2/32 4/40 0.63 [ 0.12, 3.20 ]
0.1 0.2 0.5 1 2 5 10
Analysis 6.1. Comparison 6 General IV anaesthesia versus haematoma block + sedation (midazolam),
Outcome 1 Radial length shortening.
Comparison: 6 General IV anaesthesia versus haematoma block + sedation (midazolam)
Study or subgroup General Local + sedative Risk Ratio Weight Risk Ratio
Funk 1997 9/21 4/19 100.0 % 2.04 [ 0.75, 5.54 ]
Total (95% CI) 21 19 100.0 % 2.04 [ 0.75, 5.54 ]
Total events: 9 (General), 4 (Local + sedative)
0.1 0.2 0.5 1 2 5 10
Favours general Favours local + sed
Outcome 2 Residual dorsal deformity.
Study or subgroup General Local +sedative Mean Difference Weight Mean Difference
Funk 1997 21 3.1 (9.7) 19 1.3 (2.6) 100.0 % 1.80 [ -2.51, 6.11 ]
Total (95% CI) 21 19 100.0 % 1.80 [ -2.51, 6.11 ]
-10 -5 0 5 10
Favours general Favours local + sed
Outcome 3 Timing of procedure.
Study or subgroup General Local + sedative Mean Difference Weight Mean Difference
Funk 1997 21 558 (426) 19 318 (384) 100.0 % 240.00 [ -11.02, 491.02 ]
Subtotal (95% CI) 21 19 100.0 % 240.00 [ -11.02, 491.02 ]
Funk 1997 21 127 (53) 19 51 (40) 100.0 % 76.00 [ 47.06, 104.94 ]
Subtotal (95% CI) 21 19 100.0 % 76.00 [ 47.06, 104.94 ]
Funk 1997 21 20 (13.6) 19 9.3 (5.7) 100.0 % 10.70 [ 4.34, 17.06 ]
Subtotal (95% CI) 21 19 100.0 % 10.70 [ 4.34, 17.06 ]
2
= 21.78, df = 2 (P = 0.00), I
2
=91%
-1000 -500 0 500 1000
Favours general Favours local +sed
Analysis 7.1. Comparison 7 Location of IVRA injection site: antecubital fossa versus hand dorsum,
Outcome 1 Procedural problems and adverse effects.
Comparison: 7 Location of IVRA injection site: antecubital fossa versus hand dorsum
Outcome: 1 Procedural problems and adverse effects
Study or subgroup Elbow Hand Risk Ratio Risk Ratio
1 Patients with failed cannulations
Blyth 1995 3/50 9/50 0.33 [ 0.10, 1.16 ]
Subtotal (95% CI) 50 50 0.33 [ 0.10, 1.16 ]
Total events: 3 (Elbow), 9 (Hand)
2 Injection site bleeding
Blyth 1995 0/50 5/50 0.09 [ 0.01, 1.60 ]
Subtotal (95% CI) 50 50 0.09 [ 0.01, 1.60 ]
3 Injection site haematoma
Blyth 1995 0/50 5/50 0.09 [ 0.01, 1.60 ]
Subtotal (95% CI) 50 50 0.09 [ 0.01, 1.60 ]
4 Plaster cast application problems (from injection site bleeding or haematoma)
Blyth 1995 0/50 10/50 0.05 [ 0.00, 0.79 ]
Subtotal (95% CI) 50 50 0.05 [ 0.00, 0.79 ]
5 Systematic toxicity
Blyth 1995 0/50 0/50 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 50 50 0.0 [ 0.0, 0.0 ]
0.001 0.01 0.1 1 10 100 1000
Favours elbow Favours hand
Analysis 8.1. Comparison 8 Application of an additional tourniquet during IVRA, Outcome 1 Time to
clinical anaesthesia (minutes).
Comparison: 8 Application of an additional tourniquet during IVRA
Outcome: 1 Time to clinical anaesthesia (minutes)
Study or subgroup Tourniquet Control Mean Difference Weight Mean Difference
Eastwood 1986 25 3.84 (1.46) 25 8 (2.25) 100.0 % -4.16 [ -5.21, -3.11 ]
Total (95% CI) 25 25 100.0 % -4.16 [ -5.21, -3.11 ]
-10 -5 0 5 10
Favours tourniquet Favours control
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).
Comparison: 9 Brachial plexus block technique: proximal cranial needle (PCN) versus Winnie and Collins (W+C)
Outcome: 1 Adverse effects (whole group)
Study or subgroup PCN W+C Risk Ratio Risk Ratio
1 Pneumothorax
Pippa 2000 0/30 0/30 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 30 30 0.0 [ 0.0, 0.0 ]
Total events: 0 (PCN), 0 (W+C)
2 Phrenic nerve block with respiratory failure
Pippa 2000 0/30 6/30 0.08 [ 0.00, 1.31 ]
Subtotal (95% CI) 30 30 0.08 [ 0.00, 1.31 ]
0.001 0.01 0.1 1 10 100 1000
Favours PCN Favours W+C
(Continued . . . )
(. . . Continued)
Study or subgroup PCN W+C Risk Ratio Risk Ratio
3 Subclavian artery puncture
Pippa 2000 0/30 9/30 0.05 [ 0.00, 0.87 ]
Subtotal (95% CI) 30 30 0.05 [ 0.00, 0.87 ]
0.001 0.01 0.1 1 10 100 1000
Favours PCN Favours W+C
Analysis 10.1. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 1 Failed reduction/re-
manipulation.
Comparison: 10 Muscle relaxant supplement to IVRA
Outcome: 1 Failed reduction/re-manipulation
Study or subgroup Relaxant Control Risk Ratio Risk Ratio
Esmaoglu 1995 0/9 0/8 0.0 [ 0.0, 0.0 ]
McGlone 1988 0/18 2/18 0.20 [ 0.01, 3.89 ]
Total (95% CI) 27 26 0.20 [ 0.01, 3.89 ]
Total events: 0 (Relaxant), 2 (Control)
Heterogeneity: Chi
2
= 0.0, df = 0 (P = 1.00); I
2
=0.0%
0.01 0.1 1 10 100
Favours relaxant Favours control
Analysis 10.2. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 2 Additional analgesic
required.
Outcome: 2 Additional analgesic required
Study or subgroup Relaxant Control Risk Ratio Weight Risk Ratio
Esmaoglu 1995 0/9 1/8 100.0 % 0.30 [ 0.01, 6.47 ]
Total (95% CI) 9 8 100.0 % 0.30 [ 0.01, 6.47 ]
0.01 0.1 1 10 100
Analysis 10.3. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 3 Unacceptable reduced
position of fracture.
Outcome: 3 Unacceptable reduced position of fracture
Study or subgroup Relaxant Control Risk Ratio Weight Risk Ratio
McGlone 1988 0/18 2/18 100.0 % 0.20 [ 0.01, 3.89 ]
Total (95% CI) 18 18 100.0 % 0.20 [ 0.01, 3.89 ]
0.01 0.1 1 10 100
Analysis 10.4. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 4 Duration of tourniquet
application (minutes) - whole group.
Outcome: 4 Duration of tourniquet application (minutes) - whole group
Study or subgroup Relaxant Control Mean Difference Weight Mean Difference
Esmaoglu 1995 20 65 (20.52) 20 71.75 (19.82) 100.0 % -6.75 [ -19.25, 5.75 ]
Total (95% CI) 20 20 100.0 % -6.75 [ -19.25, 5.75 ]
-100 -50 0 50 100
Analysis 10.5. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 5 Timing of sensorial and
motor blockade - whole group.
Outcome: 5 Timing of sensorial and motor blockade - whole group
1 Time to onset of sensorial block (seconds)
Esmaoglu 1995 20 57.25 (33.69) 20 122.75 (40.57) 100.0 % -65.50 [ -88.61, -42.39 ]
Subtotal (95% CI) 20 20 100.0 % -65.50 [ -88.61, -42.39 ]
2 Time to onset of motor block (seconds)
Esmaoglu 1995 20 74.5 (58.57) 20 649 (315.72) 100.0 % -574.50 [ -715.23, -433.77 ]
Subtotal (95% CI) 20 20 100.0 % -574.50 [ -715.23, -433.77 ]
3 Duration of recovery period from sensorial block (seconds)
Esmaoglu 1995 20 161 (63.23) 20 156 (57.25) 100.0 % 5.00 [ -32.38, 42.38 ]
-1000 -500 0 500 1000
(Continued . . . )
(. . . Continued)
Subtotal (95% CI) 20 20 100.0 % 5.00 [ -32.38, 42.38 ]
4 Duration of recovery period from motor block (minutes)
Esmaoglu 1995 20 12.75 (5.26) 20 2.52 (1.43) 100.0 % 10.23 [ 7.84, 12.62 ]
Subtotal (95% CI) 20 20 100.0 % 10.23 [ 7.84, 12.62 ]
2
= 106.98, df = 3 (P = 0.00), I
2
=97%
-1000 -500 0 500 1000
Analysis 10.6. Comparison 10 Muscle relaxant supplement to IVRA, Outcome 6 Adverse
effects/Complications.
Outcome: 6 Adverse effects/Complications
1 Diplopia
Esmaoglu 1995 0/20 0/20 0.0 [ 0.0, 0.0 ]
McGlone 1988 3/18 0/18 7.00 [ 0.39, 126.48 ]
Subtotal (95% CI) 38 38 7.00 [ 0.39, 126.48 ]
Heterogeneity: Chi
2
= 0.0, df = 0 (P = 1.00); I
2
=0.0%
2 Dizziness +/- nausea
Esmaoglu 1995 1/20 1/20 1.00 [ 0.07, 14.90 ]
Subtotal (95% CI) 20 20 1.00 [ 0.07, 14.90 ]
0.001 0.01 0.1 1 10 100 1000
(Continued . . . )
(. . . Continued)
3 Dysaethesia
McGlone 1988 0/18 0/18 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 18 18 0.0 [ 0.0, 0.0 ]
0.001 0.01 0.1 1 10 100 1000
Analysis 11.1. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 1 Tourniquet time
(minutes).
Comparison: 11 Analgesic (tenoxicam) supplement to IVRA
Outcome: 1 Tourniquet time (minutes)
Study or subgroup Analgesic Control Mean Difference Weight Mean Difference
1 Tenoxicam into block versus none
Jones 1996 15 36 (9.9) 15 37 (10.1) 100.0 % -1.00 [ -8.16, 6.16 ]
Subtotal (95% CI) 15 15 100.0 % -1.00 [ -8.16, 6.16 ]
2 Tenoxicam into opposite arm versus none
Jones 1996 15 33 (10.9) 15 37 (10.1) 100.0 % -4.00 [ -11.52, 3.52 ]
Subtotal (95% CI) 15 15 100.0 % -4.00 [ -11.52, 3.52 ]
3 Tenoxicam into block versus tenoxicam into opposite arm
Jones 1996 15 36 (9.9) 15 33 (10.9) 100.0 % 3.00 [ -4.45, 10.45 ]
Subtotal (95% CI) 15 15 100.0 % 3.00 [ -4.45, 10.45 ]
2
= 1.69, df = 2 (P = 0.43), I
2
=0.0%
-100 -50 0 50 100
Favours analgesic Favours control
Analysis 11.2. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 2 Time to rst
analgesia (minutes).
Outcome: 2 Time to rst analgesia (minutes)
Jones 1996 15 801 (525.5) 15 469 (505.4) 100.0 % 332.00 [ -36.97, 700.97 ]
Subtotal (95% CI) 15 15 100.0 % 332.00 [ -36.97, 700.97 ]
Jones 1996 15 538 (415.6) 15 469 (505.4) 100.0 % 69.00 [ -262.13, 400.13 ]
Subtotal (95% CI) 15 15 100.0 % 69.00 [ -262.13, 400.13 ]
Jones 1996 15 801 (525.5) 15 538 (415.6) 100.0 % 263.00 [ -76.05, 602.05 ]
Subtotal (95% CI) 15 15 100.0 % 263.00 [ -76.05, 602.05 ]
2
= 1.21, df = 2 (P = 0.55), I
2
=0.0%
-1000 -500 0 500 1000
Favours control Favours analgesic
Analysis 11.3. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 3 Number of
painkillers (co-dydramol) in 24 hours.
Outcome: 3 Number of painkillers (co-dydramol) in 24 hours
Jones 1996 15 2.1 (1.8) 15 5.3 (2.9) 100.0 % -3.20 [ -4.93, -1.47 ]
Subtotal (95% CI) 15 15 100.0 % -3.20 [ -4.93, -1.47 ]
Jones 1996 15 3.9 (2.2) 15 5.3 (2.9) 100.0 % -1.40 [ -3.24, 0.44 ]
Subtotal (95% CI) 15 15 100.0 % -1.40 [ -3.24, 0.44 ]
Jones 1996 15 2.1 (1.8) 15 3.9 (2.2) 100.0 % -1.80 [ -3.24, -0.36 ]
Subtotal (95% CI) 15 15 100.0 % -1.80 [ -3.24, -0.36 ]
2
= 2.28, df = 2 (P = 0.32), I
2
=12%
-10 -5 0 5 10
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.
Outcome: 4 Pain: numerical rating scale (0: no pain to 10: worst imaginable) in 24 hours
Jones 1996 15 1.4 (1.2) 15 3.6 (1.6) 100.0 % -2.20 [ -3.21, -1.19 ]
Subtotal (95% CI) 15 15 100.0 % -2.20 [ -3.21, -1.19 ]
Jones 1996 15 3.3 (2) 15 3.6 (1.6) 100.0 % -0.30 [ -1.60, 1.00 ]
Subtotal (95% CI) 15 15 100.0 % -0.30 [ -1.60, 1.00 ]
Jones 1996 15 1.4 (1.2) 15 3.3 (2) 100.0 % -1.90 [ -3.08, -0.72 ]
Subtotal (95% CI) 15 15 100.0 % -1.90 [ -3.08, -0.72 ]
2
= 5.46, df = 2 (P = 0.07), I
2
=63%
-10 -5 0 5 10
Analysis 11.5. Comparison 11 Analgesic (tenoxicam) supplement to IVRA, Outcome 5 Moderate or severe
pain in rst 24 hours.
Outcome: 5 Moderate or severe pain in rst 24 hours
Study or subgroup Analgesic Control Risk Ratio Weight Risk Ratio
Jones 1996 1/15 8/15 100.0 % 0.13 [ 0.02, 0.88 ]
Subtotal (95% CI) 15 15 100.0 % 0.13 [ 0.02, 0.88 ]
Total events: 1 (Analgesic), 8 (Control)
Jones 1996 5/15 8/15 100.0 % 0.63 [ 0.26, 1.47 ]
Subtotal (95% CI) 15 15 100.0 % 0.63 [ 0.26, 1.47 ]
Jones 1996 1/15 5/15 100.0 % 0.20 [ 0.03, 1.51 ]
Subtotal (95% CI) 15 15 100.0 % 0.20 [ 0.03, 1.51 ]
0.01 0.1 1 10 100
Analysis 12.1. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 1 Radial
length shortening.
Comparison: 12 Sedative (midazolam) supplement to haematoma block
Study or subgroup Sedative Control Risk Ratio Weight Risk Ratio
Funk 1997 4/19 5/19 100.0 % 0.80 [ 0.25, 2.53 ]
Total (95% CI) 19 19 100.0 % 0.80 [ 0.25, 2.53 ]
Total events: 4 (Sedative), 5 (Control)
0.1 0.2 0.5 1 2 5 10
Favours sedative Favours control
Analysis 12.2. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 2 Residual
dorsal deformity.
Study or subgroup Sedative Control Mean Difference Weight Mean Difference
Funk 1997 19 1.3 (2.6) 19 3.7 (8.1) 100.0 % -2.40 [ -6.23, 1.43 ]
Total (95% CI) 19 19 100.0 % -2.40 [ -6.23, 1.43 ]
-10 -5 0 5 10
Analysis 12.3. Comparison 12 Sedative (midazolam) supplement to haematoma block, Outcome 3 Timing
of procedure.
Study or subgroup Sedative Control Mean Difference Weight Mean Difference
Funk 1997 19 318 (384) 19 258 (324) 100.0 % 60.00 [ -165.91, 285.91 ]
Subtotal (95% CI) 19 19 100.0 % 60.00 [ -165.91, 285.91 ]
Funk 1997 19 51 (40) 19 54 (34) 100.0 % -3.00 [ -26.61, 20.61 ]
Subtotal (95% CI) 19 19 100.0 % -3.00 [ -26.61, 20.61 ]
Funk 1997 19 9.3 (5.7) 19 9.8 (3.4) 100.0 % -0.50 [ -3.48, 2.48 ]
Subtotal (95% CI) 19 19 100.0 % -0.50 [ -3.48, 2.48 ]
2
= 0.32, df = 2 (P = 0.85), I
2
=0.0%
-1000 -500 0 500 1000
Analysis 13.1. Comparison 13 Hyaluronidase (enzyme) supplement to haematoma block, Outcome 1
Unsuccessful manipulation.
Comparison: 13 Hyaluronidase (enzyme) supplement to haematoma block
Outcome: 1 Unsuccessful manipulation
Study or subgroup Enzyme Control Risk Ratio Weight Risk Ratio
London 1996 1/16 0/17 100.0 % 3.18 [ 0.14, 72.75 ]
Total (95% CI) 16 17 100.0 % 3.18 [ 0.14, 72.75 ]
Total events: 1 (Enzyme), 0 (Control)
0.01 0.1 1 10 100
Favours enzyme Favours control
Analysis 14.1. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 1 Sensory blockade
at 10 minutes (VAS: 0 (complete) to 100 (none)).
Comparison: 14 Clonidine supplement to brachial plexus block
Outcome: 1 Sensory blockade at 10 minutes (VAS: 0 (complete) to 100 (none))
Study or subgroup Clonidine Control Mean Difference Weight Mean Difference
1 Mepivacaine
Erlacher 2001 9 20 (15) 11 20 (14) 49.0 % 0.0 [ -12.83, 12.83 ]
Subtotal (95% CI) 9 11 49.0 % 0.0 [ -12.83, 12.83 ]
2 Ropivacaine
Erlacher 2001 8 25 (21) 7 22 (19) 19.7 % 3.00 [ -17.25, 23.25 ]
Subtotal (95% CI) 8 7 19.7 % 3.00 [ -17.25, 23.25 ]
3 Bupivacaine
-100 -50 0 50 100
Favours clonidine Favours control
(Continued . . . )
(. . . Continued)
Erlacher 2001 10 43 (22) 12 24 (15) 31.3 % 19.00 [ 2.94, 35.06 ]
Subtotal (95% CI) 10 12 31.3 % 19.00 [ 2.94, 35.06 ]
Total (95% CI) 27 30 100.0 % 6.53 [ -2.45, 15.51 ]
Heterogeneity: Chi
2
= 3.43, df = 2 (P = 0.18); I
2
=42%
2
= 3.43, df = 2 (P = 0.18), I
2
=42%
-100 -50 0 50 100
Analysis 14.2. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 2 Sensory blockade
at 30 minutes (VAS: 0 (complete) to 100 (none)).
Outcome: 2 Sensory blockade at 30 minutes (VAS: 0 (complete) to 100 (none))
1 Mepivacaine
Erlacher 2001 9 2 (3) 11 2 (3) 67.3 % 0.0 [ -2.64, 2.64 ]
Subtotal (95% CI) 9 11 67.3 % 0.0 [ -2.64, 2.64 ]
2 Ropivacaine
Erlacher 2001 8 10 (5) 7 9 (5) 18.3 % 1.00 [ -4.07, 6.07 ]
Subtotal (95% CI) 8 7 18.3 % 1.00 [ -4.07, 6.07 ]
3 Bupivacaine
Erlacher 2001 10 17 (8) 12 10 (5) 14.4 % 7.00 [ 1.29, 12.71 ]
Subtotal (95% CI) 10 12 14.4 % 7.00 [ 1.29, 12.71 ]
-100 -50 0 50 100
(Continued . . . )
(. . . Continued)
Total (95% CI) 27 30 100.0 % 1.19 [ -0.98, 3.36 ]
Heterogeneity: Chi
2
= 4.76, df = 2 (P = 0.09); I
2
=58%
2
= 4.76, df = 2 (P = 0.09), I
2
=58%
-100 -50 0 50 100
Analysis 14.3. Comparison 14 Clonidine supplement to brachial plexus block, Outcome 3 Duration of
motor blockade (minutes).
Outcome: 3 Duration of motor blockade (minutes)
1 Mepivacaine
Erlacher 2001 9 455 (58) 11 222 (51) 44.3 % 233.00 [ 184.58, 281.42 ]
Subtotal (95% CI) 9 11 44.3 % 233.00 [ 184.58, 281.42 ]
2 Ropivacaine
Erlacher 2001 8 716 (85) 7 711 (55) 20.3 % 5.00 [ -66.62, 76.62 ]
Subtotal (95% CI) 8 7 20.3 % 5.00 [ -66.62, 76.62 ]
3 Bupivacaine
Erlacher 2001 10 1001 (79) 12 734 (41) 35.4 % 267.00 [ 212.82, 321.18 ]
Subtotal (95% CI) 10 12 35.4 % 267.00 [ 212.82, 321.18 ]
Total (95% CI) 27 30 100.0 % 198.84 [ 166.60, 231.08 ]
Heterogeneity: Chi
2
= 36.13, df = 2 (P<0.00001); I
2
=94%
2
= 36.13, df = 2 (P = 0.00), I
2
=94%
-1000 -500 0 500 1000
Analysis 15.1. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 1 Pain during procedure.
Comparison: 15 Bupivacaine versus prilocaine for IVRA
Outcome: 1 Pain during procedure
Study or subgroup Bupivacaine Prilocaine Risk Ratio Weight Risk Ratio
1 Great pain according to doctor
Hollingworth 1982 3/79 5/90 100.0 % 0.68 [ 0.17, 2.77 ]
Subtotal (95% CI) 79 90 100.0 % 0.68 [ 0.17, 2.77 ]
Total events: 3 (Bupivacaine), 5 (Prilocaine)
2 Great pain at fracture site according to patient
Hollingworth 1982 6/78 8/87 100.0 % 0.84 [ 0.30, 2.30 ]
Subtotal (95% CI) 78 87 100.0 % 0.84 [ 0.30, 2.30 ]
3 Great pain at cuff site according to patient
Hollingworth 1982 5/77 10/86 100.0 % 0.56 [ 0.20, 1.56 ]
Subtotal (95% CI) 77 86 100.0 % 0.56 [ 0.20, 1.56 ]
0.1 0.2 0.5 1 2 5 10
Favours bupivacaine Favours prilocaine
Analysis 15.2. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 2 Unacceptable/poor result.
Outcome: 2 Unacceptable/poor result
1 Remanipulation / abandoned procedure
Hollingworth 1982 0/85 9/88 100.0 % 0.05 [ 0.00, 0.92 ]
Subtotal (95% CI) 85 88 100.0 % 0.05 [ 0.00, 0.92 ]
2 Not anatomical result / incomplete analgesia/ abandoned procedure
Hollingworth 1982 49/85 47/88 100.0 % 1.08 [ 0.83, 1.41 ]
Subtotal (95% CI) 85 88 100.0 % 1.08 [ 0.83, 1.41 ]
0.001 0.01 0.1 1 10 100 1000
Analysis 15.3. Comparison 15 Bupivacaine versus prilocaine for IVRA, Outcome 3 Adverse effects.
1 Patients with side effects
Hollingworth 1982 20/85 12/90 100.0 % 1.76 [ 0.92, 3.39 ]
Subtotal (95% CI) 85 90 100.0 % 1.76 [ 0.92, 3.39 ]
2 Tingling / pain in ngers
Hollingworth 1982 8/85 7/90 100.0 % 1.21 [ 0.46, 3.19 ]
Subtotal (95% CI) 85 90 100.0 % 1.21 [ 0.46, 3.19 ]
3 Metal taste in mouth
Hollingworth 1982 1/85 1/90 100.0 % 1.06 [ 0.07, 16.66 ]
Subtotal (95% CI) 85 90 100.0 % 1.06 [ 0.07, 16.66 ]
4 Tinnitus
Hollingworth 1982 5/85 0/90 100.0 % 11.64 [ 0.65, 207.35 ]
Subtotal (95% CI) 85 90 100.0 % 11.64 [ 0.65, 207.35 ]
5 Feeling funny (nauseous, sweaty etc)
Hollingworth 1982 11/85 4/90 100.0 % 2.91 [ 0.96, 8.79 ]
Subtotal (95% CI) 85 90 100.0 % 2.91 [ 0.96, 8.79 ]
0.001 0.01 0.1 1 10 100 1000
A P P E N D I C E S
Appendix 1. Search strategy for The Cochrane Library
#1. RADIUS FRACTURES explode all trees (MeSH)
#2. WRIST INJURIES explode all trees (MeSH)
#3. (#1 or #2)
#4. ((distal near radius) or (distal near radial))
#5. (colles:ti or smith:ti or smiths:ti)
#6. (colles:ab or smith:ab or smiths:ab)
#7. wrist*
#8. (#4 or #5 or #6 or #7)
#9. fracture*
#10. (#8 and #9)
#11. (#3 or #10)
Appendix 2. Search strategy for MEDLINE (OVID WEB)
1. Exp Radius Fractures/
2. Wrist Injuries/
3. (((distal adj3 (radius or radial)) or wrist or colles$ or smith$2) adj3 fracture$).tw
4. or/1-3
5. exp Anesthetics/
6. exp Anesthesia/
7. an?esth$.tw
8. block$1.tw
9. or/5-8
10. and/4,9
Appendix 3. Search strategy for EMBASE (OVID WEB)
EMBASE
1. (((distal adj3 (radius or radial)) or wrist or colles$ or smith$2) adj3 fracture$).tw
2. colles fracture/ or radius fracture/ or wrist fracture/ or wrist injury/
3. or/1-2
4. exp Anesthesia/
5. exp Anesthetic Agent/
6. an?esth$.tw
7. block$1.tw
8. or/4-7
9. and/3,8
10. exp Randomized Controlled trial/
11. exp Double Blind Procedure/
12. exp Single Blind Procedure/
13. exp Crossover Procedure/
14. or/10-13
15. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
16. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
(Continued)
17. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
18. (cross?over$ or (cross adj1 over$)).tw.
19. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$
or group$)).tw.
20. or/15-19
21. or/14,20
22. Animal/ not Human/
23. 21 not 22
24. and/9,23
W H A T S N E W
Last assessed as up-to-date: 5 January 2004.
Date Event Description
4 September 2008 Amended Converted to new review format.
H I S T O R Y
Protocol rst published: Issue 4, 2001
Review rst published: Issue 3, 2002
Date Event Description
6 January 2004 New search has been performed Inthis minor (the second) update, published inIssue 2, 2004, the search for trials
was extended fromJune 2003 to November 2003. No newtrials were identied.
Some minor changes to the text resulted from comments received from Mike
Bennett, an editor of the Cochrane Anaesthesia Group. Some format changes
were undertaken to comply with the newCochrane Style Guide (October 2003)
. There were no changes to the conclusions of the review.
25 June 2003 New search has been performed The rst, a minor, update of this review was published in Issue 4, 2003. The
search for trials was extended from January 2002 to June 2003. Both newly
identied studies were excluded. There were no changes to the conclusions of
the review.
C O N T R I B U T I O N S O F A U T H O R S
Helen Handoll (HH) initiated and coordinated the production of the review, starting with the compilation of the rst draft of the
protocol and subsequent revisions in RevMan. Rajan Madhok (RM) arranged funding for the review. RM and Chris Dodds (CD)
critically reviewed and rewrote the protocol.
HH, with some assistance from Lesley Gillespie, located the review studies. All three reviewers partook in study selection, critically
reviewed the included studies and piloted the quality assessment and data extraction forms. HH and CD extracted trial details and
results. HH contacted trialists for further information. HH compiled the rst draft and all subsequent revisions in RevMan. CD and
RM critically reviewed and checked all review drafts.
The rst update of the review, including the extension of the literature search, contact of trialists and preparation of the rst draft was
performed by HH. CD and RM critically reviewed the update. All three reviewers are guarantors of the review.
D E C L A R A T I O N S O F I N T E R E S T
None known.
S O U R C E S O F S U P P O R T
Internal sources
University of Teesside, Middlesbrough, UK.
External sources
East Riding and Hull Health Authority, UK.
I N D E X T E R M S
Medical Subject Headings (MeSH)
Anesthesia [
methods]; Manipulation, Orthopedic [methods]; Radius Fractures [
therapy]; Randomized Controlled Trials as Topic

MeSH check words
Aged; Female; Humans; Male

Anaesthesia For Treating Distal Radial Fracture in Adults

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Anaesthesia For Treating Distal Radial Fracture in Adults

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Anaesthesia for treating distal radial fracture in adults

Cobb AG, Houghton GR. Local anaesthetic inltration versus

Kendall JM, Allen P, Younge P, Meek SM, McCabe SE.

McGlone R, Heyes F, Harris P. The use of muscle relaxant to

Kongsholm J, Olerud C. Reduction of Colles fractures without

Indicates the major publication for the study

methods]; Manipulation, Orthopedic [methods]; Radius Fractures [

therapy]; Randomized Controlled Trials as Topic

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